Richard Grocott Mason

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Reginald Eric Barton
6 years ago
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1 Richard Grocott Mason

2 What to do with a 50 year old man with chest pain? Does the pain sound cardiac? Is this a possible acute coronary syndrome? Does patient have a previous cardiac history?

3 Natural history of coronary artery disease 1 st event Recurrent events/interventions 1 º prevention 2 º prevention/disease management

4 History is crucial Pain characteristics Location Radiation Duration Exacerbating factors Relieving factors Similarity to previous angina Diabetics & elderly atypical symptoms Language/communication problems may modify history Overall cardiovascular risk profile

5 Joint British Societies CVD Risk Prediction Chart

6 What to do with a 50 year old man with chest pain? Does the pain sound cardiac? YES Is this a possible acute coronary syndrome? YES Pain at rest or minimal effort Patient unwell/syncope/hypotension/arrhythmia Refer directly to A&E via 999

7 Hamm Lancet 358:1533,2001 Presentation Working Dx Ischemic Discomfort Acute Coronary Syndrome Davies MJ Heart 83:361, 2000 ECG No ST Elevation NSTEMI ST Elevation Biochem. Marker Final Dx Unstable Angina Myocardial Infarction NQMI Qw MI

8 Acute Anterior MI

9 Primary PCI for Acute MI 54 year old patient with 1 hour of chest pain Direct admission to catheter lab at Harefield hospital via LAS Acute occlusion After stent

64 year old man No previous cardiac history 2 days of intermittent chest pain ECG on admission normal Inferior T wave inversion on day 2 Troponin I

10 64 year old man No previous cardiac history 2 days of intermittent chest pain ECG on admission normal Inferior T wave inversion on day 2 Troponin I slightly elevated 12 hours post admission Ex smoker 5 years ago Not diabetic TC 5.4 mmol/l Normal BP No FH of CAD Severe stenosis mid RCA + thrombus

11 What to do with a 50 year old man with chest pain? Does the pain sound cardiac? YES Possible acute coronary syndrome? NO Does patient have a previous cardiac history? YES refer to Cardiology clinic NO refer to RACPC

12 RACPC ~450 patients/year New onset chest pain Seen within 2 weeks Referral GP or A&E SpR or Molly Consultant supervised All have ECG Most have ETT Some Echo/bloods/CXR Previous cardiac history/complex issues General Cardiac clinic

13 Detection of Coronary artery disease

14 Exercise ECG Need to be able to walk on treadmill Target heart rate (220 age) Need to induce ischaemia Less useful if resting ECG is abnormal False positive tests common Less specific if done on treatment Need to know pre test probability of disease

15 ST Depression at peak

16 SP ETT 9minsBRUCE protocol Symptomatic with chest pains

17 SP ETT 9minsBRUCE protocol Symptomatic with chest pains

18 Ostial RCA stenosis LMS occluded Occluded L subclavian & L common carotid 18 yr female Takayasu s arteritis Treated with CABG

19 Stress More sensitive/specific than ETT Don t need exercise Useful if abnormal ECG Rest Information of LV function (regional & global) Viability information Similar info to stress echo

20 CT and coronary disease Sept 2005

CT Coronary Calcification 1400 1200 1000 800 600 400 200 Men 25th

1200 1000 800 600 400 200 Women 0 30-34 35-39 40-44 45-49 50-54

21 CT Coronary Calcification Men 25th precentile 50th percentile 75th percentile 90th percentile Women Age Age

23 For whom is CT angiography useful? Avoid invasive angiogram Restudy after CABG Asymptomatic patients with low/intermediate risk Atypical chest pain where ETT inconclusive and low likelihood of CAD To rule out coronary disease Investigation of coronaries in heart failure

24 Disadvantages of CTA Radiation dose Contrast nephropathy Not a functional test Overestimates disease can drive anxiety and intervention The Indian test syndrome Heavy calcification may make it difficult to determine stenosis severity Not great to assess previous stents

26 Coronary angiography + PCI

27 Long term Mx of CHD Disease modifying treatments Stents only treat localised regions of coronary tree Bypass grafts treat longer regions Drugs affect all regions Therefore long term drug treatment is essential in all patients with CHD

28 Disease modifying treatments Cholesterol reduction BP reduction Antiplatelet drugs Angiotensin renin modulation Smoking cessation Glycaemic control Exercise Weight control

29 angina 92 year old lady with very limiting

30 Multiples of the URL Upper reference limit Cardiac troponin after classical AMI CK MB after AMI Cardiac troponin after microinfarction Days After Onset of AMI Modified from: ESC/ACC Comm MI redefined JACC 36: 959,2000 Wu AH et al. Clin Chem 1999;45:1104.

31 Causes of elevated Troponin Acute coronary syndrome (MI) Acute PE Chronic renal failure Pericarditis/Myocarditis Tachycardias Type A Aortic dissection Acute Heart Failure Chronic Heart Failure Strenuous exercise Cardiotoxic chemotherapy EP Ablation/ICD shock Cardiac infiltrative disease (amyloid) Cardiac contusion (blunt chest wall trauma) Sepsis/Critically ill patients Rhabdomyolysis Not a useful test for primary care

32 Chest pain conclusions Coronary artery disease is common History of chest pain is crucial Appropriate use & interpretation of tests is important Know the question Remember other causes of chest pain About 2/3 patients referred to RACPC don t have angina Rule out can be as important as early diagnosis Good opportunity for advice to reduce CV risk factors

33 What issues to consider?

34 Types of cardiac surgery Isolated Coronary bypass grafts Valve repair or replacement Combined CABG + valve procedure Aortic surgery (Transplantation) (Congenital heart disease surgery)

35 Complications post cardiac surgery Atrial arrhythmias Wound infections Chest infection Pericardial effusion DVT Anaemia/bleeding Infective endocarditis Early graft occlusion Aneurysm development

36 Secondary prevention TC < 4; LDL < 2 mmol/l BP < 130/80 Regular exercise Smoking cessation Weight control Optimal diabetic control Consider family screening for FH or advice re primary prevention where relevant

37 Cardiac procedures Coronary angioplasty TAVI (transcutaneous aortic valve intervention) EP Ablation Device therapy Pacemaker single/dual/biventricular ICD PFO closure

38 Final comments RACPC gives you open access to ETT + what ever other cardiac test is appropriate Early diagnosis and treatment of ACS saves lives Aggressive disease modifying treatments for all after ANY vascular disease diagnosis Any concerns after cardiac intervention please ring for advice

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