1. Referring in to the Chest pain pathway: The Primary Assessment Dr Ivan Benett 3/22/2011Dr Ivan Benett GPwSI Cardiology

2. Chest pain is a common presentation in primary care 20 - 40% of people present with chest pain during their lifetime. ≈1.5% of the general population consult a primary care physician each year because of chest pain symptoms. 1-3% of all primary care consultations. ≈5% of visits to emergency departments, ≈40% of emergency admissions are due to chest pain. Ruigomez A et al. Chest pain in general practice: incidence, comorbidity and mortality Family Practice 2006 23(2):167-174 Dr Ivan Benett GPwSI Cardiology3/22/2011

3. Causes of chest pain presenting to primary care Verdon F et al Chest pain in daily practice: occurrence, causes and management. Swiss Med Weekly2008;13(23-24):340-347 672 (2.7%) of consultations from 24,620 patients over 6 years 11 died in the first year after FU of which 5 from CVD Dr Ivan Benett GPwSI Cardiology3/22/2011

4. Ruigomez A et al. Chest pain in general practice: incidence, comorbidity and mortality Family Practice 2006 23(2):167-174 13 740 patients with a first diagnosis of unspecified chest pain and 20 000 age- and sex-matched controls identified from the UK General Practice Research Database. Dr Ivan Benett GPwSI Cardiology3/22/2011

5. The chest pain referral pathway Rapid Access Chest Pain Clinic  Only a minority turn out to have coronary disease  Tariff £200+ per new referral  ETT unhelpful in those of medium risk (esp. Women)  NICE – Functional imaging or Ca score Dr Ivan Benett GPwSI Cardiology3/22/2011

6. Clinical assessment of chronic chest pain. Anginal pain is : constricting discomfort in the front of the chest, or in the neck, shoulder, jaw or arms precipitated by physical exertion (or emotional stress) relieved by rest or GTN within about 5 minutes Three of the features above are defined as typical angina Two of the three features above are defined as atypical angina One or none of the features above are defined as non-anginal chest pain Management of chest pain of recent onset CG95 Dr Ivan Benett GPwSI Cardiology3/22/2011

7. Primary Assessment History Stable Angina - an episodic clinical manifestation of ischemic heart disease presenting as retrosternal chest discomfort or pain precipitated by stress or exertion that rapidly resolves with resting or nitrates. Examination & Investigation Q-Risk Pulse & BP Auscultation – Listen to the Heart for murmurs FBC, fasting BS & lipids, U&Es, TFTs ECG RISK STRATIFICATION Dr Ivan Benett GPwSI Cardiology3/22/2011

8. Diagnostic strategy for chest pain of recent onset Don’t investigate non-anginal pain routinely < 10% - no further investigation 10-30% - rule out test e.g. CT Ca score 30-60% - rule in test by functional imaging 61-90% - invasive coronary angiography 90% (with typical angina- no further investigation needed for diagnosis Management of chest pain of recent onset CG95 Dr Ivan Benett GPwSI Cardiology3/22/2011

9. Prior probability (%) of having coronary disease AgeNon-angina painAtypical anginaTypical Angina MenWomenMenWomenMenWomen LowHiLowHiLowHiLowHiLowHiLowHi 353 11985923930881078 45947222217054351922079 5523594254579104780953882 6549699297186205193975684 >70Men assume >90 if atypical or typical, Women >90% if typical and high risk, otherwise 30-60% Reassurance Functional Imaging Calcium score Invasive angiography No need for further diagnostic tests Adapted from Pryor DB, Shaw L, McCants CB et al. (1993) Value of the history and physical in identifying patients at increased risk for coronary artery disease. Annals of Internal Medicine 118(2): 81–90 Hi = High risk = diabetes, smoking and hyperlipidaemia (total cholesterol > 6.47 mmol/litre). Lo = Low risk = none of these three. Dr Ivan Benett GPwSI Cardiology 3/22/2011

10. Chest Pain Gateway Dr Ivan Benett GPwSI Cardiology3/22/2011