Collaborative advanced nurse practitioner (ANP) and senior cardiac physiologist (SCP) ECHO use in a community chest pain clinic: an audit of case management and clinical outcomes.
Authors: O'dea D , Ingram S 
Published: July 2022

Abstract

Funding Acknowledgements
Type of funding sources: None.

Background
In the primary care setting chest pain is a common presenting complaint with an over diagnosis/suspicion of stable angina, however General Practitioners (GPs) lack access to a cardiac specialist in a timely fashion, as a result 31% of all ED chest pain patients are referred to the emergency department. The Integrated community chest pain clinic (ICCPC) provides an alternative pathway for GPs to refer patients with non-acute chest pain. This clinic is advanced nurse practitioner (ANP) led in partnership with a senior cardiac physiologist (SCP) to provide cardiac diagnostics. ESC guidelines recommend echocardiography (ECHO) as a level 1b recommendation for patients with suspected coronary artery disease for the assessment of chest pain.

Purpose
The aim of this study is to assess referral to and impact of SCP provided ECHO in an integrated community chest pain clinic.

Methods
A retrospective clinical audit of all patients who were referred for ECHO over a 15-month period was performed. Clinical indication for referral, case management and final diagnosis were evaluated, approved by the hospital audit department.

Results
A total of 89 patients were referred by the ANP to the SCP for ECHO, (18%) of total patient cohort. All patients presented with chest pain and the clinical reason for referral included abnormal ECG n=25 (28%), hypertension n=24 (26%), dyspnoea n=19 (21%) or new murmur n=6 (7%). Other referral rational n= 15 (18%) included elevated NT-proBNP and long covid. Seventy percent of all cases were managed by collaborative autonomy between the ANP and SCP and discharged to the general practitioner. Collaboration with the Consultant Cardiologist was required for n=26 (30%) of cases. Of these n=4 were discharged. Twenty-two or 24% of the total number of ECHOs performed showed notable abnormalities requiring further management. This included dilated aortic root n= 6, valve disease n=8, one of which was severe requiring surgical valve replacement and regional wall motion abnormalities n=5. Three patients exhibited significant myocardial disease including Hypertrophic cardiomyopathy, Hypertrophic obstructive cardiomyopathy and Hypertrophic Cardiomyopathy with Severe Asymmetrical Hypertrophy.
Discussion
The integrated community chest pain clinic provides the patient with non-acute chest pain access to and advanced nurse practitioner and senior cardiac physiologist outside the acute setting. The provision of SCP led ECHO provides a timely and useful diagnostic tool as per ESC guidelines. Most patients post ECHO were managed by the ANP in collaboration with the cardiac physiologist. Chest pain is not always due to coronary heart disease and patients with significant myocardial and valve disease were diagnosed and promptly managed in the community setting. Advanced practice nursing and cardiac physiologist led care with access to ECHO has proven vital for this patient cohort.