Chest pain management. Ruvin Gabriel and Niels van Pelt August 2011

Transcription

1 Chest pain management Ruvin Gabriel and Niels van Pelt August 2011

2 Introduction Initial assessment Case 1 Case 2 and 3 Comparison of various diagnostic techniques Summary

3 1-2 % of GP consultations are for chest pain Majority are non cardiac Causes of chest pain ( in General practice) Musculoskeletal ~ 33% Reflux oesphagitis ~15% Stable angina ~10% Acute coronary syndromes~ 1.5% If you strongly suspect ACS, then transfer patient with urgency to hospital via ambulance

4 ..History remains the most important technique for distinguishing among the many causes of chest discomfort.. Eugene Braunwald Levine s sign

5 Probability of cardiac chest pain depends most strongly on character of chest pain, age and gender

6 Initial assessment- history and physical examination ~90% of cases, organic causes (cardiac, GI, pulmonary) can be distinguished (om non organic If suspect cardiac chest pain J Gen Intern Med 1997;12:459 ECG, troponin Refer (acutely or as outpatient)

7 ECG ST changes ( ST depression or elevation), T wave inversion,lbbb, q waves are powerful indicators of acute MI and underlying IHD. Non specific changes usua)y not important may be normal even in presence of severe 3 vessel disease. Up to 20% of patients with acute coronary syndrome have a normal ECG

8 Troponin Highly sensitive- even healthy individuals have detectable troponin Newer assays x10 more sensitive. Cutoff value of 99th percentile of normal pop. 2-4% of normal pop have an abnormal troponin level Detects myocardial necrosis- 80% abnormal 2-3 hrs a+er onset of Acute MI Associated with significant increase in major cardiac events ~30% in 30 days Chest discomfort and elevated troponin hospital admission

9 Level of troponin associated with risk of mortality

10 Not a) troponin leaks related to acute coronary syndrome Myocardial infarction defined as

11 Clinical definition of different types of myocardial infarction Type 1 Spontaneous myocardial infarction (MI) related to ischemia due to a primary coronary event such as plaque erosion and/or rupture, fissuring, or dissection Type 2 MI secondary to ischemia due to either increased oxygen demand or decreased supply, eg, coronary artery spasm, coronary embolism, anaemia, arrhythmias, hypertension, or hypotension Type 3 Sudden unexpected cardiac death, including cardiac arrest, often with symptoms suggestive of myocardial ischemia, accompanied by presumably new ST elevation, new left bundle branch block, or evidence of fresh thrombus in a coronary artery by angiography and/or at autopsy, but death occurring before blood samples could be obtained or at a time before the appearance of cardiac biomarkers in the blood Type 4 MI associated with percutaneous coronary intervention Type 5 MI associated with coronary artery bypass grafting

12 Causes of troponin leak other than acute myocardial infarction

13 Chest pain associated with troponin leak warrants further investigation as prognosis is altered irrespective of underlying condition ( ACS, PE, myocarditis, aortic dissection) Discuss patients- advice (om the on ca) cardiologist at the Auckland Heart Group

14 Case 1 47 Malaysian man assessed at his own request. His wife noted to have an ASD Very mild exertional discomfort (retrospective) Low cardiovascular risk (Heart forecaster 7%) Normal exam Exercise treadmi) test 9 min 30 mild ST changes and mild chest pressure

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16 Impression-? significant underlying CAD but relatively low pretest probability opted for CT coronary angiogram

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18 Occluded LAD

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20 Imp: Significant CAD with occlusion of the proximal LAD CT coronary angiography exce)ent method to detect ( and rule out) significant CAD Very high sensitivity and specificity a)ows detection of non obstructive coronary plaque ( not detected by other modalities) which may influence prognosis and management

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23 Case 2 48 yr old man with exertional SOB ( sma) inclines, walking dog) and mild chest tightness Previously we), running marathon 3 months earlier Cardiovascular risk 4% O/E- Ta), BMI 25.Normal exam ECG- non specific T wave inversion

24 Exercise stress echocardiogram normal baseline echo Exercised to 9 minutes but was SOB (om stage 1. No chest discomfort Post exercise- no inducible ischaemia. Peak flow 550l/ min Imp- unexplained exertional SOB..? underlying coronary ischaemia or pulmonary disease again opted for a CT coronary angiogram...

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26 Pulmonary embolus

27 Diagnosis- large spontaneous pulmonary embolus Haematology review - negative thrombophilia screen length of anticoagulation - yet to be determined. Dabigatran may be an option

28 Case 3 43 year old man Flu like i)ness, URTI symptoms Chest pain, central, pleuritic in nature initia)y, increasing in severity radiating to neck, better on sitting forward ECG - widespread concave ST elevation (0.5-1mm) Troponin elevation

29 Cardiac MRI

30 Cardiac MRI

31 Cardiac MRI

32 Chronic/Stable Chest Pain Which Investigation? TEST Sens Spec Scenario Exercise ECG 60% 85% Accesible Exercise Stress Echo 85% 85% ECG abnorm, SOB, HT, women Dobutamine Stress Echo 80% 90% Unable to exercise CT coronary angio 95% 95% False +ve ETT?, low to int pretest,?radiation

33 If asymptomatic CT coronary calcium score first?

34 Take Home Message ACUTE CHEST PAIN! History is the key! Send to Hospital if concern for Acute Coronary Syndrome ECG - ST elevation or depression, T wave inversion, Q waves Any troponin elevation requires investigation (high sensitivity assay) Troponin elevation does not always mean ACS

35 Take Home Message CHEST PAIN Investigation tools available: Exercise ECG testing Stress Echocardiography CT coronary angiography Cardiac MRI Invasive coronary angiography

36 Thank You Niels van Pelt and Ruvin Gabriel