Patients who need instant, emergency treatment can access PPCI at the earliest opportunity, whatever the hour, yet those with previously undiagnosed chest pain can also receive timely assessment and onward treatment through the service provided by the RACPC.
The concept of RACPC can trace its origins back to the National Service Framework (NSF) for Coronary Heart Disease, published in 2000, which set modern standards for the management of patients presenting with angina symptoms and aimed to provide rapid investigation and symptom relief and reduce the risk of coronary events.
More recently, the guidelines led to the widespread development of RACPC to provide specialist assessment within two weeks’ of GP referral, with RACPCs established in almost all acute trusts in England and Wales. Most UK chest pain clinics have adopted an exercise electrocardiogram (ECG) model of approach, where patients are risk-stratified based on clinical history, examination and exercise ECG.
Within major hospitals, such as University College Hospital London, the RACPC provides ‘a quick and early specialist cardiology assessment for patients with new onset of exertional chest pain thought likely to be angina, and for patients not currently under a cardiologist who have known ischaemic heart disease and worsening symptoms, who need urgent assessment.’
This consultant-led, one-stop clinic enables a rapid and definitive assessment of symptoms and investigations and results in either treatment initiation or the swift reassurance of patients without pathology. Through the RACPC system, all patients are offered an appointment within two weeks of a referral by their general practitioner (GP), with letters generally sent within 24 hours.
Viewed as a fast route of entry into cardiology services for patients with suspected ischaemic heart disease, the system allows quick access to appropriate treatment, either medication or invasive procedures and to advice on risk factor modification and prevention and to rehabilitation services.
However, patients with suspected myocardial infarction (MI), or acute coronary syndromes, should go directly to A&E and, where necessary, undergo PPCI. At RACPC, patients will have an electrocardiogram (ECG), blood tests and chest X-ray with access to an exercise ECG test while a cardiac technician monitors pulse, blood pressure and heart trace. CT calcium scoring, CT coronary angiogram, stress echocardiogram, myocardial perfusion scan, 24-hour ECG and coronary angiogram are also available as required.
West Middlesex University Hospital NHS Trust RACPC provides a one-stop service involving clinical assessment and investigations to confirm or exclude coronary artery disease and also sets the patients onwards to evidence-based treatment (revascularisation).
Led by consultant cardiologists and nurse specialists, this clinic is regarded as such a success due to the partnership and collaboration between the GPs, A&E staff, physicians who refer patients to the service, and the specialist nurse who runs the clinic supported by the medical members of the cardiology team and diagnostics department.
Gloucestershire Hospitals states the aims of the service are to review all patients within two weeks of referral; make accurate diagnosis of exertional angina; eliminate cardiac cause from those who have non-cardiac pain promptly; perform risk stratification; instigate appropriate/stop inappropriate treatments promptly; refer for onward cardiac investigation as appropriate.
Referral criteria include typical cardiac chest pain; recent onset or recurrence (within three months); patient suitable to perform Exercise Tolerance Test; patients with a pre-existing diagnosis of IHD/ CAD, who have recurrence of chest pain. Yet, for those suffering heart attack and requiring emergency PPCI, there is a wide round-the-clock network. A typical example of the PPCI network expanding within the NHS is the investment in additional specialist staff which enabled the Lister’s Hertfordshire Cardiology Centre to provide the service 24 hours a day over the last year.
Before that, the service at the hospital in Stevenage, north of London, was only available 9am-5pm, Monday to Fridays and, outside those hours, patients would have to be transported several kilometres to Papworth hospital in Cambridgeshire or Harefield in North-west London for PPCI. The development of the service means that when someone has a heart attack within the hospital’s catchment, they can always have emergency life-saving treatment locally.
Professor Diana Gorog, clinical director for cardiology, said: ‘Having rapid access to a local PPCI service, rather than being transported to another centre around an hour away, will give those suffering from a heart attack not only a greater chance of surviving, but also reduce the amount of heart muscle damage and thus improve quality of life.’
Reports from the Royal College of Physicians shows that the Hertfordshire Cardiology Centre is ensuring people who have a heart attack obtain that specialist treatment quickly and is among the top 15% in England for treating patients within 90 minutes of hospital arrival. Yet, for those who require ambulatory care, the RACPC is an effective service – and readily available.