How to investigate (Cardiac) Chest Pain

Transcription

1 RCP UPDATE IN MEDICINE 27 th November 2017 How to investigate (Cardiac) Chest Pain Justin Carter Consultant Cardiologist North Tees and Hartlepool NHS Trust

2 The spectrum of coronary disease No Disease Asymptomatic Disease Angina ACS

3 Invasive CA ETT No Rx 1º Prevention CTCA DSE MPS CMR FFR CT-FFR 2º Prevention Antianginal Rx Revascularisation PCI CABG Low PROGNOSTIC RISK High Prognosis Symptoms

4 Cardiac chest pain Traditional Model of investigation: In Theory: Diagnose on history and risk factors Risk stratify with ETT Angiogram in those with bad symptoms or early positive ETT Revascularise for SYMPTOMS or PROGNOSIS In practice: many patients get ETT (as a rule out test)

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6 Has been about the ETT Chest pain clinic Prestest probability (of CAD) determines sensitivity and specificity Good: Where pretest prob is 100% (ie known coronary disease) i.e. for prognostication

7 Chest pain clinic Prognostic disease ETT is good at identifying these patients... Non Prognostic Disease...But its often used in these patients No disease

8 Exercise ECG Stress Cardiac MRI CT FFR Invasive Coronary Angiogram CT Calcium Score Invasive FFR CT Coronary Angiogram Stress Echocardiography Nuclear Myocardial Perfusion

9 ANATOMY FUNCTION

10 ANATOMY CT Calcium Score CT coronary angiogram Invasive coronary angiogram CT-FFR Invasive FFR FUNCTION Exercise ECG Stress Echo MPS Stress MRI

11 ANATOMY FUNCTION

12 SYMPTOMS PROGNOSIS

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14 Chest pain of recent onset Implementing NICE guidance 2012 NICE clinical guideline 95

15 NICE Guidance - First step Criteria for diagnosis of angina.. clinical diagnosis if convincing Or clinical assessment plus either anatomic diagnostic test functional diagnostic test

16 NICE Guidance - Its all in the history.. Symptoms Constricting discomfort Precipitated by physical exertion Relieved by rest or GTN Typical angina: all of the above Atypical angina: two of the above Non-anginalchest pain: one or none of the above

17 NICE Guidance - Its all in the history and risk factors..

18 NICE Guidance - Testing Strategy Estimated likelihood of CAD Investigative strategy < 10% and or non-anginal CP Trust your clinical judgment No further testing for CAD 10-29% Cardiac CT (Rule out test) 30-60% Non invasive functional imaging (Uncertainty) 61-90% Invasive coronary angiography (Rule in test needed) > 90% with typical angina Trust your clinical judgment No further diagnostic testing

19 What does the NICE guidance change? 20-30% 30-60% 60-90% Atheroma or not? A lifetime of tablets? CT angiography If there is is it tight? MPS Stress echo Cardiac MRI Probably atheroma Is there ischaemia Revasc needed? Invasive angiography Almost certainly atheroma Revasc likely

20 2012 NICE Chest pain guidance Disease need revasc Invasive Cor angio Anatomy Disease need tablets No disease with Risk Factors No disease No Risk Factors ETT /DSE MPS /CMR CT Cor Angio Function (Ischaemia) Anatomy

21 Offer CT coronary angiography if: 2016 UPDATE clinical assessment indicates typical or atypical angina or clinical assessment indicates non-anginal chest pain and ECG abnormal

22 2016 NICE Chest pain Update Disease need revasc Invasive Cor angio Anatomy Disease need tablets No disease with Risk Factors No disease No Risk Factors ETT /DSE MPS /CMR CT Cor Angio Function (Ischaemia) Anatomy

23 2016 NICE Chest pain Update Disease need revasc Disease need tablets No disease with Risk Factors CT Cor Angio Anatomy No disease No Risk Factors

24 The Ideal CT report- categorising to outcome? Severe atheroma (Likely flow limiting): CT Cor Angio Disease need revasc Disease need tablets Anatomy No disease with Risk Factors No disease No Risk Factors Revasc planning (likely need ICA) Secondary prevention of risk factors Moderate Atheroma (May be flow limiting): Functional testing (as per ICA) Secondary prevention of risk factors Diffuse Mild Atheroma (Not likely flow limiting): Medical therapy for any ischaemic symptoms Secondary prevention Normal Coronaries: The pain isn t cardiac (unless functional) Primary prevention (rather than secondary prevention)

25 NICE Guidance puts CT at the centre Big change Much debate in the UK Cost / delivery implications Potential excessive follow-on testing Daily lists Radiographer led Is is quick to do Could be cheap Screen to rule in or rule out CAD at the outset of the diagnostic pathway

26 Introduction to cardiac CT

27 CT Coronary Angiography- why so hard? Constantly moving vessels, Small diameter, Calcified To overcome these issues need high Spatial and Temporal resolution How has CT come forward?

28 Single Heartbeat Scanning

29 Dual Source Cardiac CT

30 Dual Source Cardiac CT

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35 CT angio isn t as good as invasive angio So what? Agonising over if its 65% or 70% is irrelevant: <50% \ 50-70% \ >70% is enough (Function (ischaemia) probably more important than anatomy anyway)

36 SUMMARY NICE guidance puts CTCA at the centre of chest pain investigation

37 CT Cor Angio Anatomy

38 ANATOMY FUNCTION ANATOMY

39 Exercise ECG Invasive Coronary Angiogram ANATOMY Stress Cardiac MRI CT FFR Plan revascularisation FUNCTION CT Calcium Score Assess ischaemia burden ANATOMY Invasive FFR CT Coronary Angiogram Rule out CAD Nuclear Myocardial Perfusion Stress Echocardiography

40 Summary ETT and invasive angiousedto be main tests in CAD-Now there are lots of options CT provides anatomy at low cost / risk. UK guidance places it first-line Alternatively strategies: CT to rule out disease Functional test for extent of ischaemia Invasive angiogram to plan revascularisation Low to intermediate risk In known moderate disease In severe disease High end CTCA has multiple extended uses