Dr Emmanuel Ako, Consultant Cardiologist and Lead for Chest Pain, Chelsea and Westminster NHS Foundation Trust

Dr Luke Smith, Consultant in Acute and General Internal Medicine, Chelsea and Westminster NHS Foundation Trust and Guys and  St Thomas’ NHS Foundation Trust

Information intended for healthcare professionals only.  This supplement has been commissioned and funded by A. Menarini Farmaceutica Internazionale SRL and developed in partnership with Guidelines in Practice. Please see bottom of page for full disclaimer.

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Introduction

Although chronic coronary syndrome (CCS, a clinical category that includes stable angina as defined in the 2019 European Society of Cardiology guideline1) is a common diagnosis for patients entering the acute medical unit (AMU), these patients are not usually referred to the cardiology department, and as a result the burden of CCS is often under estimated by cardiologists. Patients are often poorly managed symptomatically by AMU and general practice physicians, and experience lengthy hospital admissions. 

This situation results in significant CCS-related costs: unmanaged CCS costs the NHS significant sums of money and ties up huge numbers of hospital bed days. In 2017, the Chelsea and Westminster Hospital NHS Foundation Trust spent more than £600k in CCS non-elective admissions; out of that, 86% was spent on patients that did not undergo any procedures and stayed in hospital on average 3.1 days.2 Other trusts are spending even more on CCS; for example, in 2017 another London Trust spent over £5 million in CCS non-elective admissions, with 43% of that spent on patients that had no procedures and stayed in hospital on average 5.5 days.2 In England as a whole, this equated to a total cost to the NHS of £88,304,692.3

Guidelines detailing a structured approach for patients with CCS are needed to help non-specialist physicians to manage patients and to deliver savings to the healthcare system.

A need to improve services for stable angina

Staff at West Middlesex University Hospital observed that patients with CCS frequently visit the emergency department (ED), where they are either discharged or referred to the AMU. There, they can experience lengthy inpatient stays, and their symptoms are often not managed optimally. 

Observational data collected at the AMU over a 28-day period in March 2018 found that 40% of patients with chest pain (n=68) who were admitted to the AMU had CCS. 

Additionally, a chest pain audit in the ED that took place in August 2018 found that of 422 patients who presented with chest pain, 110 were admitted to the AMU with a suspected type 1 myocardial infarction. Although 80 patients had a negative repeat troponin measurement, 70% of them were still admitted to hospital for an average of 2.7 days. Therefore, chest pain constituted a significant proportion of the AMU’s workload. 

Problems with patients presenting in secondary care

General internal medicine (GIM) and AMU physicians are not experts at managing CCS. Of the 68 patients identified with CCS in the AMU, only three had anti-anginal therapy commenced or up-titrated by AMU/GIM physicians, and only 22 of 41 patients who were seen by a cardiology registrar or senior house officer had anti-anginal therapy amended or commenced. 

The typical pathway for patients presenting with chest pain in the ED sees those with a negative troponin measurement being classed as low-risk, and often discharged with no change to their medication or admitted to the AMU. Those with a positive troponin measurement are admitted to the AMU, and then sent to cardiology or discharged, often with no change to their medication. Under these circumstances, patients may not be reviewed in primary care and will likely present to the ED again. 

Patients with cardiac risk factors, such as diabetes, hypertension, high cholesterol, or smoking status, are often admitted even if they have negative troponin results. In the chest pain audit, ED doctors said that they admitted patients ‘to prevent delayed follow-up in the community’ and ‘to prompt investigations and follow-up’.

A new guideline for managing patients in the AMU

At West Middlesex University Hospital, the close proximity of the AMU and cardiology wards enabled a partnership between staff in the two departments to improve the management of patients with CCS. 

Dr Emmanuel Ako, consultant cardiologist and lead for chest pain, and Dr Luke Smith, consultant in acute and general internal medicine in the AMU, collaborated to improve symptom management for patients, and reduce avoidable and repeat hospital admissions. 

Dr Smith developed a new guideline for the management of CCS chest pain in the AMU, consisting of a series of stepwise algorithms loosely based on the work of Manolis et al.4 to enable a structured approach to the pharmacological management of patients (Figure 1). The guideline was approved by the cardiology faculty working group and trust policy board, and introduced to the AMU in November 2018 by adding it to the hospital trust intranet. It is also planned to advertise the guideline on all computers via screensavers.

Patients commencing on anti-anginal therapy

Figure 1: Management algorithm for patients commencing on anti-anginal therapy

At the same time, Dr Ako set up a new HOT clinic (a consultant-led clinic providing rapid access for patients presenting to hospital with recent chest pain thought to be of cardiac origins), which he runs once a week with a chest pain nurse practitioner, to manage patients with CCS at low risk of major adverse cardiac events (MACE). The HOT clinic was piloted with patients with negative troponin measurement meeting the NICE criteria for CCS who were admitted on the weekend. An AMU consultant used the history, ECG, age, risk factors, and troponin (HEART) score to assess their risk of short-term MACE,5 and low-risk patients (HEART ≤4) were discharged with aspirin, statins, and at least an anti-anginal medication; they were then asked to come back for follow-up later that week. High-risk patients (HEART ≥5) were referred for a cardiology consultation and admitted (Figure 2).

HOT clinic algorithm

Figure 2: Cardiac HOT clinic pathway

Use of the guideline

The guideline, independently developed by West Middlesex University Hospital, contains a series of unique algorithms for different patient groups so that patients are treated using a tailored approach. Specific algorithms have been developed for patients who are established on a maximal dose of anti-anginal monotherapy, patients with diabetes, patients with established cardiac failure, elderly patients, and patients with renal impairment.

The algorithms consider different patient characteristics, including haemodynamic parameters, relevant comorbidities, co-administered medications, and electrophysiological rhythm, and give physicians a clear pathway by outlining which anti-anginal therapy to use according to patients’ characteristics, with a stepwise way of selecting and up-titrating drugs. To assist in decision-making, adverse events, interactions, and pharmacokinetics of anti-anginal drugs are provided. Clear inclusion and exclusion criteria based on the NICE guidelines6 help identify the patients with CCS.

Outcomes

The algorithms in the guideline empower non-specialist AMU and GIM physicians to manage CCS independently of cardiology in a standardised way. This should lead to reduced admissions, shortened length of stay for patients, better symptom management, and savings for the NHS.

The guideline has had a favourable response from AMU physicians, because it offers a structured approach to decision making and helps increasing confidence in using cardiac medications; however, GIM physicians are still somewhat nervous in doing so. Data collection will determine the effect on the number of admissions, with results expected early in 2020. Since the cardiac HOT clinic was introduced, admissions of patients with CCS were reduced from 20% to 10% over a 5-month period (November 2018–March 2019). The resulting reduction in bed days should save the trust approximately £35,000 per month. There have been no MACE among the patients who have been through the clinic.

Future plans

To empower healthcare professionals to better manage CCS patients, it is anticipated that the guideline will be introduced to medical wards and the ED.

An NHS Test Bed app, designed to address the attendance of patients with chest pain to the ED, is being piloted at Chelsea and Westminster Hospital NHS Foundation Trust. An assessment of this project is planned for August 2020 to see whether it will be possible to roll it out across the NHS. 

The initial trial for the cardiac HOT clinic only involved patients presenting at weekends, and it is planned to extend this to also include patients presenting in the week, with the clinic running 2 days a week. Therapeutics clinics to run alongside the cardiac HOT clinic have also been planned, to monitor and optimise patients’ existing therapy, reducing the burden of work on GPs and cardiology outpatients.

Key points

  • Patients with chronic coronary syndrome presenting to the ED often experience long inpatient stays and their symptoms are not managed optimally
  • The AMU and cardiology department at West Middlesex University Hospital started a collaboration to improve the management of these patients
  • A new guideline for the management of patients with chronic coronary syndrome, including a series of unique algorithms for different patient groups, was developed by Dr Luke Smith
  • A new cardiac HOT clinic to manage these patients was set up once weekly by Dr Emmanuel Ako
  • Implementation of the guideline should lead to reduced admissions, shortened length of stay for patients, better symptoms’ management, and savings for the NHS
  • Since the HOT clinic was introduced, inpatient bed days were reduced from 262 to 127, resulting in £35,000 saved per month across the trust (Nov 2018–Mar 2019) 

Conflicts of interest 

Dr Emmanuel Ako has received funding from A. Menarini Farmaceutica Internazionale SRL for presenting the finalised guideline at a sponsored meeting. The author declared no other conflicts of interest.

Dr Luke Smith has received funding from A. Menarini Farmaceutica Internazionale SRL for presenting the finalised guideline at a sponsored meeting. The author declared no other conflicts of interest.

Acknowledgements

Sonia Davies, independent medical writer, helped drafting the article in this supplement. 

References

  1. Knuuti J, Wijns W, Saraste A et al. 2019 ESC guidelines for the diagnosis and management of chronic coronary syndromes. Eur Heart J 2019; 00: 1–71.
  2. A. Menarini Farmaceutica Internazionale SRL. HES data on file for 2017/2018.
  3. A. Menarini Farmaceutica Internazionale SRL. Data on file. NP-RA-UK-0008. May 2019.
  4. Manolis A, Poulimenos L, Ambrosio G et al. Medical treatment of stable angina: a tailored therapeutic approach. Int J Cardiol 2016; 220: 445–453. 
  5. Brady W, de Souza K. The HEART score: a guide to its application in the emergency department. Turk J Emerg Med 2018; 18: 47–51.
  6. NICE. Chest pain of recent onset: assessment and diagnosis. Clinical Guideline 95. NICE, 2016. Available at: www.nice.org.uk/cg95

Further information

For further information about the guideline discussed in this supplement, please contact Dr Emmanuel Ako (e.ako@ucl.ac.uk) and Dr Luke Smith (luke.smith20@nhs.net).  

This supplement has been commissioned and funded by A. Menarini Farmaceutica Internazionale SRL and developed in partnership with Guidelines in Practice. A. Menarini Farmaceutica Internazionale SRL suggested the topic and authors, and carried out full medical approval on all materials to ensure compliance with regulations. The views and opinions expressed are not necessarily those of 
A. Menarini Farmaceutica Internazionale SRL, Guidelines in Practice, its publisher, advisers, or advertisers. No part of this publication may be reproduced in any form without the permission of the publisher. 

Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard. Adverse events should also be reported to A. Menarini Farmaceutica Internazionale SRL. Phone no. 0800 085 8678

PP-RA-UK-0231

Date of preparation: October 2019