NICE repliesBMJ 2010; 340 doi: https://doi.org/10.1136/bmj.c2391 (Published 04 May 2010) Cite this as: BMJ 2010;340:c2391
All rapid responses
Hospital based Rapid Access Chest Pain Clinics (RACPC) were set up
for General Practitioners to refer patients presenting with possible
angina (Ref. 1).
Professor Timmis & his colleagues in 2007 and 2008 queried the
effectiveness of RACPC. They doubted whether the addition of exercise
testing significantly improved the predictive accuracy of a good clinical
history when assessing the probability of disease (Ref 2, 3). Furthermore
the "less than perfect stress tests" in the RACPC, aiming to
stratify the risk of disease (Ref.4, 5), are often followed by invasive
In contrast, the new generation of low radiation, CT angiographic
scanners offer a non-invasive, highly accurate assessment of the coronary
arteries with greater than 99% specificity.
In Bexley, we have used CT angiography to introduce in the community
an attractive and cost effective alternative to RACPC, the Community Chest
Pain Clinic (CCPC). GPs refer patients with possible angina to an
experienced consultant cardiologist, based at GP surgeries, who assesses
the likelihood of disease and, if indicated, refers the patients for
Patients are collected from home and taken to a central London
scanning centre for cardiac CT angiography, using the Aquilion 1 Toshiba
640 slice scanner; they are returned home in the same day with transport
provided by Bexley Care Trust.
77 patients with chest pain were referred by their GP to the CCPC in the
first three months of the introduction of the service.
32 of these patients were discharged back to their general practitioner
with non-cardiac chest pain, based on a careful history and examination.
There have been no sequelae in these patients.
2 patients with typical ongoing angina despite good medical treatment were
referred by the community cardiologist, on clinical grounds, directly to a
London tertiary centre, where they underwent coronary angiography within
48 hours, followed by revascularisation.
43 patients underwent CT 640 slice angiography and were reviewed by the
community cardiologist a week later with their results, reported by a
specialist consultant radiologist. Of these, 2 patients with severe
proximal disease were referred for conventional angiography and pressure
wire studies. Normal patients were reassured and referred back to their
GPs. Patients with disease were treated by aggressive treatment of risk
factors and angina. If symptom free, they were discharged to GP follow up.
All patients were told they could be seen immediately if symptoms re-
appeared; none has been seen so far.
Our experience suggests that Community Chest Pain Clinic is safer, more
accurate and a great deal more convenient for the patients than RACPC. It
is also more cost effective, and its wider application would save
significant sums for a cash starved NHS.
Emeritus Consultant Cardiologist, Guys & St
1. J.P.Dougan, T.P.Mathew, J.W Riddell, M. S. Spence, P.G.
McGlinchey, G.S. Nesbitt, M. Smye, I.B. A. Menown and A.A. J. Adgey. QJ
Med 2001: 94:679-686
2. N.Sekhri, G.S. Feder, C.Junghans, H. Hemingway, A.D. Timmis. Heart
2007; 93 458-463 doi:10.1136/hrt.2006.090894
3. N. Sekhri, G. S. Feder ,C.Junghans, Sandra Eldridge, A.Umaipalan, R.
Madhu, H.Hemingway, and A.D.Timmis. BMJ 2008; 337:a2240
4. D.R. Redwood, J.S. Borer and S.E. Epstein. Circulation 1976; 54;703-706
5. G.A. Diamond and J. S. Forrester. NEJM 1979; 300:1350-1358
Competing interests: No competing interests