Referral criteria: new or recent onset of EXERTIONAL (within 3 months symptom onset) chest pain suggestive of ischaemic heart disease (IHD) or worsening symptoms in a patent with known IHD who is not under active follow-up by a cardiologist. We aim to see patients within two weeks of referral. Referrals that will be rejected: - incomplete assessment of pain and symptoms and/or missing NHS number

Is there?

Uncontrolled atrial fibrillation or flutter	?	Recent cardiac investigations?

A murmur or a history of congenital heart disease?	Significant heart failure?	Uncontrolled hypertension (BP > 180 over 100 mmHg)?	Syncope/presyncope?

If the answer is yes to any of the questions above the patient is unlikely to be suitable for Rapid Access Chest Pain Clinic. Please consider referral to other cardiology services.

Name:	Referring Dr
DOB:	01/07/2015
Address	Address
Tel No:	Tel No:
Hospital No:	Fax No:
NHS Number:	Referral Date	31/07/2015
Interpreter required? If so please state language

Is the Pain?

Constricting discomfort in the front of the chest, or in the neck, shoulders, jaw, or arms

precipitated by physical exertion

Relieved by rest or GTN within about 5 minutes.

Three of the features above are defined as typical angina

Two of the three features above are defined as atypical angina.

One or none of the features above are defined as non-anginal chest pain

Use clinical assessment and typicality of anginal pain features to estimate the likelihood of CAD using table 1 below

Hi = High risk = diabetes, smoking or hyperlipidaemia (total cholesterol > 6.47 mmol/litre). Lo = Low risk = none of these three.

Men >70 years with atypical or typical symptoms CAD estimate > 90%. Women >70 years estimate of 61-90% except women at high risk and typical symptoms risk is 90%. NB ethnicity does not alter typicality of symptoms. (Please note that diabetic and elderly patients may present with angina equivalents i.e breathlessness)

Table 1	Non-anginal chest pain	Atypical angina	Typical angina
Men	Women	Men	Women	Men	Women
Age (years)	Lo	Hi	Lo	Hi	Lo	Hi	Lo	Hi	Lo	Hi	Lo	Hi
35	3	35	1	19	8	59	2	39	30	88	10	78
45	9	47	2	22	21	70	5	43	51	92	20	79
55	23	59	4	25	45	79	10	47	80	95	38	82
65	49	69	9	29	71	86	20	51	93	97	56	84
Please state likelihood of CAD based on table 1 assessment Please Enter Blood pressure mmHg systolic/ mmHg diastolic People with less than 10% pre-test probability will not be seen in rapid access chest pain clinic consider alternative diagnosis
Relevant Past Medical History
Please attach information if less than 3 months old on lipid profile, FBC,ECG, ECHO, TFT, U&E. It is preferred that full lipid profile and recent FBC is available before clinic.
Please attach latest prescription to the referral form
It is the referring clinician responsibility to initiate the appropriate medication prior to clinic referral. Fax form : 0208 321 5333 or email WMU-tr.westmidadmin14@nhs.net Telephone : 0208 321 5610