EH 2_2015

EUROPEAN HOSPITAL Vol 24 Issue 2/15 8 CARDIOLOGY Fast specialist care saves lives TAVI: Only for hospitals with cardiac surgery and wards Rapid Access Chest Pain Clinics Restrictive ruling on cardiac procedure Many NHS hospitals in the United Kingdom have established Rapid Access Chest Pain Clinics (RACPC) to work in tandem with them in offering primary percutaneous coro- nary intervention (PPCI) – the gold standard treatment for heart attacks – 24 hours a day. Patients who need instant, emer- gency treatment can access PPCI at the earliest opportunity, what- ever the hour, yet those with previ- ously undiagnosed chest pain can also receive timely assessment and onward treatment through the ser- vice 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 assess- ment 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 electrocardio- gram (ECG) model of approach, where patients are risk-stratified based on clinical history, examina- tion and exercise ECG. Within major hospitals, such as University College Hospital London, The interdisciplinary G-BA justified a decision to restrict TAVI procedures to hospitals with cardiac surgery departments and wards by stating that complications following the pro- cedure cannot be ruled out, and that in-patient aftercare provided by heart surgeons is therefore a necessity. The decision was taken in the context of a new G-BA guideline that sets mini- mum standards for minimally invasive aortic valve interven- tions in German hospitals. Heart surgeons have therefore asserted themselves over their cardiologist colleagues with a demand that TAVIs should only be carried out in heart centres with cardiac surgery on- site, as per recommendations defined in the European Guidelines on Management of Valvular Heart Disease. In a position paper pub- lished last year, the cardiologists had argued in favour of allowing heart centres without cardiac sur- gery departments on-site to con- tinue performing these interventions under certain conditions and in the presence of a cardiac surgeon (see report in EH 2/14 www.healthcare- in-europe.com/en/article/11713- transcatheter-aortic-valve-implan- tations-tavi.html). As expected, when the deci- sion was announced Professor Jochen Cremer, President of the German Society for Thoracic and Cardiovascular Surgery (DGTHG), welcomed this move. Professor Christian Hamm, President of the German Cardiac Society (DGK) also views the G-BA guidelines, along with the mentioned quality criteria listed in the DGK posi- tion paper, as a positive contribution towards quality assurance for TAVIs in Germany. According to Hamm, there are currently 11 Heart Centres without cardiac surgery departments on site that carry out TAVIs - treating fewer than 5% of all patients undergoing this type of procedure. According to the definition of the G-BA interim arrangements, the centres are to con- tinue with the provision of cardiac surgery through cooperation agree- ments until June 2016. As for the indication for treatment, the new G-BA guideline confirms the guidelines as well as national and international recommendations cur- rently in force. For patients with a low risk score, open surgery remains the procedure of choice; TAVIs should only be carried out for older patients and those classed as inoperable. The Federal Ministry of Health is expected to pass the new G-BA guideline in coming months; only then will it be legally binding. the RACPC provides ‘a quick and early specialist cardiology assess- ment 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 dis- ease and worsening symptoms, who need urgent assessment.’ This consultant-led, one-stop clin- ic enables a rapid and definitive assessment of symptoms and inves- tigations and results in either treat- ment initiation or the swift reassur- ance of patients without pathology. Through the RACPC system, all patients are offered an appoint- ment 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 dis- ease, the system allows quick access to appropriate treatment, either medication or invasive procedures and to advice on risk factor modifi- cation and prevention and to reha- bilitation services. However, patients with suspected myocardial infarction (MI), or acute coronary syndromes, should go directly to A&E and, where neces- sary, 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 avail- able 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 treat- ment (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, physi- cians who refer patients to the ser- vice, 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 car- diac cause from those who have non-cardiac pain promptly; perform risk stratification; instigate appropri- ate/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 net- work expanding within the NHS is the investment in additional special- ist 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, out- side those hours, patients would have to be transported several kil- ometres 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 ser- vice, 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 treat- ment quickly and is among the top 15% in England for treating patients within 90 minutes of hospital arrival. Yet, for those who require ambu- latory care, the RACPC is an effective service – and readily available. The United Kingdom’s National Health Service (NHS) offers a two-pronged approach to care, diagnosis and treatment for patients with chest pains, Mark Nicholls reports In the future, TAVIs can only be carried out in German hospitals with cardiac surgery departments and cardiac wards, as decided by the German Government’s Expert Panel on Health (G-BA) last January. An interim arrangement in force until 2016 is anticipated for Heart Centres that currently carry out the TAVI procedure without cardiac surgery departments on site. The Federal Ministry of Health is still to confirm this decision, Bettina Döbereiner reports The University of London’s Rapid Access Chest Pain Clinic (RACPC) provides a quick and early specialist cardiology assessment for patients with new onset of chest pain Source: Edwards Lifesciences

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