Absolute risk assessment for guiding cardiovascular risk management in a chest pain clinic.

OBJECTIVES: To assess the efficacy of a pro-active, absolute cardiovascular risk-guided approach to opportunistically modifying cardiovascular risk factors in patients without coronary ischaemia attending a chest pain clinic. DESIGN: Prospective, randomised, open label, blinded endpoint study. SETTING: The rapid access chest pain clinic of Royal Hobart Hospital, a tertiary hospital. PARTICIPANTS: Patients who presented to the chest pain clinic between 1 July 2014 and 31 December 2017 who had intermediate to high absolute cardiovascular risk scores (5-year risk ≥ 8%). Patients with known cardiac disease or from groups with clinically determined high risk of cardiovascular disease were excluded. MAIN OUTCOME MEASURES: The primary endpoint was change in 5-year absolute risk score (Australian absolute risk calculator) at follow-up (at least 12 months after baseline assessment). Secondary endpoints were changes in lipid profile, blood pressure, smoking status, and body mass index, and major adverse cardiovascular events. RESULTS: The mean change in risk at follow-up was +0.4 percentage points (95% CI, -0.8 to 1.5 percentage points) for the 98 control group patients and -2.4 percentage points (95% CI, -1.5 to -3.4 percentage points) for the 91 intervention group patients; the between-group difference in change was 2.7 percentage points (95% CI, 1.2-4.1 percentage points). Mean changes in lipid profile, systolic blood pressure, and smoking status were larger for the intervention group, but not statistically different from those for the control group. CONCLUSIONS: An absolute cardiovascular risk-guided, pro-active risk factor management strategy employed opportunistically in a chest pain clinic significantly improved 5-year absolute cardiovascular risk scores. TRIAL REGISTRATION: Australia New Zealand Clinical Trial Registry, ACTRN12617000615381 (retrospective).

Evaluating the benefits of a rapid access chest pain clinic in Australia.

OBJECTIVES: To compare the outcomes and safety of a rapid access chest pain clinic (RACPC) in Australia with those of a general cardiology clinic. DESIGN: Prospective comparison of the outcomes for patients attending an RACPC and those of historical controls. SETTING: Royal Hobart Hospital cardiology outpatient department. PARTICIPANTS: 1914 patients referred for outpatient evaluation of new onset chest pain (1479 patients seen in the RACPC, 435 patients previously seen in the general cardiology clinic). MAIN OUTCOME MEASURES: Service outcomes (review times, number of clinic reviews); adverse events (unplanned emergency department re-attendances at 30 days and 12 months; major adverse cardiovascular events at 12 months, including unplanned revascularisation, acute coronary syndrome, stroke, cardiac death). RESULTS: Median time to review was shorter for RACPC than for usual care patients (12 days [IQR, 8-15 days] v 45 days [IQR, 27-89 days]). All patients seen in the RACPC received a diagnosis at the first clinic visit, but only 139 patients in the usual care group (32.0%). There were fewer unplanned emergency department re-attendances for patients in the RACPC group at 30 days (1.6% v 4.4%) and 12 months (5.7% v 12.9%) than in the control group. Major adverse cardiovascular events were less frequent among patients evaluated in the RACPC (0.2% v 1.4%). CONCLUSIONS: Patients were evaluated more efficiently in the RACPC than in a traditional cardiology clinic, and their subsequent rates of emergency department re-attendances and adverse cardiovascular events were lower.