1. Case History 1 : Sorting out chest pain in general practice Dr Albert Ko / GP Panel

2. Ascot Cardiology Symposium Dr Albert Ko 2013

3. Presenting Symptoms 70 yrs old male with prolonged cough for 6 months Recent improvement with a 10 day course of AB Associated with rhino-sinusitis and some postnasal discharge Shortness 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!

4. 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

5. Physical Exam and Investigations Regular pulse and normal heart sounds Very mild airflow obstruction on spirometry CXR showed atelectasis at the right lung base with very mild cardiomegaly Suggestions by the respiratory physician Extended the AB for a further 11 days Otrivine and Butacort nasal spray Further investigations such as?

6. Further Investigations BNP given the very mild cardiomegaly on CXR – 186 (normal 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

7. Coronary Angiography

8. Treatment options Medical – Drug therapy Surgical – CABG PCI – Complex multi vessel disease with chronic total occlusion of both the RCA and L Circumflex A

9. LAD – Pre/Post PCI

10. LCx – Pre/Post PCI

11. RCA – Pre/Post PCI

12. Presenting Symptoms 54 years old Handyman with worsening SOB/cough associated with a tight chest after working under a dusty and damp house No CV risk factors Given 3 courses of AB – Roxithromycin with little effect CXR – Possible pleural plaque Referral to Respiratory Physician CT chest – Unremarkable

13. Further Actions He 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

14. Coronary Angiography

15. Treatment Medical – Drug therapy Surgical – CABG PCI – Complex two vessel disease with LAD/diagonal bifurcation stenosis and chronic total occlusion of the RCA

16. LAD/Diagonal Pre/Post PCI

17. RCA Pre/Post PCI

18. Discussion Points Silent 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 SOB GP referral to the appropriate medical sub-specialty can often influence the treatment outcome PCI is non inferior to CABG in expert hands