Dr Alasdair Patrick. Mr Patrick Gladding Cardiologist and Internal Medicine North Shore Hospital Auckland
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1 Dr Alasdair Patrick Gastroenterologist and General Physician Middlemore Hospital Mr Patrick Gladding Cardiologist and Internal Medicine North Shore Hospital Auckland 8:30-9:25 WS #90: Chest Pain 9:35-10:30 WS #102: Chest Pain (Repeated)
2 Chest Pain Syndromes for GPs Dr. Patrick Gladding Ascot Hospital/WDHB
3 Differential Diagnosis Cardiac pain Acute MI, angina Pericarditis Heart failure Rare: HCM Chest wall pain GORD Panic disorder/anxiety Pneumonia PE Aortic dissection 3
4 What is the diagnosis? 4
5
6 No Troponin level is normal n = 54,000
7 Ultra-sensitive troponin Ultrasensitive troponin is highly personalised Clinical Biochemistry 45 (2012)
8 Pericarditis ECGs Case
9 9
10 CAD: Not just an Epicardial disease
11 Remodelling of coronary arterioles 11
12 Wall stress and pressure 12
13 13
14 Intracoronary acetylcholine (ACH) demonstrating constriction of the coronary arteries (arrow) and intracoronary nitroglycerin (NTG) coronary angiography demonstrating dilation. C. Noel Bairey Merz, and Carl J. Pepine Circulation. 2011;124: Copyright American Heart Association, Inc. All rights reserved.
15 Methods of diagnosis of CMVD SPECT PET 15
16 A new clinical entity 16
17 Advanced ECG Sensitive, high sampling frequency, accurate.
18 New model of CV disease LVH Hypertension LVER Diabetes CAD 18
19 Chest pain 70 year old male with indigestion-like central discomfort, relieved with belching Some exertional component PHx HTN, dyslipidaemia, home stress Ix 12L ECG TC 6.5, LDL 4
20
21 Options Medical Mx Refer to Outpatients Refer to ED/Inpatient Investigations: ETT ESE DSE CTCA Sensitivity 67% Sensitivity 90%
22 REST STRESS 22
23 Dyspnoea 53 year old male with breathlessness, not well over Xmas period Keen surfer PHx: no conventional risk factors Ix 12L ECG
24
25 Risk factor assessment 56 year old male asymptomatic PHx HTN, dyslipidaemia TC 6.7, HDL 1.1, LDL 4.3, Trig 3.4 Ix 12L ECG hs-troponin CAC scoring
26
27 CAC versus CTCA CAC score Low dose radiation (1mSv) May miss soft plaque (young pts) Diagnostic test for low, intermediate risk Will detect soft plaque Radiation = one year bkgd (10mSv) 1:200 risk of fatal cancer (<x3 risk of pedestrian MVA) Sensitivity %
28 Lifetime risk
29 Other chest symptoms 83 year old male light-headedness PHx mildly overweight, HTN Meds: Amlodipine 2.5mg od Ix BP 12L ECG Mg, K, TSH
30 30
31 31
32 32
33 ETT 33
34 4:30 mins 34
35 CT coronary angiogram 35
36 Treatment 36
37 Other chest symptoms 46 year old male heart fluttering PHx vertebral artery dissection, posterior CVA Ix 12L ECG Mg, K, TSH
38
39 Palpitations and chest pain 62 year old female palpitations PHx EtOH 30u/wk, dyslipidaemia (TC 7.6) Ix 12L ECG Mg, K, TSH Holter
40 40
41 Holter report and diary LOW YIELD 41
42 Era of Mobile Health 42
43 43
44 Differential Diagnosis Cardiac pain Acute MI, angina Pericarditis Heart failure Rare: HCM Chest wall pain GORD Panic disorder/anxiety Pneumonia PE D-dimer 93-95% sensitivity 50% specificity Aortic dissection 44
45 Bullet in heart 45
46 Advanced ECG $3,500 46
47 Dr Alasdair Patrick Gastroenterologist
48 If it is not the heart.then what is it? Dr Alasdair Patrick Gastroenterologist MacMurray Gastroenterology
49 Overview Background (Non Cardiac Chest Pain) What is it? What could it be? Investigations of NCCP Treatment of NCCP
50 History Huge burden of disease 20 at least per day at MMH Causes a lot of concern for the patient 30% of angiograms are normal RF obesity (OR 3), Fam Hx GERD (OR 2.8) Aspirin use, smoking More common in woman 3:1 Generates a lot of work for cardiologists!
51 Always need to rule out a cardiac cause!! Good cardiac prognosis if normal angiogram Good long term data available Lichtlen et al JACC Observational study 176 patients with normal angio inc LV Typical and atypical symptoms Median follow up 12.4 years ( )
52 Cardiac mortality 0.09%
53 Does seeing a cardiologist help? Robertson et al- Heart May 2007 All comers to a rapid access chest pain clinic
54 Does seeing the cardiologist help? HADS= hospital anxiety/ depression scale, 14 four point questions, over 8 abnormal, HAI= Hospital anxiety inventory, 18 qtn
55 So does NCCP matter? There is a significant burden of disease ½ to 2/3 admitted to ED thought to have NCCP Non cardiac chest pain estimated to cost $300M per year in the US Prognosis of NCCP at 4 years in Australia 90% have ongoing symptoms» Eslick et al NGM 2008
56 Consultations in preceding 12 months 28% work absentee. No difference in CCP vs NCCP Sydney- Eslick, Talley APT 2004
57 Does making a diagnosis help? Yes! 4 year follow up of 104 Spanish patients Structured direct telephone interview Patients who trusted their medical diagnosis had better Quality of life and less health resource use Rox et al: Rev Esp Enferm Dig 2002
58 What have we learnt so far? These patients are younger They are anxious Cardiologists make them worse They have an excellent prognosis But they continue to consult and worry Making a diagnosis helps Improve QALY Reduces costs
59 What is the differential? A definitive diagnosis can be made in up to 85% of patients Vantrappen, Janssens: Eur Heart J 1986 Musculoskeletal 15% Respiratory Psychiatric Estimated 17-43% of NCCP patients Gastroenterology Commonest cause! 30-60% GORD 30% motility disorders George N APT 2016
60 How does GORD cause NCCP? Possible mechanisms GORD induced coronary spasm GORD induced chest wall pain Oesophageal chest pain Chemoreceptors Abnormal reflux Normal reflux with increased sensitivity Mechanoreceptors GORD induced contraction Motility disorders Nutcracker, spasm
61 GORD induced coronary spasm! Coronary blood flow 2 studies shown distal acid infusion can change Q 51 patients post coronary angiogram had endoscopy, 24 hr ph and manometry Underwent Bernstein test with concurrent TOE with LAD perfusion doppler 49% significant decrease flow» They had significant abn ph tests Rosztoczy et al: Int J Cardiol 2007 Chauhan et al: Eur Heart J 1996
62 GORD induced chest wall pain! Sarkar et al; Lancet 356:1154, 2000
63 Oesophageal chest pain-chemoreceptors Normal reflux with increased sensitivity Normal people reflux 48 times per day Sarkar et al; Lancet 356:1154, 2000
64 Oesophageal chest pain-mechanoreceptors Both circular and longitudinal muscle contraction has been shown to cause pain Seen in Motility disorders E.g. Nutcracker oesophagus Balaban et al Gastroent 1999;116:29-37
65 Now what have we learnt? The commonest non cardiac cause of chest pain is the oesophagus Reflux Motility disorders A definitive diagnosis can be made in 85%» Vantrappen, Janssens: Eur Heart J 1986
66 If making a diagnosis helps what investigations should we do? PPI challenge Endoscopy ph studies ph/impedance BRAVO capsule Manometry
67 Meta-analysis of PPI challenge
68 Findings on endoscopy in NCCP Dickman et al: Am J Gastro 2007;102: Faybush, Fass G Clin NA 2004:33; 41-54
69 ph/impedance studies ½ abnormal test with 1/3 symptom correlation Maine et al Gut 2006;55:
70 Value of extended recording time BRAVO Prakash, Clouse Am J Gastro 2006; 101(3):446-52
71 Manometry Dekel et al APT 2003; 18:
72 Treatment of GORD induced NCCP Lifestyle advice Acid suppression Visceral analgesics SSRI and TCA Nissen fundoplication Dissparate results
73 Conclusion NCCP is common and a problem Oesophageal causes are most common Reflux, hypersensitivity, dysmotility Primary care rules of thumb Rule out cardiac cause PPI challenge (70-80%) respond then refer Endoscopy ph study Manometry Making a diagnosis helps Thanks
74 Comparison between cardiology and gastroenterology
75 Comparison between cardiology and gastroenterology
76 The only comprehensive digestive disease centre in Auckland The only place with full diagnostic and therapeutic services Full endoscopy services BRAVO Capsule endoscopy ph/impedance High resolution Manometry Halo Breath testing Consultations in a team environment 10 Gastroenterologists 1 Hepatologist Upper and Lower GI surgeons Dietician Health Psychologist Clinical nurse specialists
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