Rapid assessment of chest pain Dr Phil Avery Prince Philip Hospital Hywel Dda Health Board PCCS 18 th May 2011

Angina Common symptom reflecting obstructive CAD A clinical diagnosis based on the doctors interpretation of the patients story Tests are required to evaluate risk and optimise management

Background In the UK: 1% of visits to a GP are because of chest pain up to 40% of emergency hospital admissions are because of chest pain almost 2 million people have or have had angina

Anginal Chest Pain Type : Crushing/vice-like (Levines sign) Site : Variable, classically retrosternal But also arms L>R Neck + jaw Can be one or combinations of the above

Stable Angina Precipitated by exertion, emotion, cold winds Gradual onset secs. Relieved by rest within (2-15) mins/ GTN within 2-3 mins. Often associated with shortness of breath

Risk factors that increase suspicion of angina Previous history of documented IHD History of revascularisation (PTCA/CABG) Smoking Hypertension Hyperlipidaemia Diabetes Male sex Family History (male <55/female <65) Older age

Atypical clinical symptoms at presentation Elderly or diabetic patients often present with: – Breathlessness – Tachycardia – Nausea or vomiting – Sweating and clamminess

Chest pain of recent onset Implementing NICE guidance March 2010 NICE clinical guideline 95

Features of stable angina – Constricting discomfort in the front of the chest, neck, shoulders, jaw or arms – Precipitated by physical exertion – Relieved by rest or GTN in about 5 minutes People with – Non-anginal chest pain have one or none of these features Atypical angina: two features Typical angina: all three features

Table 1

Diagnostic testing Estimated likelihood of CAD 10–29% Estimated likelihood of CAD 30–60% Estimated likelihood of CAD 61–90% Offer CT calcium scoringOffer non-invasive functional imaging Offer invasive coronary angiography if appropriate If CT calcium score is: zero, investigate other causes of chest pain 1 – 400, offer 64-slice (or above) CT coronary angiography >400, follow pathway for 61 – 90% CAD If reversible myocardial ischaemia uncertain, offer invasive coronary angiography Offer non-invasive functional imaging if invasive coronary angiography not appropriate If significant CAD uncertain, offer non-invasive functional imaging

Exercise ECG The accuracy of the test depends on prevalence in that population Gives mostly prognostic information Most useful in middle aged men with atypical symptoms where pre-test probability 30-70% 70% sensitivity CAD 80%specificity 20% false +ve in women Not useful as screening test in asymptomatic individuals

High Risk Significant ST depression with pain stage I or II. High incidence of CAD Slow ST recovery Fall in systolic BP > 20mmHg Angina within 6 min with or without ST change Dangerous arrhythmia

Low Risk Able to reach stage 3 with no ST change Able to reach stage 4, despite ST change Negative test at stage IV < 1% chance of severe CAD Statistics: Angina and ST depression of 1mm gives a predictive accuracy of 90% Overall sensitivity 66% specificity 79%

Important causes of non-cardiac chest Pain Pulmonary embolus Aortic dissection Pericarditis Pleurisy GI Mucsuloskeletal

Clinical skills Rapid access chest pain clinic started Llanelli 2002 Clinical history not automatic ETT Assessment by experienced clinician, consultant associate specialist or GP with special interest Between 2002 and patients seen and 366 (51%) discharge on day as non cardiac on clinical history and resting ECG alone Were we right?

Follow up patients of the 366 had been readmitted Notes found on all patients, none had been admitted with a cardiac problem 6 patients had died 5 died of non cardiac cause 1 cause of death unknown