General practice advice for the management of suspected angina

The Wessex Regional Cardiac Unit (WRCU) has written to all practices that referred a patient to the Rapid Access Chest Pain Clinic and who was not seen prior to the cessation of face to face outpatient consultations. The letter detailed that, should the GP have a significant concern that the patient has angina, they should prescribe appropriate anti angina and prevention medication. This is due to the fact that further investigations which might normally be recommended, such as stress testing, CT scanning or angiography, are not available for outpatient investigation especially during the surge phase. This will allow patients who do have coronary disease to be appropriately managed and protected whilst those who may not are unlikely to come to harm with appropriate medication.

Any patient who becomes unstable with suspected ACS should be admitted to hospital through the normal pathway of care.

To further support GPs with decision making a Rapid Advice and Guidance service has been introduced at a consultant level. The relevant consultant can still ask for investigations if deemed essential. However, in patient with chronic coronary syndromes, there is no evidence of prognostic benefit from intervention and this is reserved for those who continue to struggle despite medical therapy. As such, the unit is not currently undertaking stress echo but does have access to both MRI and CT scanning, although the latter is limited as this is a key COVID respiratory investigation.

Through the A&G process, the unit will admit patients to hospital where appropriate, and can also provide a limited telephone consultation if this is felt necessary by the responsible consultant. However, the vast majority of patients will be both protected and in many cases substantially improved with the medication and not need further assessment, even post COVID.

The key message for general practice is that protecting patients with suspected coronary disease and angina with medical therapy is the best management at present. If, having done so, or if the situation is more complex, the advice and guidance process is available to support.  The new way of working through the A&G process is likely to be one of the things retained, along with more streamlined and virtual outpatient clinics, after the Covid crisis.