Approach to Chest Pain Approach to Chest Pain and Anginaand Angina

Part IPart I Diagnosis and Risk StratificationDiagnosis and Risk Stratification

Mirek Otremba – Revised 2007Mirek Otremba – Revised 2007

ReferencesReferences

ACC/AHA Guideline on Chronic Stable Angina ‘02ACC/AHA Guideline on Chronic Stable Angina ‘02Circ. 1999; 99:2829-2848Circ. 1999; 99:2829-2848Update in JACC 2003; 41:159-168Update in JACC 2003; 41:159-168www.acc.orgwww.acc.org

CCS Consensus on Chronic Ischemic Heart CCS Consensus on Chronic Ischemic Heart DiseaseDisease

Can J Cardiol 2000; Vol 16 no. 12: 1515-1535Can J Cardiol 2000; Vol 16 no. 12: 1515-1535

Chronic Stable AnginaChronic Stable AnginaNEJM 2005; 352: 2524-34NEJM 2005; 352: 2524-34

Noninvasive tests in patients with stable CADNoninvasive tests in patients with stable CADNEJM 2001; 344: 1840-1845NEJM 2001; 344: 1840-1845

ObjectivesObjectives

1.1. How to make the diagnosis of angina or CADHow to make the diagnosis of angina or CAD

2.2. When to order further testing to make the When to order further testing to make the diagnosis diagnosis of anginaof angina

3.3. When to order further testing to determine When to order further testing to determine prognosisprognosis (risk stratification) (risk stratification)

4.4. To understand the limitations of various testsTo understand the limitations of various tests

Clinical ScenarioClinical Scenario

A healthy 50 yr old man experienced 15 minutes of sharp, A healthy 50 yr old man experienced 15 minutes of sharp, epigastric, left sided chest pain while mowing the lawn.epigastric, left sided chest pain while mowing the lawn.

He stopped and the pain resolved in 5 min. The pain did He stopped and the pain resolved in 5 min. The pain did not radiate and there was no diaphoresis or dyspnea.not radiate and there was no diaphoresis or dyspnea.

Does this patient have angina?Does this patient have angina?

How would you classify his symptoms?How would you classify his symptoms?(ie typical, atypical angina, or non-cardiac chest pain)(ie typical, atypical angina, or non-cardiac chest pain)

Classification of chest painClassification of chest pain

Typical anginaTypical angina

Atypical anginaAtypical angina

Noncardiac chest painNoncardiac chest pain

1. Substernal chest discomfort with characterstic quality and duration

2. Provoked by exertion or emotional stress

3. Relieved by rest or NTG

Meets 2 of the above characteristics

Meets one or none of the typical characteristics

Classification of Classification of severityseverity of angina of angina

Class IClass I

Class IIClass II

Class IIIClass III

Class IVClass IV

No angina with ordinary physical activity

Angina with strenuous/prolonged exertion

Early-onset limitation of ordinary activity (2 blocks/1 flight)

Worse after meals, in cold temp, or emotional stress

Marked limitation of ordinary activity

Inability to carry out any physical activity without angina

Angina occurs at rest

History and PhysicalHistory and Physical

You next ask about risk factors…You next ask about risk factors…

To increase pre-test probabilityTo increase pre-test probabilityLipids, DM, HTN, smoking, and Fam. HxLipids, DM, HTN, smoking, and Fam. Hx

Plus a past hx of PVD, or StrokePlus a past hx of PVD, or Stroke

…his father had an MI at the age of 50 yrs, and he is unaware of his lipid status.

History and PhysicalHistory and Physical

You perform a focused physical looking You perform a focused physical looking for signs of heart disease or a non cardiac for signs of heart disease or a non cardiac source of chest pain.source of chest pain.

On examination he is moderately obese (BMI 30), with a BP 140/80, and HR 80. The cardiac and chest exam is normal.

His CBC, lytes, ECG and CXR are all normal

What is his pre-test probability of CAD?What is his pre-test probability of CAD?

Pre-test likelihood of CADPre-test likelihood of CAD

Nonanginal Nonanginal chest painchest pain Atypical anginaAtypical angina Typical anginaTypical angina

AgeAge MM FF MM FF MM FF

3535 3-353-35 1-191-19 8-598-59 2-392-39 30-8830-88 10-7810-78

4545 9-479-47 2-222-22 21-7021-70 5-435-43 51-9251-92 20-7920-79

5555 23-5923-59 4-254-25 45-7945-79 10-4710-47 80-9580-95 38-8238-82

6565 49-6949-69 9-299-29 71-8671-86 20-5120-51 93-9793-97 56-8456-84

Does the pt fit into one of the following?Does the pt fit into one of the following?1.1. Noncardiac c/p and low pretest prob…Noncardiac c/p and low pretest prob…

2.2. Diagnosis of angina is established Diagnosis of angina is established (high pretest prob)(high pretest prob)

3.3. Diagnosis is still not clearDiagnosis is still not clear…(intermediate pretest prob)…(intermediate pretest prob)

Is the DIAGNOSIS established after the Is the DIAGNOSIS established after the

Hx/Px and initial tests?Hx/Px and initial tests?

• No further testing needed.

• Pt does not have angina

• No further diagnostic testing needed.

• Pt needs risk stratification for prognosis

• Consider the following tests to make a diagnosis…

Diagnosis of CADDiagnosis of CAD

You decide to classify his chest pain as atypical, You decide to classify his chest pain as atypical, and estimate his pre-test probability of CAD as and estimate his pre-test probability of CAD as intermediate ( 65%)intermediate ( 65%)

Nonanginal chest painNonanginal chest pain Atypical anginaAtypical angina Typical anginaTypical angina

AgeAge MM FF MM FF MM FF

3535 3-353-35 1-191-19 8-598-59 2-392-39 30-8830-88 10-7810-78

4545 9-479-47 2-222-22 21-7021-70 5-435-43 51-9251-92 20-7920-79

5555 23-5923-59 4-254-25 45-7945-79 10-4710-47 80-9580-95 38-8238-82

6565 49-6949-69 9-299-29 71-8671-86 20-5120-51 93-9793-97 56-8456-84

Is this high enough to Is this high enough to give him a diagnosis of give him a diagnosis of CAD and start treatment?CAD and start treatment?

How would you How would you confirm the diagnosis?confirm the diagnosis?

Diagnostic Tests for CADDiagnostic Tests for CAD

ECG Exercise Stress Testing (GXT)ECG Exercise Stress Testing (GXT) Stress test plus imaging (nuclear or echo)Stress test plus imaging (nuclear or echo) Pharmacologic testing (dipyridamole-MIBI, or Pharmacologic testing (dipyridamole-MIBI, or

Dobutamine-MIBI/Echo)Dobutamine-MIBI/Echo) Angiography (gold standard test)Angiography (gold standard test)

What test is the most appropriate for him?What test is the most appropriate for him?

DIAGNOSTIC TestsDIAGNOSTIC TestsACC/AHA Guidelines Circ. 1999; 99:2829-48ACC/AHA Guidelines Circ. 1999; 99:2829-48

Exercise ECG (GXT) for diagnosisExercise ECG (GXT) for diagnosis Class IClass I

Pts with intermediate pretest prob. (with normal ECG)Pts with intermediate pretest prob. (with normal ECG) Class IIa and IIbClass IIa and IIb

Suspected vasospastic anginaSuspected vasospastic angina

Pts with high or low pretest prob of CADPts with high or low pretest prob of CAD Class IIIClass III

Baseline ECG abn. (LBBB, paced ECG, WPW, >1mm ST Baseline ECG abn. (LBBB, paced ECG, WPW, >1mm ST depression)depression)

Click here to see theClick here to see the ACC/AHA classification systemACC/AHA classification system

Diagnostic TestsDiagnostic Tests

Stress imaging studies (nuclear or echo)Stress imaging studies (nuclear or echo) Class IClass I

Pts with intermediate pretest prob. and Pts with intermediate pretest prob. and abnormalabnormal ECGECG

Class IIClass II

Pts with low or high pretest prob. and abn. ECGPts with low or high pretest prob. and abn. ECG

Pts Pts unableunable to exercise… to exercise…use pharmacological stress use pharmacological stress Dypyridamole sestamibi or Dypyridamole sestamibi or Dobutamine echo/sestamibiDobutamine echo/sestamibi

Test Characteristics ofTest Characteristics ofNon-invasive testingNon-invasive testing

Diagnostic Diagnostic testtest SnSn SpSp LR +LR + LR -LR -

Exercise TestExercise Test 6868 7777 33 0.420.42

Nuclear StressNuclear Stress 8888 7777 3.83.8 0.160.16

Stress EchoStress Echo 7676 8888 6.36.3 0.270.27

…for occlusive CAD

2D ECHO2D ECHO

What about rest ECHO in the diagnosis of What about rest ECHO in the diagnosis of chest pain or CAD?chest pain or CAD?Class IClass I

Pts with signs of AS or HOCMPts with signs of AS or HOCMPts with findings of CHFPts with findings of CHF

Class IIIClass IIIPts with none of the above findings Pts with none of the above findings i.e. routine echo is not indicated in the dx of anginai.e. routine echo is not indicated in the dx of angina

Angiography (Gold standard)Angiography (Gold standard)

How about angiography for diagnosis?How about angiography for diagnosis? Class IClass I

Pts who have survived sudden cardiac deathPts who have survived sudden cardiac death Class IIClass II

Pts with uncertain dx after noninvasive testsPts with uncertain dx after noninvasive tests

Pts who cannot undergo noninvasive testsPts who cannot undergo noninvasive tests Class IIIClass III

Pts who “want to know” but are low prob.Pts who “want to know” but are low prob.

Diagnostic TestingDiagnostic Testing

You decide to order a routine treadmill test.You decide to order a routine treadmill test. Exercise time:Exercise time: 10 min (~10 METS) 10 min (~10 METS) Symptoms:Symptoms: fatigue, no chest pain. fatigue, no chest pain. HR and BP response:HR and BP response: appropriate (80% predicted HR) appropriate (80% predicted HR) ECG response:ECG response: 1mm down sloping ST-segment depression in 3 1mm down sloping ST-segment depression in 3

leads at peak exercise.leads at peak exercise.

How do you interpret this result?How do you interpret this result?Does he have CAD? (what is post test probability)Does he have CAD? (what is post test probability)What is his Prognosis?What is his Prognosis?

Interpreting Exercise TestsInterpreting Exercise Tests

4 components to interpreting a stress test4 components to interpreting a stress test1. 1. SymptomsSymptoms (angina) during or after the test (angina) during or after the test2. 2. ECG changesECG changes during or after exercise during or after exercise

ST depression > 1mm 80ms after J pointST depression > 1mm 80ms after J pointST elevationST elevation

3. 3. Hemodynamic responseHemodynamic response to exercise (HR and BP change) to exercise (HR and BP change)4. 4. WorkloadWorkload in METs in METs

Need to consider all 4 parts when interpreting testNeed to consider all 4 parts when interpreting test For For prognosisprognosis: :

workload in METs is more important than ST changesworkload in METs is more important than ST changes Use the Duke Treadmill Score to calculate Use the Duke Treadmill Score to calculate

risk/prognosisrisk/prognosis

Our patient:

Fagan Nomogram

Post-test probability of CAD = 85%

DTS score = 5

(formula and interpretation later)

Clinical symptoms may not predict Clinical symptoms may not predict coronary artery disease burdencoronary artery disease burden

18

21 22

28

1113

25

22

28

1311

20

2931

9

0

5

10

15

20

25

30

35

% m

en w

ith

fin

din

gs

on

an

gio

gra

ph

y

Mild StableAngina

DisablingStable Angina

ProgressiveEffort Angina

Normal

1 Vessel

2 Vessel

3 Vessel

Left Main

Similar for women

Risk StratificationRisk Stratification

Risk StratificationRisk Stratification

Once the Once the clinical diagnosisclinical diagnosis of angina is probable or of angina is probable or confirmed then the pt needs confirmed then the pt needs risk assessmentrisk assessment

The choice of test is based on the pt’s ECG and The choice of test is based on the pt’s ECG and physical abilityphysical ability

• Normal ECG – may use GXT Normal ECG – may use GXT (click to see AHA)(click to see AHA)

• With an abnormal ECG use stress imagingWith an abnormal ECG use stress imaging• If unable to exercise use pharmacological stressIf unable to exercise use pharmacological stress• For some patients angiography may be the best For some patients angiography may be the best

initial test initial test (click to see AHA)(click to see AHA)

Duke Treadmill Score (DTS)Duke Treadmill Score (DTS)

DTS = DTS = [exercise time (mins)] [exercise time (mins)] –– [ 5 x ST segment deviation (mm)] [ 5 x ST segment deviation (mm)] –– [ 4 x angina index ] [ 4 x angina index ]

0 no angina0 no angina

1 angina occurs1 angina occurs

2 angina reason for stopping test2 angina reason for stopping test

Risk (DTS)Risk (DTS) 4-yr survival4-yr survival Annual mortalityAnnual mortality

Low (>5)Low (>5) 99%99% 0.25%0.25%

Mod (-10 to 4)Mod (-10 to 4) 95%95% 1.25%1.25%

High (< -10 )High (< -10 ) 79%79% 5%5%

Imaging in risk stratificationImaging in risk stratification

Nuclear ImagingNuclear Imaging NormalNormal imaging predicts imaging predicts good prognosisgood prognosis (<1 %/yr) (<1 %/yr)

Stress EchoStress Echo A A negativenegative test predicts a test predicts a low risklow risk for future events for future events

Risk dictates managementRisk dictates management

Predicted annual Predicted annual mortality mortality < 1 %< 1 % can be managed medicallycan be managed medically

Pts with Pts with mortality mortality 1-3 % / yr1-3 % / yr consider either cath or exercise imaging study for further risk consider either cath or exercise imaging study for further risk

assessmentassessment

Pts with Pts with mortality mortality >3 % / yr>3 % / yr should be referred for cath.should be referred for cath.

Our Patient:

DTS 5 = Low Risk

Annual mortality = 0.25%

SummarySummary

1.1. Start with the Hx and P/E Start with the Hx and P/E • estimate the estimate the pre-test probabilitypre-test probability of CAD of CAD

2.2. Decide whether the patient needs testingDecide whether the patient needs testing• to to make a diagnosismake a diagnosis of CAD or of CAD or • the diagnosis established clinically, but need the diagnosis established clinically, but need

testing to determine testing to determine prognosis.prognosis.

3.3. Make decisions about therapyMake decisions about therapy• medical vs. PCI/CABG medical vs. PCI/CABG

• based on the patient’s based on the patient’s risk assessmentrisk assessment

THE ENDTHE END

ACC/AHA Classification SystemACC/AHA Classification System

Class IClass I:: Conditions for which there is evidence and/or general Conditions for which there is evidence and/or general agreement that a given procedure or treatment is useful agreement that a given procedure or treatment is useful or effective.or effective.

Class IIClass II:: Conditions for which there is conflicting evidence and/or Conditions for which there is conflicting evidence and/or divergence of opinion about the usefulness/efficacy of a divergence of opinion about the usefulness/efficacy of a procedure or treatment.procedure or treatment.Class IIaClass IIa: weight of evidence/opinion in favor of : weight of evidence/opinion in favor of usefulnessusefulnessClassIIbClassIIb: Usefulness less well established: Usefulness less well established

Class IIIClass III:: Conditions for which there is evidence and/or general Conditions for which there is evidence and/or general agreement that the procedure/treatment is not agreement that the procedure/treatment is not useful/effective and in some cases may be harmful. useful/effective and in some cases may be harmful.

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Exercise Testing for Risk Exercise Testing for Risk StratificationStratification

Exercise Testing for risk stratification and Exercise Testing for risk stratification and prognosisprognosis Class IClass I

Pts undergoing Pts undergoing initialinitial evaluation evaluation

Pts with significant change in symptomsPts with significant change in symptoms Class IIIClass III

Pts with severe comorbidity and not appropriate for Pts with severe comorbidity and not appropriate for revascularizationrevascularization

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Angiography for Risk Angiography for Risk StratificationStratification

Angiography for risk assessmentAngiography for risk assessment Class IClass I

Pts with CCS III or IV anginaPts with CCS III or IV angina

Pts with high risk noninvasive testsPts with high risk noninvasive tests

Pts with angina and CHF or poor LV functionPts with angina and CHF or poor LV function Class IIIClass III

Pts with angina responding to medical Tx and low Pts with angina responding to medical Tx and low risk or normal stress testrisk or normal stress test

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