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GPs' emergency referrals for chest pain 'justified'

By Rob Finch

Emergency referrals are justified for patients with suspected acute coronary syndrome, according to new Government-funded research.

The Health Technology Assessment on chest pain in primary care published last week recognised the difficulties GPs face when judging whether a patient's chest pain is of cardiac origin.

The assessment ­ which will be used to inform the development of NICE guidance ­ will help ease pressure on GP emergency referrals which have been under intensifying scrutiny since the Prime Minister accused GPs of 'misusing' them in 2000.

The assessment team, led by Dr Jonathan Mant of the department of primary care and general practice at the University of Birmingham, identified no clinical features that had a strong predictive value in ruling out acute coronary syndrome.

GPs were therefore justified in urgently referring patients suspected to have the condition for further assessment in a specialist setting ­ regardless of any ECG results, it said.

The two most useful clinical features for GPs to use were pleuritic pain and pain on palpitation, the assessment said.

For myocardial infarction, the only key diagnostic sign was ST elevation on an ECG. Only a completely normal ECG was useful in ruling out MI, it said.

ECG investigation of coronary heart disease was found to be only of limited value although an exercise ECG was superior to a resting ECG.

The assessment stressed the importance of inpatient assessment for suspected coronary heart disease and rapid-access chest pain clinics for suspected acute coronary syndrome.

It called for further research to establish the best way of triaging patients with suspected acute coronary syndrome.

It also called for a study to ascertain the cost-effectiveness of pre-hospital thrombolysis in rural areas.

Dr Scott Turner, a GP in Dereham, Suffolk, and a hospital practitioner in A&E at the Norfolk and Norwich University Hospital Trust, said: 'Sometimes, it's very obviously cardiac and it's easy to make an emergency referral. But where you are uncertain, there is little you can do to

diagnose a cardiac problem.'

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