Rapid Access Chest Pain Clinics supported by long term data

Excellent long-term cardiovascular outcomes are achieved in patients managed at a Rapid Access Chest Pain Clinic (RACPC) in Sydney, new research shows.

The five year findings, published in Heart, Lung & Circulation, add to previously published short-term results of a low risk of cardiovascular events at 28 days in a RACPC cohort.

The model of care for patients assessed as low risk in the ED comprises direct referral for exercise stress testing and early review by a cardiologist in the RACPC.

The follow-up study reviewed outcomes for all 1,133 patients who presented to the Concord Repatriation General Hospital RACPC between 2008 and 2017.

It found that following their initial treatments and post-RACPC discharge, 3.0% of patients experience a major adverse cardiovascular event (MACE), mostly within the first two years.

These events included 19 patients (1.7%) with acute myocardial infarction (AMI), 13 (1.1%) with non-AMI revascularisations, and three (0.3%) cardiac deaths.

Of the 19 AMIs, 18 underwent revascularisation (15 PCI; 3 CABG). Of the 13 non-AMI patients who underwent revascularisation, five had PCI and eight had CABG.

As well as the three cardiac deaths (AMI, ischaemic heart disease and unspecified cardiac arrhythmia), there were 31 non-cardiac deaths, mostly from cancer.

The study found the total mortality rate in 15–54 year-olds through the RACPC was comparable to the expected mortality in a matched population (0.21% vs 0.20%; RR 1.05; p=0.89).

“For age groups above 54 years old, the mortality rate per patient-year was lower than the expected mortality rate per patient-year. The difference was most pronounced in the 65–74 years age group, with mortality at 0.54% per patient-year compared with the expected mortality rate of 1.76%, representing a relative risk of 0.31,” it said.

The researchers said the lower mortality rate may be a consequence of medical therapy started in the RACPC or RACPC patients subsequently receiving more regular GP or specialist cardiology care than they would have otherwise.

They said their findings were largely consistent with other Australian data.

“In an Australian metropolitan tertiary referral hospital setting, RACPC patients appear to have excellent short and long-term cardiovascular outcomes, with an age-dependent—as good as, or better than expected—mortality rate compared to the general population…,: they concluded.

Senior investigator on the study Associate Professor Harry Lowe, told the limbic the RACPC model could be offered in more hospitals.

However it was probably limited to larger hospitals as the clinic was essentially a daily or almost daily service.

Further research was required to answer remaining questions such as the most suitable initial investigations and whether or not there was capacity to transfer the model of care into rural settings.

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