Chest Pain Clinic Protocol
1.1) Referral criteria
1.2) Age limit
1.3) Allocation of patients
2. Patients attending the RACPC
2.2) Exercise Tolerance Testing
3. Further investigations
3.1) Coronary Angiograms
3.2) Myocardial Perfusion Scans
6. Clinic timetable
7. Forms and information sheets for use in the Rapid Access Chest Pain Clinic
i. Myocardial Perfusion Scan appointment sheet
ii. Myocardial Perfusion Scan prescription sheet
iii. Myocardial Perfusion Scan information sheet ‘What Happens Now’
iv. Chest Pain Clinic Documentation forms
v. Indications for Exercise Tolerance Testing
vi. End points for Exercise Tolerance Testing
vii. Procedure for patients unfit to treadmill due to other medical
The Clinic was established in 2007 at the Bradford Royal Infirmary. It is staffed by 2
full time Sisters who rotate through the chest pain clinic, rapid access chest pain
clinic (RACPC) and visit patients admitted to the wards with chest pain (where the
working diagnosis is one of ACS).
The Chest Pain Clinic aims to provide a one-stop chest pain service, to investigate
and reassure patients quickly. It is different from the rapid access clinic in that it is
specifically for patients with a pre-existing diagnosis of ischaemic heart disease in
whom symptoms have recurred or previously stable symptoms have deteriorated.
The clinic aims to rule in or rule-out chest pain being related to coronary artery
disease and risk stratify patients for further investigation.
The Chest Pain Clinic has been established for patients who are:
A) Referred from their GP or casualty with an established history of ischaemic heart
disease (previous MI, previous PCI or CABG, confirmed diagnosis of angina ie
objective evidence of ischaemia on previous ETT/perfusion scan) who have
developed new onset of chest pain likely to be angina or in whom previously
stable chest pain has suddenly deteriorated. The referral is faxed to the clinic, a
fax will be sent back by the next working day to confirm receipt. This is not the
rapid access clinic and is not subject to the 14 day target that applies to that clinic
but the principle is that patients should be seen quickly and preferably within 14
days of the decision to refer.
B) Referred from the medical admissions unit (MAU), Ward 22 and Ward 3/6 for
exercise tolerance testing, where there is a discharge diagnosis of suspected
Note History is not taken for ward patients. ETT’s will not be booked for
patients that are not admitted with chest pain and where the discharge
diagnosis is given as being non-cardiac in nature. Patients referred through this
route must be able to walk on a treadmill.
C) Exclusion criteria:
Aortic Stenosis (known or suspected)
1.2 Age Limit
There is no age limit for patients attending the clinic.
1.3 Allocation of patients
Patients requiring OPA/ further investigations will be allocated to the consultant on
Patients booked for Coronary Angiography, may be allocated to a different
The nurses in the RACPC are suitably qualified in nursing patients with cardiac
conditions especially Acute Coronary Syndrome and MI.
They will have a minimum of 5 years CCU/ Cardiology experience at E Grade or
The nurses will have a current ALS qualification.
The nurses will have undertaken a clinical skills and examination course and be
competent in chest auscultation and the taking of clinical history.
The nurses will be registered nurse prescribers
2. Assessing patients attending the chest pain
• When a patient attends the chest pain clinic, he/ she will be greeted by the
reception staff and directed to the appropriate waiting area. The reception staff
will ensure that a ‘patient waiting’ sign is placed on the front desk.
• A routine 12 lead electrocardiogram (ECG) will be performed on ALL patients by
a technician/ cardiographer, prior to history taking.
• History and physical examination will be taken from all patients referred from their
GP’s and A&E. No history will be taken for patients from other sources.
• If history is typical of anginal pain and there are no contra-indications for exercise
tolerance testing, an ETT will be performed. If patients are found to have systolic
murmurs an Echocardiogram will be performed. If unable to exercise during visit,
see Procedure for patients unfit for treadmill due to other medical
• If history is atypical the patient can be reassured and discharged back to their
GP. GP’s may be advised to refer them on for further investigation e.g.: Gastric or
2.2 Exercise Tolerance Testing
ETT will not be done if there is:
• Poor mobility
• Left bundle branch block on the resting ECG
• Hypertension (if BP is greater than >180/100)
• Aortic Stenosis (discuss with cardiologist)
• Recent MI/ suspected Acute Coronary Syndrome
• Hypertrophic cardiomyopathy
Please note full contraindications for ETT and reasons for termination of ETT
are in the exercise rooms, if in doubt discuss with a senior cardiac
physiologist/ consultant cardiologist.
Patients are continually monitored during the test (ECG and BP). The aim is to reach
a minimum of 85% - 100% predicted maximum heart rate (PMHR); worked out as
220 minus the age of the patient.
The test may be terminated for the following reasons:
• ST depression of 2mm with chest pain
• ST depression of 3mm without chest pain
• Drop in systolic BP during exercise
• Patient cannot continue on the treadmill
• Arrhythmias (see Endpoint information) and discuss with cardiologist if
The Duke Treadmill Score is used to determine the result of the exercise test.
The Duke Treadmill Score
(Exercise time – 1 (min) if Mod Bruce) – (5x max ST depression) –
- 4x2 Limiting chest pain
- 1 Non-limiting chest pain
- 0 No angina
3. Further investigations
3.1) If the treadmill score is –4.5 or less; the patient is booked directly for coronary
These must be booked prior to the patient leaving the department. This is
booked onto Prism the Cardiology Database. Patients will be given an agreed
date and time to attend.
• If history is good and there are resting ECG changes or features of instability
i.e.: rest pain, patients can be directly booked for a Coronary Angiogram or
admitted if necessary. If unsure please discuss directly with a consultant.
3.1) If the patient is unable to walk on the treadmill and the history is typical of
angina, patients are directly booked for a myocardial perfusion scan. These
patients must be booked prior to discharge. Phone ext 4133 to book an
appointment, fill in the pre-printed appointment sheet and give to patient with
an information sheet. Send/ (fax to 4134) the request form and prescription
sheet to medical physics. The allocated consultant must be specified on the
Bloods will be taken for patients booked for coronary angiography. Bloods will
be taken for FBC, U+E’s, glucose, renal, TFT and total cholesterol and HDL/
Patients discharged back to their GP’s with a diagnosis of Angina, without the
need for further hospital investigation will be given blood forms and advised to
return back to their GP’s for bloods taking. The GP will be advised to consider
commencing on a Statin and Ace-Inhibitor if not already on these when the
results are available or to increase the dose of a statin if LDL cholesterol is
>2mmol/l or total cholesterol >4mmol/l. The patient will be told that the GP will
be advised to refer the patient back to the general cardiology clinic if
symptoms persist despite intensified medical therapy.
4. Medication on discharge for patients diagnosed with Angina
Patients are given a 14 - day supply of tablets. If unsure discuss with cardiologist.
Many patients will already be on some cardioactive medications given that they have
a pre-existing diagnosis of IHD. The following list is the minimum that patients
should be prescribed.
If heart rate >60 and there are no contra-indications, commenced on Bisoprolol 5 mg
4.2 Calcium-channel blockers
Where beta-blockers are contra-indicated, patients are to be commenced on Tildiem
LA 200mg OD.
Patients will be commenced on Aspirin 75 mg OD, unless contra-indicated or patient
unable to tolerate. If allergic to Aspirin patients should be commenced on Clopidogrel
75 mg OD. If aspirin causes dyspepsia then it should be co prescribed with
lansoprazole 30mg od.
4.4 GTN spray
Patients will be dispensed a GTN spray, with detailed advice of how and when to
(They will be instructed when to call for emergency assistance.)
Patients will be commenced on Simvastatin 40g mg nocte.
Patients already on a beta blocker or rate limiting calcium antagonists should be
prescribed nicorandil 10mg bd. If they are already on this then prescribe ISMN MR
30mg od to be increased to 60mg od after 1 week.
Letters will be dictated to tape and given to the secretary of the on-call cardiologist
Discharge letters will be typed by the next working day and sent back to the GP’s
once signed within 24 hours.
6) Timetable for Rapid Access Chest Pain Clinic
Day Rapid Access Slots available Clinic times
Monday 6 8.30 - 11.00
Tuesday 6 8.30 – 11.00
Wednesday 6 morning/ 4 afternoon 8.30 - 11.00/
2.00 – 3.30
7. Forms and information sheets for use in the Rapid Access Chest Pain Clinic
DEPARTMENT OF MEDICAL PHYSICS
BRADFORD ROYAL INFIRMARY Tel. 01274 364133
Duckworth Lane Fax 01274 364134
Patient Name:………………………………………Hos. No. or Date of Birth:………………
We have been asked by Dr/Mr ………………………………….to perform a Myocardial
Perfusion scan of the heart, for you.
APPOINTMENT DETAILS – Rest Study
You should fast for 6 hours prior to the attendance time.
Could you please avoid caffeine. (E.g. Coffee, tea, cola) for 24 hours prior to the
attendance time, PRIOR TO EACH APPOINTMENT. You may drink milk, water, fruit
juice for example.
Are you asthmatic? Do you have an inhaler other than a GTN spray?. If the
answer is ‘YES’ to either of these questions, the nursing staff or doctors
should have informed the department, please let them know.
You may be in the department for between 2½ and 4 hours.
Your Stress study (second day) will be on:
Please read the following instructions carefully
Please take all medicines as normal; - we will need a list of these which we can
obtain from your medical casenotes.
Please fast for 6 hours prior to the attendance time on both days
Please avoid caffeine starting from 24 hours prior to each appointment (Caffeine
will interfere with the results of this study)
The following contain Caffeine and must be avoided:
Tea (including fruit tea) Coffee
Chocolate & chocolate products Cola
Cough & Cold remedies (Check labels) Decaffeinated
If you have any queries, please ask a member of the nursing staff for further
information, either from themselves or to contact a member of staff from this
MYOCARDIAL PERFUSION SCAN INTRAVENOUS DRUG PRESCRIPTION AND AS
REQUIRED DRUG CHART.
PATIENT NAME ………………………… HOSPITAL NUMBER / DOB ..…………
Known Allergies/ Sensitivities……………………………………………
AGENT Date Time Name of Quantity/ Vo Infusion Special Batc Admin Witness
TO BE of of drug Dose l period Instructions h No by
USED admin admin
Adenosine kg per 6 As per
(Adenoscan minute minutes myoview
AGENT TO Date of Time Name of Quantity/ Dilutant/ Vol Infusion Special Batch Admin Witness
BE USED admin of drug Dose Solution period Instructions No by
Dobutamine myoview Normal 50 21 As above
protocol Saline mls minutes
Please indicate stressing agent to be used by placing an ‘X’ in the ‘Agent to Be Used’ box.
• If patient takes inhalers and / or has a history of asthma or other significant airways disease please
select dobutamine as the stressing agent to be used.
DRUGS TO BE GIVEN WHEN REQUIRED.
Drug Dose Route Admin by Date Time
Buccal suscard 2-5 mg Buccal For continuing chest pain after GTN spray.
GTN Spray 400 mcg Sublingual For immediate relief of chest pain.
Paracetamol 500mg- 1g Orally For non-cardiac pain.
Ventolin 1-2 puffs Inhaled For wheeziness.
Normal Saline 10 mls Intravenously Intravenous flush.
Drs Sig ……………….. Print Name ………………… Date …………………
No drugs will be given to the patient unless prescription sheet is signed and dated by referring doctor.
Refer to Medical Physics protocol and guidelines for detailed administration information.
SO WHAT HAPPENS NOW?
MYOCARDIAL PERFUSION SCAN
You have been assessed by the doctor in the Rapid Access Chest Pain Clinic and they feel that it is
necessary to further investigate the cause of your chest pain. This will be done by performing a
Myocardial Perfusion Scan.
This will be carried out in the Medical Physics Department at Bradford Royal Infirmary. Before
leaving the clinic today, you should have been given a date for this procedure to be performed but if
you have not, you will receive an appointment through the post within the next couple of days. If you
haven’t heard from the hospital within 7 working days of your visit, please telephone the secretary of
your named cardiology consultant.
WHAT DOES THE SCAN INVOLVE?
The scan itself looks at how well the blood is flowing to your heart muscle and is performed over 2
separate days. This is so that we can look at the blood flow to your heart on one day when it is in a
relaxed state and again when it is slightly stressed. To obtain the best information from this scan it is
important to do each part on a separate day.
On the first day of the test, a small amount of radioactive tracer will be injected into a vein in your
arm (this will hurt no more than having a routine blood test and the tracer is quite safe). The tracer is
taken up by the heart muscle and then a specialised camera is used to take pictures. The camera is
similar to an x-ray machine and will move slowly around the outside of your body whilst you are
lying on a couch for about 20 minutes.
For the second part of the test you will be given an injection that will “exercise” your heart. Your
heart and blood pressure will be monitored closely throughout this procedure.
It is best to wear something loose and comfortable for the test, preferably which unbuttons at the
HOW LONG WILL IT TAKE?
On the first day we will need you to rest in the waiting room for 30 minutes before we can inject the
tracer. Once you are given the tracer you should be ready to leave within 2 to 3 hours.
The second day of the test takes around the same time but without the 30 minute rest at the start.
HOW WILL I FIND OUT ABOUT THE RESULTS?
We cannot give you the results of the report on the day. The pictures and report will be sent to your
consultant and he will look at these and decide what, if any, further action needs to be taken. The
consultant will then write to your GP detailing the results and any recommendations. If you require a
further appointment in the hospital cardiology clinic, an appointment will be sent through the post to
you. This process can take up to 21 days.
If at any time, you have any queries, please do not hesitate to contact the secretary of your consultant.
Signature _________________________ Date _____________
EXERCISE TOLERANCE TEST
1. Diagnosis of chest pain (ALL AGES)
2. Risk stratification of myocardial ischaemia.
3. Objective assessment of symptoms and disability.
Indications 1 and 2 are CONTRA-INDICATED when the ST segment is obscured,
• Left ventricular hypertrophy
• Left bundle branch block
• Ventricular pre-excitation
Exercise electro-cardiograms MUST NOT be performed on patients who have:
1. Untreated, life threatening cardiac arrhythmia.
2. Unstable angina.
3. Acute myocardial infarction (within four days).
4. Severe aortic or mitral Stenosis.
5. Hypertrophic cardiomyopathy.
6. Severe pulmonary hypertension.
7. Acute illness (pulmonary embolism, pneumonia etc).
8. Marked hypertension (Systolic BP >180 mmHg or Diastolic BP >100)
9. Uncontrolled severe cardiac failure.
10. Recent cerebro-vascular accident (CVA) within 6 weeks.
11. The patient refuses the test.
12. A senior cardiac technician with ACLS qualification is not in the room and
one other technician/ nurse/ doctor is not in the room.
13. The crash trolley is not in the department.
14. The patient is unable to walk on the treadmill.
END POINTS FOR EXECISE TOLERANCE TESTING
ABSOLUTE END POINTS
The test must be terminated if any of the following occur:
1. ST segment depression of 3mm or more. Or 2 mm with chest pain.
2. ST segment elevation of 2mm or more. Rapid ST Elevation with chest pain, the test
should be discontinued immediately.
3. A fall in systolic BP (20mmHg) or fall in heart rate (15bpm).
4. Serious rhythm disorders
II. 2nd/3rd degree AV block
III. Increasing degree of AV or SA block
V. AF fibrillation/ flutter
VI. Any escape or accelerated ectopic rhythm
5. Marked Hypertension SBP >230mmHg
6. Signs of peripheral circulatory insufficiency
ii. Diminished pulse
iii. Clammy skin
iv. Staggering gait
v. Confusion or disorientation
Relative end points
2. Severe exercise limitation symptoms
• Chest Pain
3. Increasing frequency of ventricular or supraventricular extrasytolic beats (25%)
RAPID ACCESS CHEST PAIN CLINIC
PROCEDURE FOR PATIENTS UNFIT FOR TREADMILL DUE TO OTHER
This procedure is only to be followed where patients clinical diagnosis and future
management requires exercise stress testing.
This procedure will be followed when:
• Patients cannot be exercised during their appointment for Rapid Access Chest
Pain Clinic due to another pre-existing medical complaint and they are not
suitable to be booked for myocardial perfusion scan.
1. Patients will be advised that an exercise test will be arranged as soon as they
are able to complete the test.
2. A letter will be sent to the GP/Consultant whose care they are under (e.g.
Surgeon) advising them to write to the Rapid Access Chest Pain Clinic at the
Bradford Royal Infirmary as soon as the patient is well enough to undertake
stress testing. The letter will include:
• Information on stress testing to aid this decision
• An agreed management plan for the patient
• Phone contact details of the Chest Pain Clinic Nurses should problems arise.
• The GP/Consultant will also be advised that the chest pain clinic nurses will
contact them by phone every two weeks to check on progress and expedite the
stress test as soon as practical.
3. The patient will be advised of the management plan:
• Immediate treatment explained.
• Information given relevant to their diagnosis – including action to take if they
experience further chest pain.
• Contact details for the chest pain clinic nurses.
4. The patients details will be recorded on an excel database:
• Date of attendance at the clinic
• Reason they were unable to walk on the treadmill
• Date to next contact the GP/Consultant regarding fitness and suitability to re-
Authors/ Development Team Dr Steven Lindsay/Sister Vicky Watson/ Sister