Dr Alasdair Patrick

Gastroenterologist and

General Physician

Middlemore Hospital

8:30 - 9:25 WS #90: Chest Pain

9:35 - 10:30 WS #102: Chest Pain (Repeated)

Mr Patrick GladdingCardiologist and

Internal Medicine

North Shore Hospital

Auckland

Chest Pain Syndromes for GPs

Dr. Patrick Gladding

Ascot Hospital/WDHB

Differential Diagnosis

• Cardiac pain

– Acute MI, angina

– Pericarditis

– Heart failure

– Rare: HCM

• Chest wall pain

• GORD

• Panic disorder/anxiety

• Pneumonia

• PE

• Aortic dissection3

What is the diagnosis?

4

No Troponin level is normal

n = 54,000

Ultra-sensitive troponin

• Ultrasensitive troponin is highly personalised

Clinical Biochemistry 45 (2012) 714–716

Pericarditis ECGs

Case

9

CAD: Not just an Epicardial disease

Remodelling of coronary arterioles

11

Wall stress and pressure

12

13

Intracoronary acetylcholine (ACH) demonstrating constriction of the coronary arteries (arrow)

and intracoronary nitroglycerin (NTG) coronary angiography demonstrating dilation.

C. Noel Bairey Merz, and Carl J. Pepine Circulation.

2011;124:1477-1480

Copyright © American Heart Association, Inc. All rights reserved.

Methods of diagnosis of CMVD

15

SPECT

PET

A new clinical entity

16

Advanced ECG

• Sensitive, high sampling frequency, accurate.

New model of CV disease

18

Diabetes

LVH

CAD

LVER

Hypertension

Chest pain

• 70 year old male with indigestion-like central discomfort,

relieved with belching

• Some exertional component

• PHx HTN, dyslipidaemia, home stress

• Ix

– 12L ECG

– TC 6.5, LDL 4

Options

• Medical Mx

• Refer to Outpatients

• Refer to ED/Inpatient

• Investigations:

– ETT

– ESE

– DSE

– CTCA

Sensitivity 67%

Sensitivity 90%

22

REST STRESS

Dyspnoea

• 53 year old male with breathlessness, not well over Xmas

period

• Keen surfer

• PHx: no conventional risk factors

• Ix

– 12L ECG

Risk factor assessment

• 56 year old male asymptomatic

• PHx HTN, dyslipidaemia

– TC 6.7, HDL 1.1, LDL 4.3, Trig 3.4

• Ix

– 12L ECG

– hs-Troponin

– CAC scoring

CAC versus CTCA

• Diagnostic test for low, intermediate risk

• Will detect soft plaque

• Radiation = one year bkgd(10mSv)

• 1:200 risk of fatal cancer (<x3 risk of pedestrian MVA)

• CAC score

• Low dose radiation (1mSv)

• May miss soft plaque (young pts)

Sensitivity 95-100%

Lifetime risk

Other chest symptoms

• 83 year old male light-headedness

• PHx mildly overweight, HTN

• Meds: Amlodipine 2.5mg od

• Ix

– BP

– 12L ECG

– Mg, K, TSH

30

31

32

ETT

33

4:30 mins

34

CT coronary angiogram

35

Treatment

36

Other chest symptoms

• 46 year old male “heart fluttering”

• PHx vertebral artery dissection, posterior CVA

• Ix

– 12L ECG

– Mg, K, TSH

Palpitations and chest pain

• 62 year old female palpitations

• PHx EtOH 30u/wk, dyslipidaemia (TC 7.6)

• Ix

– 12L ECG

– Mg, K, TSH

– Holter

40

• Holter

report and

diary

• LOW

YIELD

41

Era of Mobile Health

42

43

Differential Diagnosis

• Cardiac pain– Acute MI, angina

– Pericarditis

– Heart failure

– Rare: HCM

• Chest wall pain

• GORD

• Panic disorder/anxiety

• Pneumonia

• PE –– D-dimer 93-95% sensitivity 50% specificity

• Aortic dissection44

Bullet in heart

45

Advanced ECG

46

$3,500

patrickg@theranosticslab.com

Dr Alasdair PatrickGastroenterologist

If it is not the heart….then what is it?

Dr Alasdair PatrickGastroenterologist

MacMurray Gastroenterology

Overview

• Background (Non Cardiac Chest Pain)

– What is it?

– What could it be?

• Investigations of NCCP

• Treatment of NCCP

History

• Huge burden of disease

– 20 at least per day at MMH

– Causes a lot of concern for the patient

• 30% of angiograms are normal

– RF obesity (OR 3), Fam Hx GERD (OR 2.8)

– Aspirin use, smoking

– More common in woman 3:1

– Generates a lot of work for cardiologists!

Always need to rule out a cardiac cause!!

• Good cardiac prognosis if normal angiogram

– Good long term data available

• Lichtlen et al JACC 1995 -Observational study

– 176 patients with normal angio inc LV

– Typical and atypical symptoms

– Median follow up 12.4 years (5.8-15.8)

Cardiac

mortality 0.09%

Does seeing a cardiologist help?

• Robertson et al- Heart May 2007

– All comers to a rapid access chest pain clinic

Does seeing the cardiologist help?

HADS= hospital

anxiety/ depression

scale, 14 four point

questions, over 8

abnormal, HAI=

Hospital anxiety

inventory, 18 qtn

So does NCCP matter?

• There is a significant burden of disease– ½ to 2/3 admitted to ED thought to have NCCP

– Non cardiac chest pain estimated to cost $300M per year in the US

• Prognosis of NCCP at 4 years in Australia– 90% have ongoing symptoms

» Eslick et al NGM 2008

Consultations in preceding 12 months

28% work absentee.

No difference in CCP

vs NCCP

Sydney- Eslick, Talley APT 2004

Does making a diagnosis help?

• Yes!

– 4 year follow up of 104 Spanish patients

– Structured direct telephone interview

– Patients who trusted their medical diagnosis had better Quality of life and less health resource use

– Rox et al: Rev Esp Enferm Dig 2002

What have we learnt so far?

• These patients are younger

• They are anxious– Cardiologists make them worse

• They have an excellent prognosis– But they continue to consult and worry

• Making a diagnosis helps – Improve QALY

– Reduces costs

What is the differential?

• A definitive diagnosis can be made in up to 85% of patients

– Vantrappen, Janssens: Eur Heart J 1986

– Musculoskeletal 15%

– Respiratory

– Psychiatric• Estimated 17-43% of NCCP patients

– Gastroenterology• Commonest cause!

• 30-60% GORD

• 30% motility disorders

• George N APT 2016

How does GORD cause NCCP?

• Possible mechanisms– GORD induced coronary spasm– GORD induced chest wall pain

• Oesophageal chest pain– Chemoreceptors

• Abnormal reflux• Normal reflux with increased sensitivity

– Mechanoreceptors• GORD induced contraction• Motility disorders

– Nutcracker, spasm

GORD induced coronary spasm!

• Coronary blood flow

– 2 studies shown distal acid infusion can change Q

• 51 patients post coronary angiogram had endoscopy, 24 hr pH and manometry

• Underwent Bernstein test with concurrent TOE with LAD perfusion doppler

– 49% significant decrease flow

» They had significant abN pH tests

Rosztoczy et al: Int J Cardiol 2007

Chauhan et al: Eur Heart J 1996

GORD induced chest wall pain!

Sarkar et al; Lancet 356:1154, 2000

Oesophageal chest pain-Chemoreceptors

• Normal reflux with increased sensitivity

– “Normal people reflux 48 times per day”

Sarkar et al; Lancet 356:1154, 2000

Oesophageal chest pain-Mechanoreceptors

• Both circular and longitudinal muscle contraction has been shown to cause pain

– Seen in Motility disorders

• E.g. Nutcracker oesophagus

Balaban et al Gastroent 1999;116:29-37

Now what have we learnt?

• The commonest non cardiac cause of chest pain is the oesophagus

– Reflux

– Motility disorders

• A definitive diagnosis can be made in 85%» Vantrappen, Janssens: Eur Heart J 1986

If making a diagnosis helps what investigations should we do?

• PPI challenge

• Endoscopy

• pH studies

– pH/Impedance

– BRAVO capsule

• Manometry

Meta-analysis of PPI challenge

Findings on endoscopy in NCCP

Dickman et al: Am J Gastro 2007;102:1173-79

Faybush, Fass G Clin NA 2004:33; 41-54

pH/Impedance studies

• ½ abnormal test with 1/3 symptom correlation

Maine et al Gut 2006;55:1398-1402

Value of extended recording timeBRAVO

Prakash, ClouseAm J Gastro 2006; 101(3):446-52

Manometry

Dekel et al APT 2003; 18:1083-89

Treatment of GORD induced NCCP

• Lifestyle advice

• Acid suppression

• Visceral analgesics

– SSRI and TCA

• Nissen fundoplication

– Dissparate results

Conclusion

• NCCP is common and a problem• Oesophageal causes are most common

– Reflux, hypersensitivity, dysmotility

• Primary care rules of thumb– Rule out cardiac cause– PPI challenge (70-80%) respond then refer

• Endoscopy• pH study• Manometry

• Making a diagnosis helps• Thanks

Comparison between cardiology and gastroenterology

Comparison between cardiology and gastroenterology

The only comprehensive digestive disease centre in Auckland

Consultations in a team environment

10 Gastroenterologists

1 Hepatologist

Upper and Lower GI surgeons

Dietician

Health Psychologist

Clinical nurse specialists

The only place with full diagnostic and therapeutic servicesFull endoscopy services

BRAVO

Capsule endoscopy

pH/Impedance

High resolution Manometry

Halo

Breath testing