Transcript 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
v
Cardiac Entrapment
Nodule
Pericarditis
Atelectesis
v
Hiatus
Hernia
PE
GERD
NICE Guidelines
The diagnosis of stable angina is made from:
 a clinical assessment alone
 or in combination with
a diagnostic test
v
NICE Clinical Guideline 95. 2010 www.nice.org.uk/guidance/C G95
Exclude Other Causes
 Cardiac Causes
 Hypertrophic Cardiomyopathy
 Aortic Stenosis
 Myo-Pericarditis
 Non-Cardiac Causes
v
 Musculoskeletal
 Gastric
 Pulmonary causes (incl: PE, pneumonia )
Non Anginal Type Symptoms
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Continuous or prolonged symptoms
Unrelated to activity
Pleuritic
Gastric: relationship to eating, nocturnal
v
Making The Diagnosis
“Pre-test probability” has emerged when trying to
diagnose angina.
 Typicality of symptoms
 Age
 Risk factors
 ECG abnormality
v
Pre-Test Probability
The method of:
“% Likelihood of having coronary disease”
 <10%
 10-29%
 30-60%
 60-90%
 >90%
v
Pryor DB et al, Annals of Internal Medicine 1993 118; 81-90
“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 < 5v minutes
Typical Angina: all the above symptoms
Atypical Angina: two of the above features
Not Angina: one or none of the above
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
v
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
v
 Common: angiographically
normal NSTEMI (10-25%)
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
v
RACE?
ECG
 Don’t rule out angina based on normal ecg
 Consider: LBBB
Pathological Q waves
ST, or T wave abnormalities
v
 An abnormal ECG increases the probability in any group
Identifying CV Risk
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Age
LDL-c
Smoking
HDL
Systolic Blood Pressure
Diabetes
Triglycerides
Family History
Snoring
 Poor church attendance
v
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%
v
Pre Test Probability
v
Pre Test Probability
(10-90%)
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Blood Tests to exclude exacerbants
Rx Aspirin
Consider Diagnostics based on PPP
Treat risk factors
Treat as Angina
v
(>90%)
 Rx as Angina
Unstable Angina
PPP (10-29%)
Offer Calcium Scoring (low radiation 1mSv)
= 0 : Investigate other causes
1-400:
Cardiac CT
Angiography
Yes: Rx as Angina
U: Functional Imaging
v No: Other causes
>400 Cardiac Catheterisation
Calcium Scoring
v
Cardiac CT Angiography
v
The diameter of the
Total lesion (bulk)
predicts events
Bulky –
at risk
Bulky –
inflamed
Healing –
Remodeled
PPP (30-60%)
Offer Non-invasive Functional Imaging
Reversible Myocardial Ischaemia?
Uncertain
Cardiac
Catheter
Yes v
No
Rx: Angina
Other
causes
Non-Invasive Functional Testing
Consider availability and expertise:
 Myocardial Perfusion Scintigraphy SPECT
 Stress Echocardiography
 Cardiac MRI with perfusion imaging
v
PPP (60-90%)
Consider Cardiac Catheterisation
No
Yes
Offer Functional Imaging
Reversible Ischaemia
Other Ix
Offer Cardiac Catheter
v
Rx as Angina
Imaging
Significant Disease
Functional
Other Ix
Cardiac Catheterisation
 Risks
 Proceed to PCI
 Value in women
v
> 90% Probability
 No need for investigations
 Treat for Angina
Further Management:
 Progressive Symptoms
 Intolerance to medication
 Associated Symptoms
v
ANGIOGRAPHY
What About the Exercise Test?
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Poor diagnostic test?
Functional Assessment
Therapeutic Value
Effort Tolerance
 Prognostic value
 Especially in women
 Chronotropic response
v
Treatment
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Treat with Aspirin and Beta blocker
Be guided by symptoms
Refer to Rapid access Chest Pain Clinic
Treat before considering intervention
v
Assumptions about Women
 “... Their hormones protect them....”
 “... Women represent less risk than men..”
 “... Women’s tests are usually
false positives
v
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
v
Women behave
differently to men
Pathophysiology- Differences
 Less anatomical obstructive coronary disease
 Erosive Coronary disease
 Microvascular dysfunction
v
 Abnormal Coronary Reactivity
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
v
Worse Outcomes
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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
v
 Greater exposure to inflammation
Coronary Reactivity: Microvascular
Dysfunction
Angina + Ischaemic Test + Normal Coronaries
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Greater frequency of plaque erosion
Retinal artery narrowing (clinical indicator in women)
More prominent positive remodelling
More microvascular ischaemia:
v
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
v
associated with improved outcome
 Abnormal reactivity not associated
with risk factors
Bonetti PO JACC 2004 44; 2137
Peripheral Hypereactivity
v
Rubenstein R 2010 EHJ 31:1142
Treatment in Women
 Restoration of endothelial dysfunction associated with
improved prognosis
 Risk Factor Modification
 Asprin + Statin + ACEI
 Imipramine
 Ranolazine
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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
v
Shaw LJ Circulation 2008 117, 1787