Chest pain clinic referral guide

WIH has introduced CT Coronary Angiography (CT-CA) as an option for patients referred to the Rapid Access Chest Pain Clinics. This is the test recommended by both SIGN and NICE in patients presenting with suspected angina due to its sensitivity and diagnostic accuracy. The option of a Treadmill Exercise Test remains as this is still sometimes the best test for the patient. Patient selection is critical to allow the most appropriate test to be carried out. The referral guidance on SCI is being updated to reflect this for future referrals.

We have provided some information below to outline the changes. 

The WIH chest pain clinic is a Cardiac Nurse Specialist run service for patients with:

• New Onset Chest Pain of unknown aetiology (Suspected Angina)
• Patients with known Angina who have had a change in symptoms suggesting worsening of disease

NICE have produced helpful guidance on the likelihood of angina based on the following three factors:

• constricting discomfort in the front of the chest, or in the neck, shoulders, jaw or arms
• precipitated by physical exertion
• relieved by rest or GTN within about 5 minutes.

Patients with none of the above are extremely unlikely to have Angina and an alternative diagnosis and investigation route is recommended.

Patients should be referred using SCI Gateway:

• Western Isles > Western Isles Non-GP Locations/Providers > Western Isles Hospital > General Medicine > Direct Access Cardiac Tests > Create

The following investigations should be completed at the time of referral to allow appropriate triage and assessment as patients will often not be seen face to face until the day of their test:

• Bloods
• FBC (to rule out anaemia as an aetiological factor)
• TSH (to rule out thyroid dysfunction as an aetiological factor)
• U+E (to allow assessment of most suitable modality of investigation)
• Cholesterol/HDL (Random, if not done in the last five years) to help with treatment planning
• ECG
• A current ECG must be included with the SCI referral to allow appropriate triage of investigation modality. Patients with Atrial Fibrillation and some other conditions are less suitable for CT-CA and a current ECG will allow effective triage prior to attendance.
• Presence of an undiagnosed murmur (patients will often need an ECHO prior to an exercise test if not already performed)

The following condition/ drug history will be required for triage and will be automatically extracted from EMIS (for primary care referrals). If this information is not coded please ensure that these conditions are highlighted.

• Asthma (History of Active Condition)
• Patients who undergo a CT-CA will be given beta blockers. Patients with Active Asthma (on daily inhalers) will have an alternative investigation performed in most circumstances.
• Diabetes
• Diabetic patients on Metformin (patients will be instructed by the service not to take this on the day of the test if undergoing CT-CA).

CT- Coronary Angiograms cannot be requested directly, they are only available via referral to the WIH Rapid Access Chest Pain Clinic. If you require further information please contact either myself (davidrigby@nhs.net) or Debra Vickers (debra.vickers@nhs.net)

Uist and Barra Patients: these still have the option of being seen in Benbecula by Dr Mark Johnson for an ETT only. Please state at the time of referral whether the patient is to be seen in Benbecula or in the WIH clinic