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Case History 1 : Sorting out chest pain in general
practiceDr Albert Ko / GP Panel
Case Presentation 1Ascot Cardiology Symposium
Dr Albert Ko2013
Presenting Symptoms70 yrs old male with prolonged cough for 6 months Recent improvement with a 10 day course of ABAssociated with rhino-sinusitis and some postnasal
dischargeShortness of breath on exertion with reduced exercise
capacity The cough mainly started while he was away yachting
at the world championship in the US and won!
What would you do? Do nothing, offer reassurance that he is better than
most 70 years old
Refer to a respiratory physician
Refer to a cardiologist
Physical Exam and InvestigationsRegular pulse and normal heart soundsVery mild airflow obstruction on spirometryCXR showed atelectasis at the right lung base with
very mild cardiomegaly
Suggestions by the respiratory physicianExtended the AB for a further 11 daysOtrivine and Butacort nasal sprayFurther investigations such as?
Further InvestigationsBNP given the very mild cardiomegaly on CXR – 186
(normal <35 and clear cut LVF >400)Echocardiogram – Multiple regional wall motion
abnormalities with mild reduction in overall systolic function
Resting ECG – Symmetrical T inversion in the inferior and lateral leads (normal 6/12 ago)
ESE – Little improvement in LV contractility after 7 min of the Bruce Protocol and stopping due to SOB. He had no CP
Coronary Angiography
Treatment optionsMedical – Drug therapy
Surgical – CABG
PCI – Complex multi vessel disease with chronic total occlusion of both
the RCA and L Circumflex A
LAD – Pre/Post PCI
LCx – Pre/Post PCI
RCA – Pre/Post PCI
Presenting Symptoms54 years old Handyman with worsening SOB/cough
associated with a tight chest after working under a dusty and damp house
No CV risk factorsGiven 3 courses of AB – Roxithromycin with little
effectCXR – Possible pleural plaqueReferral to Respiratory Physician CT chest – Unremarkable
Further ActionsHe was not better and got to the stage where he
became very limited in his ET yet he still continued to work and took Panadol for it
Referred to Cardiology just prior to Christmas
ESE – Positive at 5 min with worsening CP and SOB associated with significant ST depression and wall motion abnormality
Coronary Angiography
Treatment Medical – Drug therapy
Surgical – CABG
PCI – Complex two vessel disease with LAD/diagonal bifurcation
stenosis and chronic total occlusion of the RCA
LAD/Diagonal Pre/Post PCI
RCA Pre/Post PCI
Discussion PointsSilent Ischemia – A proportion of patients never has
any chest pain SOBOE – Angina equivalent The merit of BNP in sorting out cardiac verse
respiratory cause of Cough and SOBGP referral to the appropriate medical sub-specialty
can often influence the treatment outcomePCI is non inferior to CABG in expert hands