NICE clinical guideline (CG 95) recommended risk stratification and management of patients presenting with chest pain of recent originusing a new protocol driven pathway. There has been variable adoption of the NICE guidance on chest pain of recent origin (CG 95) across the country and this has not been implemented in Cornwall, mainly because of the concerns regarding the increased demand for non invasive investigations and its cost implications. Patients referred with chest pain of recent onset are clinically evaluated in the specialist nurse lead rapid access chest pain clinics (RACPC). We undertook a retrospective study to compare the current practice with the NICE recommended clinical algorithm.Materials and methods
278 consecutive patients who attended the RACPC at the Royal Cornwall hospital between 1st January and 31st March 2013 were included in the analysis. Following initial assessment suitable patients (90%) underwent exercise tolerance testing. All the patients were then discussed with the supervising consultant cardiologist and a further management plan was decided. Based on the typicality of the chest pain and risk factors, the Pryor risk score was calculated retrospectively and patients categorised in to the five risk categories as per the NICE algorithm.The actual investigations performed were compared with the investigation suggested by the NICE guideline. The difference in cost between the two pathways was calculated and extrapolated to calculate the annual cost impact.Results
The mean age was 60 years and there were 51% males. Hypercholesterolaemia (69%) was the most frequent risk factor, followed by smoking (20%) and diabetes mellitus (12%). Based on the clinical characteritics, 97 patients (35%) had non-anginal chest pain, 124 patients (45%) had atypical chest pain and 56 patients (20%) had typical cardiac chest pain. Implementing the NICE guidance will result in significantlymore patients being discharged directly to general practice, significantly more patients undergoing CT angiography or CT calcium scoring, 45% more patients having functional imaging and 39% more patients requiring invasive angiography (Figure 1) The adoption of NICE guidance will cost £68,536more per year (Figure 2).Results
As expected the NICE guidance resulted in an increase in demand for non invasive and invasive imaging.Conclusion
The implementation of NICE clinical guidance (CG 95) driven pathway will result in a greater proportion initial discharge to the community at the expense of increase demand in non invasive and invasive coronary imaging. However, the overall cost impact remains modest and an early decision can be arrived at in a significantly higher number of patients.