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MANAGING CHEST PAINDr Carl Shakespeare, Consultant Cardiologist MD FRCP FACC FESC
BMI The London Independent Hospital Queen Elizabeth Hospital
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The Killers
Coronary Disease Aortic Dissection Pulmonay Embolism
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Pericarditis
GERD
Hiatus Hernia
Atelectesis
NoduleCardiac Entrapment
PE
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NICE Guidelines
The diagnosis of stable angina is made from:
a clinical assessment alone
or in combination with a diagnostic test
NICE Clinical Guideline 95. 2010 www.nice.org.uk/guidance/C G95
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Exclude Other Causes
Cardiac Causes Hypertrophic Cardiomyopathy Aortic Stenosis Myo-Pericarditis
Non-Cardiac Causes Musculoskeletal Gastric Pulmonary causes (incl: PE, pneumonia )
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Non Anginal Type Symptoms
Continuous or prolonged symptoms Unrelated to activity Pleuritic Gastric: relationship to eating, nocturnal
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Making The Diagnosis
“Pre-test probability” has emerged when trying to diagnose angina.
Typicality of symptoms
Age
Risk factors
ECG abnormality
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Pre-Test Probability
The method of: “% Likelihood of having coronary disease”
<10% 10-29% 30-60% 60-90% >90%
Pryor DB et al, Annals of Internal Medicine 1993 118; 81-90
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“Typicality” of Symptoms
Angina Pain is:
Constricting/tight in front of chest, neck, shoulders, jaws or arms
Induced by physical exertion/mental stress Relieved by GTN in < 5 minutes
Typical Angina: all the above symptoms
Atypical Angina: two of the above features
Not Angina: one or none of the above
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Atypical Symptoms...
Ischaemic equivalents:Dyspnoea on exertionReduced effort tolerancePalpitations
Atypical Description: (especially women!)Shortness of breath, palpitations
Nausea, indigestion,
Fatigue, sweating,
Back and jaw pain
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Cardiac Symptoms in Women
Less “exertional symptoms” than men More atypical: prolonged, neck, throat, rest More angina less angiographic disease
(50%) 50% continue to have chest pain, hospitalisation,
and diagnostic uncertainty. 2X increase in non-fatal MI
Common: angiographically normal NSTEMI (10-25%)
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Risk Factors
The presence of risk factors may add to the diagnosis
The absence of risk factors doesn’t exclude the diagnosis (25% coronary events occur in the absence of significant risk factors)
High risk includes: Smoking, Diabetes, Lipids
RACE?
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ECG
Don’t rule out angina based on normal ecg Consider: LBBB
Pathological Q wavesST, or T wave abnormalities
An abnormal ECG increases the probability in any group
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Identifying CV Risk
Age LDL-c Smoking HDL Systolic Blood
Pressure Diabetes Triglycerides Family History Snoring Poor church
attendance
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Age
Increased Pre Test Probability in any group
Male> 70 years 90% in typical and atypical symptoms.
Women > 70 years (atypical) 60-90% (typical + high risk) >90%
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Pre Test Probability
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(10-90%) Blood Tests to exclude exacerbants Rx Aspirin Consider Diagnostics based on PPP Treat risk factors Treat as Angina
(>90%) Rx as Angina Unstable Angina
Pre Test Probability
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PPP (10-29%)
Offer Calcium Scoring (low radiation 1mSv) = 0 : Investigate other causes
1-400: Cardiac CT Yes: Rx as Angina Angiography U: Functional Imaging No: Other causes
>400 Cardiac Catheterisation
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Calcium Scoring
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Cardiac CT Angiography
Bulky – at risk
Bulky – inflamed
Healing – Remodeled
The diameter of the Total lesion (bulk) predicts events
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PPP (30-60%)
Offer Non-invasive Functional Imaging
Reversible Myocardial Ischaemia?
Uncertain Yes No
Cardiac Rx: Angina Other
Catheter causes
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Non-Invasive Functional TestingConsider availability and expertise:
Myocardial Perfusion Scintigraphy SPECT Stress Echocardiography Cardiac MRI with perfusion imaging
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PPP (60-90%)
Consider Cardiac Catheterisation
No Yes
Offer Functional Imaging Offer Cardiac Catheter
Reversible Ischaemia Significant Disease
Other Ix Rx as Angina Functional Other Ix
Imaging
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Cardiac Catheterisation
Risks Proceed to PCI Value in women
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> 90% Probability
No need for investigations Treat for Angina
Further Management: Progressive Symptoms Intolerance to medication ANGIOGRAPHY Associated Symptoms
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What About the Exercise Test?
Poor diagnostic test? Functional Assessment Therapeutic Value Effort Tolerance Prognostic value Especially in women Chronotropic response
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Treatment
Treat with Aspirin and Beta blocker Be guided by symptoms Refer to Rapid access Chest Pain Clinic Treat before considering intervention
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Assumptions about Women
“... Their hormones protect them....”
“... Women represent less risk than men..”
“... Women’s tests are usually false positives
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Realities about Women
Their hormones do protect them until age 45
Women’s incidence then becomes similar to men’s
Women’s outcomes are worse than men’s
Women behave differently to men
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Pathophysiology- Differences
Less anatomical obstructive coronary disease
Erosive Coronary disease
Microvascular dysfunction
Abnormal Coronary Reactivity
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Novel Risk Factors
Traditional risk factors underestimate IHD risk in women
Higher CRP in women Inflammatory basis Raised autoimmunity hsCRP relates to:
DM II Metabolic syndrome
Hormone deficiency
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Worse Outcomes
Women not taken seriously Less diagnostic tests Angiographically normal Less adherence to guidelines Clustering of risk factors + novel risk factors, and
loss of oestrogen activity Greater exposure to inflammation
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Coronary Reactivity: Microvascular Dysfunction
Angina + Ischaemic Test + Normal Coronaries
Greater frequency of plaque erosion Retinal artery narrowing (clinical indicator in
women) More prominent positive remodelling More microvascular ischaemia:
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Endothelial Dysfunction
Key component of atherogenesis; predicts CV events
Assessed with: coronary, Brachial artery vasodilatation Nitric oxide dependent pathway
Abnormal activity associated with 4x mortality
Restoration of Endothelial Function associated with improved outcome Abnormal reactivity not associated with risk factors
Bonetti PO JACC 2004 44; 2137
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Peripheral Hypereactivity
Rubenstein R 2010 EHJ 31:1142
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Treatment in Women
Restoration of endothelial dysfunction associated with improved prognosis
Risk Factor Modification Asprin + Statin + ACEI Imipramine Ranolazine
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Statistics
No decrease in sudden death in women
Symptomatic women have more persisting symptoms
Higher hospitalization
Greater adverse outcomes than men despite < significant anatomical
disease and > systolic function
Shaw LJ Circulation 2008 117, 1787