MANAGING CHEST PAIN Dr Carl Shakespeare, Consultant Cardiologist MD FRCP FACC FESC BMI The London Independent Hospital Queen Elizabeth Hospital

v The Killers  Coronary Disease  Aortic Dissection  Pulmonay Embolism

v Pericarditis GERD Hiatus Hernia Atelectesis Nodule Cardiac Entrapment PE

v NICE Guidelines The diagnosis of stable angina is made from:  a clinical assessment alone  or in combination with a diagnostic test NICE Clinical Guideline G95www.nice.org.uk/guidance/C

v Exclude Other Causes  Cardiac Causes  Hypertrophic Cardiomyopathy  Aortic Stenosis  Myo-Pericarditis  Non-Cardiac Causes  Musculoskeletal  Gastric  Pulmonary causes (incl: PE, pneumonia )

v Non Anginal Type Symptoms  Continuous or prolonged symptoms  Unrelated to activity  Pleuritic  Gastric: relationship to eating, nocturnal

v Making The Diagnosis “Pre-test probability” has emerged when trying to diagnose angina.  Typicality of symptoms  Age  Risk factors  ECG abnormality

v 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 ; 81-90

v “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

v Atypical Symptoms...  Ischaemic equivalents: Dyspnoea on exertion Reduced effort tolerance Palpitations  Atypical Description: (especially women!) Shortness of breath, palpitations Nausea, indigestion, Fatigue, sweating, Back and jaw pain

v 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%)

v 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?

v ECG  Don’t rule out angina based on normal ecg  Consider: LBBB Pathological Q waves ST, or T wave abnormalities  An abnormal ECG increases the probability in any group

v Identifying CV Risk  Age  LDL-c  Smoking  HDL  Systolic Blood Pressure  Diabetes  Triglycerides  Family History  Snoring  Poor church attendance

v 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%

v Pre Test Probability

v (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

v 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 >400Cardiac Catheterisation

v Calcium Scoring

v Cardiac CT Angiography Bulky – at risk Bulky – inflamed Healing – Remodeled The diameter of the Total lesion (bulk) predicts events

v PPP (30-60%) Offer Non-invasive Functional Imaging Reversible Myocardial Ischaemia? Uncertain Yes No Cardiac Rx: Angina Other Catheter causes

v Non-Invasive Functional Testing Consider availability and expertise:  Myocardial Perfusion Scintigraphy SPECT  Stress Echocardiography  Cardiac MRI with perfusion imaging

v PPP (60-90%) Consider Cardiac Catheterisation NoYes Offer Functional ImagingOffer Cardiac Catheter Reversible IschaemiaSignificant Disease Other Ix Rx as Angina Functional Other Ix Imaging

v Cardiac Catheterisation  Risks  Proceed to PCI  Value in women

v > 90% Probability  No need for investigations  Treat for Angina Further Management:  Progressive Symptoms  Intolerance to medication ANGIOGRAPHY  Associated Symptoms

v What About the Exercise Test?  Poor diagnostic test?  Functional Assessment  Therapeutic Value  Effort Tolerance  Prognostic value  Especially in women  Chronotropic response

v Treatment  Treat with Aspirin and Beta blocker  Be guided by symptoms  Refer to Rapid access Chest Pain Clinic  Treat before considering intervention

v Assumptions about Women  “... Their hormones protect them....”  “... Women represent less risk than men..”  “... Women’s tests are usually false positives

v 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

v Pathophysiology- Differences  Less anatomical obstructive coronary disease  Erosive Coronary disease  Microvascular dysfunction  Abnormal Coronary Reactivity

v 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

v 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

v 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:

v 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 ; 2137

v Peripheral Hypereactivity Rubenstein R 2010 EHJ 31:1142

v Treatment in Women  Restoration of endothelial dysfunction associated with improved prognosis  Risk Factor Modification  Asprin + Statin + ACEI  Imipramine  Ranolazine

v 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 , 1787