Multimorbidity in patients with undifferentiated chest pain attending an advanced nurse practitioner integrated community chest pain assessment clinic- a snapshot
S Ingram, M WilliamsAbstract
Background
The Advanced Nurse Practitioner (ANP) integrated community chest pain clinic (ICCPC) provides an alternative for General Practitioners to refer patients with non-acute chest pain, providing timely assessment and emergency dept. avoidance. Referral criteria are non-acute chest pain ≥ 30 years of age. The role of the ANP is to differentiate between a non-anginal versus anginal aetiology.
Purpose
Multimorbidity (MM) is defined by NICE (2016) as the presence of two or more long-term health conditions in an individual. Multimorbidity is frequently associated with chronic disease i.e. heart failure and known coronary artery disease (CAD), but less is known about MM in undifferentiated chest pain population. The aim was to assess the level of MM in this cohort and any relationship with the ESC estimation of clinical likelihood of obstructive CAD (CAD risk).
Method
A 4-month retrospective audit of 158 patients assessed by the ANP in the community chest pain clinic was performed. MM was calculated utilising the Charleston co-morbidity index (CCI) and the Measuring Multimorbidity index (M3). ESC chronic coronary syndrome guidelines (Vrints et al. 2024) calculated risk factor weighted risk clinical likelihood of obstructive CAD risk. Spearman’s rho test was used to examine if any relationship existed between CAD risk and CCI and M3 scores. Ethical approval was given by the department of quality, safety and risk management.
Results
The average age was 59 yrs, 45% of whom were ≥ 60 yrs. The CAD risk allocated was, very low risk 73% (n=72), low risk 33% (n=52) and moderate risk 21% (n=33). As per the M3, 4 (2.5%) patients had no comorbid conditions with n=71 (44%) of CCI scores indicating high MM. Age does not factor in the M3 score. Both CCI and M3 were statistically significant for CAD risk and MM at <.001. There is a correlation between a higher risk of CAD and CCI and M3. The correlation coefficient for CAD risk /CCI is 0.597, a strong positive relationship. The correlation coefficient for CAD risk /M3 is 0.352, a medium strength positive relationship.
Conclusion
In this ANP assessed community-based cohort of patients with undifferentiated chest pain, multimorbidity was a feature of this cohort. The ESC risk of CAD was correlated with the patient’s multi-morbidity utilising both scores. Increasing age is a factor in the CCI score and almost half of this population were ≥ 60 years. This community population are often complex to assess, with the added potential impact of multimorbidity on assessment, differential diagnosis, investigation and management. Measuring MM is therefore a vital component of patient assessment and community-based workload management.