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MANAGING CHEST PAIN

MANAGING CHEST PAIN. Dr Carl Shakespeare, Consultant Cardiologist MD FRCP FACC FESC BMI The London Independent Hospital Queen Elizabeth Hospital. The Killers. Coronary Disease Aortic Dissection Pulmonay Embolism. Cardiac Entrapment. Nodule. Pericarditis. Atelectesis.

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MANAGING CHEST PAIN

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  1. MANAGING CHEST PAIN Dr Carl Shakespeare, Consultant Cardiologist MD FRCP FACC FESC BMI The London Independent Hospital Queen Elizabeth Hospital

  2. The Killers • Coronary Disease • Aortic Dissection • Pulmonay Embolism

  3. Cardiac Entrapment Nodule Pericarditis Atelectesis Hiatus Hernia PE GERD

  4. NICE Guidelines The diagnosis of stable angina is made from: • a clinical assessment alone • or in combination with a diagnostic test • NICE Clinical Guideline 95. 2010 www.nice.org.uk/guidance/C G95

  5. Exclude Other Causes • Cardiac Causes • Hypertrophic Cardiomyopathy • Aortic Stenosis • Myo-Pericarditis • Non-Cardiac Causes • Musculoskeletal • Gastric • Pulmonary causes (incl: PE, pneumonia )

  6. Non Anginal Type Symptoms • Continuous or prolonged symptoms • Unrelated to activity • Pleuritic • Gastric: relationship to eating, nocturnal

  7. Making The Diagnosis “Pre-test probability” has emerged when trying to diagnose angina. • Typicality of symptoms • Age • Risk factors • ECG abnormality

  8. Pre-Test Probability The method of: “% Likelihood of having coronary disease” • <10% • 10-29% • 30-60% • 60-90% • >90% Pryor DB et al, Annals of Internal Medicine 1993 118; 81-90

  9. “Typicality” of Symptoms Angina Pain is: • Constricting/tight in front of chest, neck, shoulders, jaws or arms • Induced by physical exertion/mental stress • Relieved by GTN in < 5 minutes Typical Angina: all the above symptoms Atypical Angina: two of the above features Not Angina: one or none of the above

  10. Atypical Symptoms... • Ischaemic equivalents: Dyspnoea on exertion Reduced effort tolerance Palpitations • Atypical Description: (especially women!) Shortness of breath, palpitations Nausea, indigestion, Fatigue, sweating, Back and jaw pain

  11. Cardiac Symptoms in Women • Less “exertional symptoms” than men • More atypical: prolonged, neck, throat, rest • More angina less angiographic disease (50%) • 50% continue to have chest pain, hospitalisation, and diagnostic uncertainty. • 2X increase in non-fatal MI • Common: angiographically normal NSTEMI (10-25%)

  12. Risk Factors • The presence of risk factors may add to the diagnosis • The absence of risk factors doesn’t exclude the diagnosis (25% coronary events occur in the absence of significant risk factors) • High risk includes: Smoking, Diabetes, Lipids RACE?

  13. ECG • Don’t rule out angina based on normal ecg • Consider: LBBB Pathological Q waves ST, or T wave abnormalities • An abnormal ECG increases the probability in any group

  14. Identifying CV Risk • Age • LDL-c • Smoking • HDL • Systolic Blood Pressure • Diabetes • Triglycerides • Family History • Snoring • Poor church attendance

  15. Age Increased Pre Test Probability in any group • Male> 70 years 90% in typical and atypical symptoms. • Women > 70 years • (atypical) 60-90% • (typical + high risk) >90%

  16. Pre Test Probability

  17. (10-90%) Pre Test Probability • Blood Tests to exclude exacerbants • Rx Aspirin • Consider Diagnostics based on PPP • Treat risk factors • Treat as Angina (>90%) • Rx as Angina Unstable Angina

  18. PPP (10-29%) Offer Calcium Scoring (low radiation 1mSv) = 0 : Investigate other causes 1-400: Cardiac CT Yes:Rx as Angina Angiography U: Functional Imaging No: Other causes >400 Cardiac Catheterisation

  19. Calcium Scoring

  20. Cardiac CT Angiography The diameter of the Total lesion (bulk) predicts events Healing – Remodeled Bulky – at risk Bulky – inflamed

  21. PPP (30-60%) Offer Non-invasive Functional Imaging Reversible Myocardial Ischaemia? Uncertain Yes No Cardiac Rx: Angina Other Catheter causes

  22. Non-Invasive Functional Testing Consider availability and expertise: • Myocardial Perfusion Scintigraphy SPECT • Stress Echocardiography • Cardiac MRI with perfusion imaging

  23. PPP (60-90%) Consider Cardiac Catheterisation No Yes Offer Functional Imaging Offer Cardiac Catheter Reversible Ischaemia Significant Disease Other Ix Rx as Angina Functional Other Ix Imaging

  24. Cardiac Catheterisation • Risks • Proceed to PCI • Value in women

  25. > 90% Probability • No need for investigations • Treat for Angina Further Management: • Progressive Symptoms • Intolerance to medication ANGIOGRAPHY • Associated Symptoms

  26. What About the Exercise Test? • Poor diagnostic test? • Functional Assessment • Therapeutic Value • Effort Tolerance • Prognostic value • Especially in women • Chronotropic response

  27. Treatment • Treat with Aspirin and Beta blocker • Be guided by symptoms • Refer to Rapid access Chest Pain Clinic • Treat before considering intervention

  28. Assumptions about Women • “... Their hormones protect them....” • “... Women represent less risk than men..” • “... Women’s tests are usually false positives

  29. Realities about Women • Their hormones do protect them until age 45 • Women’s incidence then becomes similar to men’s • Women’s outcomes are worse than men’s Women behave differently to men

  30. Pathophysiology- Differences • Less anatomical obstructive coronary disease • Erosive Coronary disease • Microvascular dysfunction • Abnormal Coronary Reactivity

  31. Novel Risk Factors • Traditional risk factors underestimate IHD risk in women • Higher CRP in women • Inflammatory basis • Raised autoimmunity • hsCRP relates to: • DM II • Metabolic syndrome • Hormone deficiency

  32. Worse Outcomes • Women not taken seriously • Less diagnostic tests • Angiographically normal • Less adherence to guidelines • Clustering of risk factors + novel risk factors, and loss of oestrogen activity • Greater exposure to inflammation

  33. Coronary Reactivity: Microvascular Dysfunction Angina + Ischaemic Test + Normal Coronaries • Greater frequency of plaque erosion • Retinal artery narrowing (clinical indicator in women) • More prominent positive remodelling • More microvascularischaemia:

  34. Endothelial Dysfunction • Key component of atherogenesis; predicts CV events • Assessed with: coronary, Brachial artery vasodilatation Nitric oxide dependent pathway • Abnormal activity associated with 4x mortality • Restoration of Endothelial Function associated with improved outcome • Abnormal reactivity not associated with risk factors Bonetti PO JACC 2004 44; 2137

  35. Peripheral Hypereactivity Rubenstein R 2010 EHJ 31:1142

  36. Treatment in Women • Restoration of endothelial dysfunction associated with improved prognosis • Risk Factor Modification • Asprin + Statin + ACEI • Imipramine • Ranolazine

  37. Statistics • No decrease in sudden death in women • Symptomatic women have more persisting symptoms • Higher hospitalization • Greater adverse outcomes than men despite < significant anatomical disease and > systolic function Shaw LJ Circulation 2008 117, 1787

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