CHEST PAIN ASSESSMENTCHEST PAIN ASSESSMENT

Jamil MayetJamil Mayet

Consultant CardiologistConsultant Cardiologist

Progression of the Atherosclerotic PlaqueProgression of the Atherosclerotic Plaque

Fibrous Fibrous CapCap

Lipid Lipid

CoreCore PlateletsPlatelets

ThrombusThrombus

Rupture andRupture andhaematomahaematoma

LumenLumenLipid Lipid

CoreCore

Smooth Smooth MuscleMuscleCellsCellsLumenLumen

Fibrous Fibrous CapCap

Lumen

Lipid Lipid

CoreCoreMacrophagesMacrophages

Unstable Stable

Myocardial infarctionMyocardial infarction

• Overall MI death rate 30-40%Overall MI death rate 30-40%• 50% deaths prior to hospital admission50% deaths prior to hospital admission• MI is the first presentation of IHD in 50% of MI is the first presentation of IHD in 50% of

patientspatients

Unstable AnginaUnstable Angina

0

100,000

UA is as serious UA is as serious a problem as MIa problem as MI

2%–10% treated UA 2%–10% treated UA patients will experience patients will experience an MI prior to discharge an MI prior to discharge

As many as 5% die As many as 5% die despite hospital despite hospital treatment for UAtreatment for UA

30-day event rate (death 30-day event rate (death or MI) is 20% despite or MI) is 20% despite conventional therapyconventional therapy

MI UA

White. Am J Cardiol. 1997;80:2B–10B, Landau et al. N Engl J Med.1994;330:981–993, Klootwijk et al. Lancet. 1999;353(suppl):10–15, Balsano et al. Circulation. 1990;82:17–26

Nu

mb

er o

f p

atie

nts

651,000

747,000

200,000

300,000

400,000

500,000

600,000

700,000

800,000

900,000

1,000,000

Discharge diagnosis

Stable Angina PectorisStable Angina Pectoris

• PrevalencePrevalence– 1.1% in patients aged 30-591.1% in patients aged 30-59– 2.6% in patients aged over 602.6% in patients aged over 60

Angina PectorisAngina Pectoris• Stable anginaStable angina

– Death/MI rate 3-4.6% per yearDeath/MI rate 3-4.6% per yearFry J. The natural history of angina in a general practice. J Roy Coll of Fry J. The natural history of angina in a general practice. J Roy Coll of Gen Pract 1976; 26:643-8Gen Pract 1976; 26:643-8

Kannel WB, Feinleib M. Natural History of angina in the Framingham Kannel WB, Feinleib M. Natural History of angina in the Framingham Study. Prognosis and Survival. Am J Cardiol 1972; 29:154-62Study. Prognosis and Survival. Am J Cardiol 1972; 29:154-62

• New onset angina New onset angina – Death/MI 14% within 6 monthsDeath/MI 14% within 6 months

Duncan B, Fulton M, Morrison SL et al. Prognosis of new andDuncan B, Fulton M, Morrison SL et al. Prognosis of new and worsening worsening angina pectoris. Brit Med J 1976; 1: 981-5 angina pectoris. Brit Med J 1976; 1: 981-5

Chest Pain AssessmentChest Pain Assessment

• ChallengesChallenges– Making a correct diagnosis Making a correct diagnosis – Early risk stratificationEarly risk stratification– Symptom reliefSymptom relief– Optimal treatment of high risk patientsOptimal treatment of high risk patients

Assessment of chronic chest painAssessment of chronic chest pain

• History of painHistory of pain– ExertionalExertional

• Likelihood of anginaLikelihood of angina– Risk factorsRisk factors

• ECGECG• ECG with provocationECG with provocation

– Exercise ECG, nuclear scan, stress echoExercise ECG, nuclear scan, stress echo

• Angiography for diagnosisAngiography for diagnosis

Assessment of chest painAssessment of chest pain

• AngiographyAngiography– For diagnosisFor diagnosis– For assessing riskFor assessing risk– For assessing suitability for PTCA / CABGFor assessing suitability for PTCA / CABG

• DO NOT UNDERESTIMATE THE DO NOT UNDERESTIMATE THE LIFESTYLE RESTRICTION OF LIFESTYLE RESTRICTION OF ANGINAANGINA

Treatment of anginaTreatment of angina

• AspirinAspirin

• Oral anti-anginalsOral anti-anginals– Beta-blockers, nitrates, ca antagonists, Beta-blockers, nitrates, ca antagonists,

nicorandilnicorandil

• Sub-lingual GTNSub-lingual GTN

• Secondary preventionSecondary prevention

History : The painHistory : The pain>50% who describe one of these have anginal pain>50% who describe one of these have anginal pain• CrushingCrushing• Heavy, pressureHeavy, pressure• TightTight40% who describe one of these have anginal pain40% who describe one of these have anginal pain

• BurningBurning

• IndigestionIndigestion4 times risk of anginal pain if patient’s pain radiates to 4 times risk of anginal pain if patient’s pain radiates to

Jaw Jaw oror Shoulder Shoulder oror Arm Arm

Presentation ECG in acute Presentation ECG in acute coronary syndromescoronary syndromes

• Early mortalityEarly mortality– LBBBLBBB 20%20%– Anterior ST elevationAnterior ST elevation 12%12%– Inferior ST elevationInferior ST elevation 8%8%– ST depressionST depression 15%15%– Normal ECGNormal ECG 2%2%

Initial ECGInitial ECG

UAUA AMIAMI

• NormalNormal 43%43% 10%10%

• T inversionT inversion 26%26% 14%14%

• ST depressionST depression 20%20% 20%20%

• ST elevationST elevation 45%45%

• BBB BBB 11% 11% 11%?11%?

Hamm Hamm Rouan Rouan

NEJM 1997 NEJM 1997 AJC 1989AJC 1989

ECGECG

• If it shows changes which may be acute this If it shows changes which may be acute this objective information outweighs any clinical objective information outweighs any clinical opinion that may have been gathered from opinion that may have been gathered from history & examinationhistory & examination

• If it is normal it has not helped. The patient If it is normal it has not helped. The patient

may be having an AMImay be having an AMI or unstable angina or unstable angina

• Early changes are subtleEarly changes are subtle

• Inexperienced doctors miss 20% significant Inexperienced doctors miss 20% significant abnormalitiesabnormalities

Troponin for risk stratificationTroponin for risk stratificationTroponin for risk stratificationTroponin for risk stratification

Lindahl et al. NEJM 2000

Troponin TTroponin T

DefibrillationDefibrillation

• Primary VF rate post MIPrimary VF rate post MI 5% 5%• Success of DC ShockSuccess of DC Shock 90% 90%

National Service Framework: People National Service Framework: People with symptoms of possible MI with symptoms of possible MI should receive help from should receive help from appropriately trained person with a appropriately trained person with a defibrillator within 8 minutesdefibrillator within 8 minutes

Management of ACSManagement of ACSGeneral principlesGeneral principles

• Risk stratificationRisk stratification• Appropriate acute medical managementAppropriate acute medical management• Identify coronary anatomy in high risk patients; Identify coronary anatomy in high risk patients;

otherwise stress imagingotherwise stress imaging• PCI vs. CABG based on extent of coronary PCI vs. CABG based on extent of coronary

disease, LV function and presence of co-morbid disease, LV function and presence of co-morbid factorsfactors

• Long term medical management; risk factor Long term medical management; risk factor modificationmodification

Time-Benefit Curve(GISSI-1)

47

2317

10.6

<1Hr <3Hr 3-6Hr 6-9Hr0

10

20

30

40

50

Re d

uc t

ion

i n M

or t

a lit

y (%

)

National Service Framework: Possible MI National Service Framework: Possible MI patients should be assessed professionally and, if patients should be assessed professionally and, if indicated, receive aspirin and thrombolysis indicated, receive aspirin and thrombolysis within 60 minutes of the call for helpwithin 60 minutes of the call for help

Thrombolysis for AMIThrombolysis for AMI

PTCA vs ThrombolysisMajor complications

1.9 2.2

0

8.1

5.9

2.8

Reinfarction Death Stroke0

2

4

6

8

10

Pa

tie

nts

(%

)

PTCA

Lysis

P=0.001 P=0.02 P=0.003

n = 636 n=539

Therapeutic options

• Antiplatelet TherapyAntiplatelet Therapy– Aspirin, Thienopyridines, GP IIb/IIIa inhibitorsAspirin, Thienopyridines, GP IIb/IIIa inhibitors

• Anti-CoagulantsAnti-Coagulants– LMWHLMWH

• Anti-Ischaemic TherapyAnti-Ischaemic Therapy– Beta-Blockers, Nitrates, Ca Antagonists, Beta-Blockers, Nitrates, Ca Antagonists,

NicorandilNicorandil

• Coronary RevascularisationCoronary Revascularisation• Secondary PreventionSecondary Prevention

– StatinsStatins– ACE InhibitorsACE Inhibitors

Effect of Anti-platelet Drugs on Vascular Effect of Anti-platelet Drugs on Vascular Events ( Death, MI, CVA)Events ( Death, MI, CVA)

13.5

10.6

18.4

6.9

4.46

17.1

14.4

22.2

9.2

4.85

Prior MI Acute MI Prior CVA / TIA Other risk Primary Prevention0

5

10

15

20

25Anti-platelet drugs

Placebo

36 38 37

23 4

Hazard Rates for CV death, MI, CVAHazard Rates for CV death, MI, CVACURE STUDYCURE STUDY

Lancet 2001;358:527-33

Month

Clopidogrel in ACSClopidogrel in ACSPCI - CUREPCI - CURE

Lancet 2001;358:527-33

Troponin Positive (Death/MI 30 days)Troponin Positive (Death/MI 30 days)Troponin Positive (Death/MI 30 days)Troponin Positive (Death/MI 30 days)

Heparin Vs LMWH in ACSHeparin Vs LMWH in ACSPooled data from TIMI IIB & ESSENCE TrialsPooled data from TIMI IIB & ESSENCE Trials

Endpoint: Death/MI/Urgent Revascu;arisation

Antman et al., Circ 1999;100:1602

IV Beta-Blocker & MI in Thrombolytic EraIV Beta-Blocker & MI in Thrombolytic Era(TIMI-IIB)(TIMI-IIB)

5.42.7

13.7

5.1

Mortality (Rx in 2hrs) Reinfarction0

2

4

6

8

10

12

14

16

Rat

e (%

)

iv Beta-Blocker

Control

p=0.01

p=0.02

PTCA and stentingPTCA and stenting

Secondary Prevention / Secondary Prevention / CommunicationCommunication

• Address coronary risk factorsAddress coronary risk factors

• Communication with primary care needs Communication with primary care needs to be perceived as a hospital priorityto be perceived as a hospital priority– For patient safetyFor patient safety– For addressing secondary preventionFor addressing secondary prevention– For building GP registriesFor building GP registries