Chest Pain Dr Robert Huggett Consultant Cardiologist
Outline Diagnosis of cardiac chest pain 2016 NICE update on stable chest pain Assessment of unstable chest pain/acs and MI definition
Scope of the problem Guzman Castillo M, Gillespie DOS, Allen K, Bandosz P, Schmid V, et al. (2014) Future Declines of Coronary Heart Disease Mortality in England and Wales Could Counter the Burden of Population Ageing.
CHD In men still commonest cause of death in UK 15% (8% women) Chest pain: 1% of GP visits & 5% of ED visits AMI is the first presentation of IHD in 50% of patients
Origins of the word angina Angina Pectoris by William Heberden in 1772 From Greek anchone strangling 1570s from Latin angina inflammation/infection of the throat
Basics: Physiology The heart has a very high basal oxygen consumption (80%) Flow is tightly coupled to oxygen demand. This is largely achieved by altering tone within the resistance arterioles Coronaries are End arteries. Coronary flow must increase fivefold during exercise to accommodate the increase in MV O 2
Coronary Disease Progression
Experimental Versus Clinical Stenosis Severity Gould, K. L. J Am Coll Cardiol Img 2009;2:1009-1023
NICE 2016 Chest pain Assessment Chest pain Non-cardiac Reassure Stable Intermittent Angina Acute Unstable Admit 1. Assessment, treat and refer 2. Confirm Diagnosis
Original NICE CG95 (2010) CADScore <10% 10 29%, low 30 60, intermediate 61 90, high >90 No Test CT calcium scoring followed by CT angiography if calcium score >0 Functional imaging (dobutamine stress echocardiography, myocardial perfusion scan, cardiac MRI) Invasive coronary angiography Treat as angina Non-cardiac pain Consider other causes May need angiogram to guide revascularisation
Need for a NICE guidance update in 2016? Need for clearer prognostic data and guidance on treatment Need for reasonable costs and speed New Cardiac CT technology since 2004 Appeal for non-invasive imaging New Trials: CONFIRM, SCOT-Heart, PROMISE.
NICE CG95 (2016 update) 1. Clinical assessment of the likelihood of CAD, based on the typicality of the chest pain instead of the previous PTP risk score 2. All patients with new onset chest pain with atypical or typical anginal features, as well as those with non-cardiac chest pain and an abnormal resting ECG, should first be investigated with CTCA 3. Stable chest pain patients whose pain is not angina need no further cardiac testing 4. Use functional imaging first line for known CAD or uncertain CTCA results
NICE CG95 (2016 update) 1. Clinical assessment of the likelihood of CAD, based on the typicality of the chest pain instead of the previous PTP risk score 2. All patients with new onset chest pain with atypical or typical anginal features, as well as those with non-cardiac chest pain and an abnormal resting ECG, should first be investigated with CTCA 3. Stable chest pain patients whose pain is not angina need no further cardiac testing
Assess typicality Chest Pain Stable Anginal pain is: 1. constricting discomfort in the front of the chest, or in the neck, shoulders, jaw, or arms 2. precipitated by physical exertion 3. relieved by rest or GTN within about 5 minutes 3 of the features above 2 of the 3 features above 1 or none of the features above = typical angina = atypical angina = non-anginal pain **Possible angina includes non-anginal pain with an abnormal resting ECG
Non-anginal pain Continuous or very prolonged and/or Unrelated to activity and/or Brought on by breathing in and/or Associated with symptoms such as dizziness, palpitations, tingling or difficulty swallowing. Consider causes of chest pain other than angina (such as gastrointestinal or musculoskeletal pain).
Clinical Assessment according to NICE Take a History and Examination Do a resting 12-lead ECG Arrange blood tests to identify conditions which exacerbate angina CXR only if suspect lung tumour If possible angina: Rx GTN, aspirin, statin, beta blocker or calcium antagonist **Do not Exclude an ACS when people have a normal resting 12-lead ECG. Assess symptoms of CP differently in ethnic groups or sexes Use GTN to diagnose CP
Clinical Assessment Consider prescribing ACE inhibitors for people with stable angina and diabetes Should be offered statin treatment in line with Lipid modification (NICE CG67) Should not be routinely offered anti-anginal drugs other than beta blockers or calcium channel blockers as first-line treatment for stable angina
NICE CG95 (2016 update) 1. Clinical assessment of the likelihood of CAD, based on the typicality of the chest pain instead of the previous PTP risk score 2. All patients with new onset chest pain with atypical or typical anginal features, as well as those with non-cardiac chest pain and an abnormal resting ECG, should first be investigated with CTCA 3. Stable chest pain patients whose pain is not angina need no further cardiac testing
Cardiac CT Low cost, high sensitivity Provides extra info on vessel wall Value is in it s high NPV of 97-100%
CTCA is a relatively new technique
Soft plaque visualisation
CTCA as first line test Curr Cardiovasc Imaging Rep. 2017; 10(5): 15.
SCOT-HEART Study, prognostic benefits per NICE CG95 2016 Philip D Adamson et al. Heart doi:10.1136/heartjnl-2017-311508
Prognosis following CTCA- Scot Heart Post hoc data
NICE CG95 (2016 update) 1. Clinical assessment of the likelihood of CAD, based on the typicality of the chest pain instead of the previous PTP risk score 2. All patients with new onset chest pain with atypical or typical anginal features, as well as those with non-cardiac chest pain and an abnormal resting ECG, should first be investigated with CTCA 3. Stable chest pain patients whose pain is not angina need no further cardiac testing
SCOT-HEART, prognostic benefits per CG95 2016 Philip D Adamson et al. Heart doi:10.1136/heartjnl-2017-311508
Unstable chest pain Pain at rest for more than 15mins Pain associated with nausea and sweating New onset chest pain(12-72hrs), or abrupt deterioration in previously stable angina and/or abnormal ECG
The degree of symptoms do not correlate well with the extent of CHD
ACS history pitfalls Painless AMI common with age, women and diabetics By age 85 MAJORITY of AMI are painless equivalents include: Dyspnoea (commonest) With age: syncope, weakness, confusion Cold sweats & dizziness
Acute coronary syndromes Includes unstable angina and acute myocardial infarction (AMI).
Acute MI Myocardial necrosis /cell death due to prolonged myocardial ischaemia STEMI: Patients with ST-segment elevation in at least two contiguous leads NSTEMI: patients without ST-segment elevation at presentation
MI is classified into various types, The majority of STEMI patients are classified as a type 1 MI (with evidence of a coronary thrombus), some STEMIs fall into other MI types STEMI, also occurs in the absence of obstructive coronary artery disease (CAD). Termed: myocardial infarction with non-obstructive coronary arteries (MINOCA)
Classification of MI (on clinical situation).
3 rd Universal Definition for Type 1 and 2 AMI Rise(and/or fall) of Tn with at least one value above the 99 th percentile and at least one of the following: 1. Symptoms of ischaemia. 2. New significant ST-T wave changes or left bundle branch block. 3. Pathological Q waves on ECG. 4. Imaging evidence of new or presumed loss of viable myocardium or regional wall motion abnormality. 5. Intracoronary thrombus detected on angiography or autopsy. Please consider using term: Secondary Myocardial injury if the above definition is not fulfilled.
Distinguishing MI from injury
Troponin Detectable troponin has now become the norm and has to be differentiated according to different concentration levels Troponin I or T rise within 3-6H and then remain elevated for about one week Serial testing, at least 6H after symptom onset improves sensitivity In ACS an increased troponin is a marker for increased risk of AMI and death It does not diagnose cardiac ischemia or MI
Implications of Hs Tn
Differential diagnosis of ACS
ACS Evaluation in ED Quality of Chest pain Symptom orientated examination Short Hx of likelihood of CAD ECG (ST elevation) STEMI ACS possible Non-cardiac Reperfusion with PCI Validation with serial ECGs and Tn GRACE score Echocardiogram
Checklist for treatment if ACS likely 1. **Check bleeding risk** 2. Aspirin 300mg loading followed by 75mg od 3. Loading dose of Ticagrelor or clopidogrel 4. LMW heparin 5. Oral beta blocker if tachycardic or Hypertensive without HF
NSTEMI New/revised concepts
NICE and ESC recommend GRACE 2.0 score for ACS
2017 STEMI New/revised concepts Time to PCI: The time STEMI diagnosed to wire crossing (eliminated door to balloon ) Time limits for opening IRA 0-12 (class I) 12-48 (class IIa) Selection of fibrinolysis if anticipated delay >120mins
STEMI: ECG to wire crossing
Summary CTCA is now first line for typical or atypical anginal stable chest pain ACS in the future Women, those with comorbidities, and the frail elderly, are increasing and at higher risk of adverse cardiovascular outcomes and require careful optimisation of treatment
The Lancet 2017 389, 1730-1739DOI: (10.1016/S0140-6736(17)30752-3)
Lancet 2017; 389: 1730 39
Questions?