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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, formerly at Chelsea and Westminster NHS Foundation Trust and currently at Guys and St Thomas’ NHS Foundation Trust

Introduction

Chronic coronary syndrome (CCS), a clinical category that includes stable angina as defined in the 2019 European Society of Cardiology guideline,1 is a common diagnosis for patients visiting the emergency department (ED) with chest pain. Patients at low risk with CCS who have troponin-negative chest pains, therefore, ruling out myocardial injury associated with acute coronary syndromes,1 are often referred to the acute medical unit (AMU), where they may experience lengthy inpatient stays, and their anginal symptoms are often not managed optimally.

Best practice management of CCS should aim to reduce the risk of future cardiovascular events and mortality, manage patients’ symptoms, and improve their quality of life.1 Therefore, not only does unmanaged CCS negatively impact patient outcomes, it also 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 who did not undergo any procedures and stayed in hospital on average 3.1 days.2 An audit carried out at West Middlesex University Hospital over 28 days in March 2018 found that 40% of patients with chest pain (n=68) who were admitted to the AMU had CCS, but only three of them had anti-anginal therapy commenced or uptitrated by non-cardiology physicians working in the unit.

Improving symptom management for patients with CCS 

Staff in the AMU and cardiology departments at West Middlesex University Hospital collaborated 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, developed a care pathway for patients with CCS to reduce length of stay in hospital and avoidable hospital admissions, and to help non-cardiologists in the AMU improve symptom management for these patients.

They used a three-pronged approach to optimise care, by:

  • creating a new guideline for the management of CCS chest pain in the AMU, consisting of a series of stepwise algorithms, to provide non-cardiology physicians with a structured approach when prescribing anti-anginals;
  • setting up a consultant-led rapid access HOT clinic to allow safe discharge of appropriate patients with CCS at low risk of major adverse cardiac events (MACE);
  • developing the Care Information Exchange app (developed in collaboration with Patient Knows Best and Chelsea and Westminster Hospital), a personal health record shared with healthcare professionals to give patients autonomy over their care. 

Algorithm

Decisions about prescribing anti-anginal therapy can be complex as the medication needs to be tailored to each patient’s haemodynamic profile, electrophysiological rhythm, cardiac and non-cardiac comorbidities, and requires an understanding of drug pharmacokinetics and pharmacodynamics. To simplify decision making for the non-cardiologist, the new guideline includes algorithms for specific patient groups, which take all these factors into account, and incorporates a précis of the different drugs available. The core algorithm gives drug therapy recommendations for patients with stable angina not on anti-anginal therapy (Figure 1).3

Further algorithms give prescribing advice for patients already on anti-anginal therapy, patients with diabetes, heart failure or renal impairment, and older people.

The guideline has been updated to allow for more fluid use, such as to encourage alternative drug use in the case of adverse events or non-response, and to reinforce the use of ranolazine in patients with both stable angina and diabetes. The anti-anginal ranolazine has been shown to reduce HbA1c without increasing the risk of hypoglycaemia so may additionally improve glycaemic control for patients with stable angina and diabetes.5

The HOT clinic

The HOT clinic, which is run by a consultant cardiologist, was set up to provide a safety net to enable patients with CCS to be discharged. The HEART score is used in the AMU to assess patients’ risk of short-term MACE:6 patients at low risk (HEART ≤4) are discharged and given a date to attend the HOT clinic for follow-up in a few days, while those at higher risk (HEART ≥5) are referred for a cardiology consultation and admitted (Figure 2). 

The HEART score is a simple tool that allows evidence-based decision making about the safety of discharge for patients with CCS,7 so removes some reluctance of physicians to discharge patients from the AMU. As patients have early access to the HOT clinic, physicians also have greater confidence in facilitated discharge. 

Patient empowerment

The Care Information Exchange app helps patients with CCS take control of their condition by enabling them to share information about their condition or management plan with healthcare professionals, including ECG or echocardiogram results, and drug history/allergic reactions; to arrange outpatient clinic appointments; and to communicate directly with cardiology staff in the HOT clinic or ambulatory clinic to prevent emergency admissions.

In the HOT clinic, patients are advised that anti-anginal medication is meant to help with symptoms and are encouraged to visit their GP if their symptoms do not improve to uptitrate or try another medication. 

Outcomes

A re-audit after 6 months of adopting the new care pathway showed improvement in all areas. The percentages in anti-anginal prescribing were calculated on the basis of the pre- and post-intervention audits. A retrospective assessment was carried out to see if the patient had any amendment to their anti-anginal medication by the acute/physician at the time of interaction with the consultant, for example, prior to the intervention, 4% of patients had their anti-anginal medication adjusted by a non-cardiologist. After the implementation of the intervention (six months later), this had risen to 18%; a 14% rise in patients who had their anti-anginals optimised by non-cardiologist. This also included:

  • increased facilitated discharge to the HOT clinic: 54% of all stable angina patients
  • significant reduction in length of stay with 82% of patients remaining as inpatients less than 24 hours and inpatient bed days reduced from 262 to 127 a month
  • burden on cardiologists significantly reduced with patient referrals from AMU reduced from 60% to 36%
  • financial savings of between £35,000 and £60,000 per month
  • excellent patient feedback 
  • no MACE.

The care pathway was shortlisted as runner up in the 2020 BMJ Stroke & Cardiovascular Awards and is included in the Getting It Right First Time (GIRFT) national programme as an example of a cardiology model that improves outcomes and patient experience without the need for radical change or additional investment. 

Patient case study 
  • A 65-year-old man with diabetes and hypertension, and a long standing history of chest pains attended the ED on Friday complaining of chest pains. He had a negative troponin measurement and negative ECG so was discharged the same day from the acute medical take with HOT clinic follow-up. The cardiology consultant in the HOT clinic contacted him on Wednesday – the patient was still having chest pains so was listed for an angiogram. The angiogram showed sluggish flow in keeping with microvascular angina. In the patient’s discharge summary, the GP was given all the escalation doses of anti-anginal medications and the advice that the patient should not have another angiogram unless he had a positive troponin event or ECG changes. 
  • The care pathway saved around 3 bed days for the hospital and the patient was happy that he did not have to stay in hospital over the weekend. He was satisfied with having an angiogram done quickly and that his medication was optimised in a timely manner, with his GP given clear information about further anti-anginal prescribing.

Dissemination of best practice in CCS management

Since November 2019, the team has been asked by staff from other trusts to give talks about the care pathway for patients with CCS, to provide a copy of the guideline, or to be involved with pathway change or service development programmes in their institutions. One institution has used the team’s audit tool to do their own audit to investigate the areas in which they can make savings, improve patients’ care, and improve protocols.

In April 2020 during the COVID-19 pandemic, the team began to do outreach work with local GPs to help them with anti-anginal prescribing for patients with CCS who were not being seen in hospital. About 33 GP practices in the Hounslow area have now been trained in the management of CCS using a virtual training programme, upskilling them to use the hospital’s guideline so they can be confident in prescribing and have access to help if needed. Other trusts have also requested GP training on the guideline.

Future plans

A new HOT clinic has been set up at Chelsea and Westminster Hospital since March 2021. Another audit cycle of CCS patients at West Middlesex University Hospital is planned to assess if there have been any further improvements since the guidance has been further embedded into practice.

Dr Smith has been working with the South East London same day emergency care (SDEC) working group and the London Ambulance Service to develop pathways for chest pain at Guy’s and St Thomas’ NHS Foundation Trust to develop more streamlined and efficient management of community chest pain and their interaction with secondary services. Part of this has been developing pathways for NHS 111 direct entry into SDEC and 999 direct chest pain pathways, which bypass the ED. Future aims will involve incorporating the CCS management guidance into decision making processes for NHS 111 patients who are routed to the SDEC. Data collection is ongoing.

Key points 
  • Patients with chronic coronary syndrome (CCS) who experience chest pain often do not have their symptoms managed optimally in hospital
  • The AMU and cardiology department at West Middlesex University Hospital introduced a new care pathway to improve the management of these patients
  • Staff developed a guideline for the management of patients with CCS, including a series of unique algorithms for different patient groups, and set up a rapid access cardiac HOT clinic for low-risk patients with CCS
  • After adopting the new care pathway, inpatient bed days were reduced, patients received better symptom management, and the NHS made substantial financial savings
  • In the last year, local GPs have been trained to use the guideline, thus increasing their confidence in prescribing anti-anginals for patients with CCS
  • Other trusts around England have incorporated aspects of the care pathway in their hospitals to improve the care of patients with CCS.

Acknowledgements

Sonia Davies, independent medical writer, helped draft 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 2020; 41: 407–477.
  2. A. Menarini Farmaceutica Internazionale SRL. Chelsea and Westminster Foundation Trust 2017/2018 and West Middlesex Hospital Episode Statistics. Data on File. 2018/2019.
  3. Smith L, Ako E. Guidelines for the management of stable anginal chest pain in the acute medical unit (AMU). Version 10. April 2021; 1–26. 
  4. A. Menarini Farmaceutica Internazionale SRL. Ranexa 375 mg prolonged-release tablets—summary of product characteristics. October 2020. www.medicines.org.uk/emc/product/6442
  5. Teoh IH, Banerjee M. Effect of ranolazine on glycaemia in adults with and without diabetes: a meta-analysis of randomised controlled trials. Open Heart 2018; 5: e000706.
  6. 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.
  7. Yang SM, Chan CH, Chan TN. HEART pathway and Emergency Department Assessment of Chest Pain Score–Accelerated Diagnostic Protocol application in a local emergency department of Hong Kong: an external prospective validation study. Hong Kong Journal of Emergency Medicine 2020; 27: 30–38.
  8. Chelsea and Westminster NHS Trust. Data on File

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). 

Conflicts of interest 

Dr Emmanuel Ako has been paid an honorarium to develop this article. Dr Ako has also received consultancy fees from other pharmaceutical companies, which includes A. Menarini Farmaceutica Internazionale SRL, for activities other than developing this article. 

Dr Luke Smith has received payment from A. Menarini Farmaceutica Internazionale SRL in development of this work. 

This promotional 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 authors were paid honoraria. The views and opinions of the authors are not necessarily those of 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.

PP-RA-UK-0626

Date of preparation: July 2021