MANAGING CHEST PAINDr Carl Shakespeare, Consultant Cardiologist MD FRCP FACC FESC

BMI The London Independent Hospital Queen Elizabeth Hospital

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The Killers

Coronary Disease Aortic Dissection Pulmonay Embolism

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Pericarditis

GERD

Hiatus Hernia

Atelectesis

NoduleCardiac Entrapment

PE

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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

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Exclude Other Causes

Cardiac Causes Hypertrophic Cardiomyopathy Aortic Stenosis Myo-Pericarditis

Non-Cardiac Causes Musculoskeletal Gastric Pulmonary causes (incl: PE, pneumonia )

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Non Anginal Type Symptoms

Continuous or prolonged symptoms Unrelated to activity Pleuritic Gastric: relationship to eating, nocturnal

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Making The Diagnosis

“Pre-test probability” has emerged when trying to diagnose angina.

Typicality of symptoms

Age

Risk factors

ECG abnormality

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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

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“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

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Atypical Symptoms...

Ischaemic equivalents:Dyspnoea on exertionReduced effort tolerancePalpitations

Atypical Description: (especially women!)Shortness of breath, palpitations

Nausea, indigestion,

Fatigue, sweating,

Back and jaw pain

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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%)

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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?

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ECG

Don’t rule out angina based on normal ecg Consider: LBBB

Pathological Q wavesST, or T wave abnormalities

An abnormal ECG increases the probability in any group

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Identifying CV Risk

Age LDL-c Smoking HDL Systolic Blood

Pressure Diabetes Triglycerides Family History Snoring Poor church

attendance

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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%

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Pre Test Probability

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(10-90%) Blood Tests to exclude exacerbants Rx Aspirin Consider Diagnostics based on PPP Treat risk factors Treat as Angina

(>90%) Rx as Angina Unstable Angina

Pre Test Probability

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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

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Calcium Scoring

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Cardiac CT Angiography

Bulky – at risk

Bulky – inflamed

Healing – Remodeled

The diameter of the Total lesion (bulk) predicts events

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PPP (30-60%)

Offer Non-invasive Functional Imaging

Reversible Myocardial Ischaemia?

Uncertain Yes No

Cardiac Rx: Angina Other

Catheter causes

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Non-Invasive Functional TestingConsider availability and expertise:

Myocardial Perfusion Scintigraphy SPECT Stress Echocardiography Cardiac MRI with perfusion imaging

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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

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Cardiac Catheterisation

Risks Proceed to PCI Value in women

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> 90% Probability

No need for investigations Treat for Angina

Further Management: Progressive Symptoms Intolerance to medication ANGIOGRAPHY Associated Symptoms

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What About the Exercise Test?

Poor diagnostic test? Functional Assessment Therapeutic Value Effort Tolerance Prognostic value Especially in women Chronotropic response

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Treatment

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

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Assumptions about Women

“... Their hormones protect them....”

“... Women represent less risk than men..”

“... Women’s tests are usually false positives

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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

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Pathophysiology- Differences

Less anatomical obstructive coronary disease

Erosive Coronary disease

Microvascular dysfunction

Abnormal Coronary Reactivity

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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

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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

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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 microvascular ischaemia:

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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

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Peripheral Hypereactivity

Rubenstein R 2010 EHJ 31:1142

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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

Shaw LJ Circulation 2008 117, 1787