1. Chest pain of recent onset
Dr Dave Smith

2. Introduction
Chest pain is a cause for concern for patients and doctors
Potential serious underlying condition
10% of acute chest pain presentations are due to stable angina
Efficient and effective strategy needed for assessment and management

3. The reasons why we take chest pain seriously
Coronary heart disease (CHD) is the most common cause of death in the UK
1 in 5 men and 1 in 7 women die from the disease
CHD is also the most common cause of premature death in the UK
19% of premature deaths in men and 10% of premature deaths in women were from CHD
Over 2 million people living in UK estimated to have or have had angina

4. “Sorting the wheat from the chaff”
Chest pain is a very common symptom, 20% to 40% of the general population will experience chest pain in their lives
In the UK, at least 1% of visits to a GP are due to chest pain
Approximately 5% of visits to the emergency department are due to a complaint of chest pain, and up to 40% of emergency hospital admissions are due to chest pain

5. The worst end of the ACS spectrum - STEMI

6. But what about NSTEMI and Unstable angina?
Outnumber STEMI 3:1
Increasing incidence

7. Prognosis of ACS

8. 5 year follow up of ACS patients
Rehospitalization:
Average 1.6 per patient
31.2% had >1 admission
9.2% had 5+ admissions
Death:
STEMI (19%) died
non-STEMI (22%)
unstable angina (UA) (17%).
68% of STEMI deaths after hospital discharge
86% for non-STEMI
97% for UA.

9. The reasons why we take chest pain seriously
Total mortality rate in angina patients presenting to rapid access chest pain clinics is 2.8% to 6.6% per annum
Compared with:
1.4% to 6.5% per annum mortality rate for cardiovascular disease
0.3% to 5.5% per annum for non fatal MI
Chest pain or discomfort caused by acute coronary syndromes (ACS) or angina has a potentially poor prognosis, emphasising the importance of prompt and accurate diagnosis

10. Acute versus chronic chest pain
Acute chest pain:
Chest pain / discomfort which has occurred recently and may still be present, is of suspected cardiac origin and which may be due to an acute coronary syndrome (myocardial infarction or unstable angina)

11. Acute chest pain – is it a heart attack?

12. Is pain cardiac in origin?
Is chest pain due to myocardial ischaemia / infarction
Need to consider:
history of the chest pain
presence of cardiovascular risk factors
history of ischaemic heart disease and any previous treatment
previous investigations for chest pain
History is everything!!!!

13. Initial assessment -history
Do they still have pain? When was the last pain? Within the last 12 hours?
Initially assess people for any of the following symptoms, which
may indicate an ACS:
Pain in the chest and/or other areas (for example, the arms, back or jaw) lasting longer than 15 minutes
Chest pain associated with nausea and vomiting, marked sweating, breathlessness, or particularly a combination of these
Chest pain associated with haemodynamic instability
New onset chest pain, or abrupt deterioration in previously stable angina, with recurrent chest pain occurring frequently and with little or no exertion, and with episodes often lasting longer than 15 minutes.

14. The do not’s
Do not assess symptoms of an ACS differently in men and women.
Not all people with an ACS present with central chest pain as the
predominant feature
Do not assess symptoms of an ACS differently in ethnic groups.
There are no major differences in symptoms of an ACS among
different ethnic groups.

15. If you suspect ACS Perform 12 lead ECG as soon as possible
ST elevation/ new LBBB
ST depression/ T wave inversion
No ECG changes
PPCI pathway
Admit
Serial ECG’s
Review previous ECG’s
Do not exclude ACS in patients with normal ECG’s

16. Immediate management of ACS
Pain relief – GTN initially
300mg aspirin loading dose
Monitor pulse, blood pressure, O2 sats and heart rhythm
Take blood for troponin measurement
Oxygen is not to be given routinely (unless SpO2 < 94%)
Immediate assessment
Haemodynamic status
Signs of complications – pulmonary oedema, cardiogenic shock
Signs of non-coronary causes of acute chest pain

17. Non-coronary causes of acute chest pain
Investigations to be considered:
Chest x-ray – complications of ACS such as pulmonary oedema
other diagnoses – pneumothorax
– pneumonia
CT chest – rule out other diagnoses such as pulmonary embolism or aortic dissection
– not to diagnose ACS

18. Stable (intermittent) chest pain

19. Angina Pathophysiology
Working definition:
Angina is a symptom of myocardial ischaemia that is recognized clinically by its character, its location and its relation to provocative stimuli.
Relation to CAD:
Angina is usually caused by obstructive CAD that is sufficiently severe to restrict oxygen delivery to the cardiac myocytes.
Generally speaking angiographic luminal obstruction found during invasive
coronary angiography estimated at ≥ 70% is regarded as “severe” and likely
to be a cause of angina, but this will depend on other factors listed below that
influence ischaemia independently of lesion severity.

20. Supply-demand mismatch
Myocardial oxygen demand
Myocardial blood supply

21. Angina Pathphysiology
Factors intensifying ischaemia. Such factors allow less severe lesions
(say ≥ 50%) to produce angina:
Reduced oxygen delivery: anaemia, coronary spasm
Increased oxygen demand: tachycardia, left ventricular
hypertrophy
Large mass of ischaemic myocardium: proximally located and longer lesions

22. Angina Pathphysiology
Factors reducing ischaemia. Such factors may render severe lesions
(≥70%) asymptomatic:
Well developed collateral supply
Small mass of ischaemic myocardium: distally located lesions
Old infarction in the territory of coronary supply

23. Angina Pathophysiology
Angina without epicardial CAD:
When angina with evidence of ischaemia occurs in patients with angiographically “normal” coronary arteries (syndrome X) pathophysiological mechanisms are often unclear.

24. Making a diagnosis of angina
Making a diagnosis of stable angina caused by CAD in people with chest pain is not always straightforward
Clinical assessment alone may be sufficient to confirm or exclude a diagnosis of stable angina, but when there is uncertainty, additional diagnostic testing (functional or anatomical testing) guided by the estimates of likelihood of coronary artery disease is required.
Diagnose stable angina based on one of the following:
clinical assessment alone or
clinical assessment plus diagnostic testing (that is, anatomical testing for obstructive CAD and/or functional testing for myocardial ischaemia).

25. Clinical assessment - history
Take a detailed clinical history documenting:
The age and sex of the person
The characteristics of the pain, including its location, radiation, severity, duration and frequency, and factors that provoke and relieve the pain
Any associated symptoms, such as breathlessness
Any history of angina, MI, coronary revascularisation, or other cardiovascular disease
Any cardiovascular risk factors.
History is everything!!

26. Clinical assessment - examination
Carry out a physical examination to:
Identify risk factors for cardiovascular disease
Identify signs of other cardiovascular disease
Identify non-coronary causes of angina (for example, severe aortic stenosis, cardiomyopathy
Exclude other causes of chest pain.
Examination usually helps diagnose non-coronary disease!!

27. Making a diagnosis on clinical assessment
Anginal pain is:
Constricting discomfort in the front of the chest, or in the neck,
shoulders, jaw, or arms
Precipitated by physical exertion
Relieved by rest or GTN within about 5 minutes.
Use clinical assessment and the typicality of anginal pain features listed below to estimate the likelihood of CAD:
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

28. Typicality of symptoms
Include the typicality of anginal pain features in all requests for diagnostic investigations and in the person's notes.

29. Likelihood of CAD
Removed in 2016

30. Angina more likely
Factors, which make a diagnosis of stable angina more likely:
Increasing age
Whether the person is male
Cardiovascular risk factors including:
A history of smoking
Diabetes
Hypertension
Dyslipidaemia
Family history of premature CAD
Other cardiovascular disease
History of established CAD, for example previous MI, coronary revascularisation

31. Angina less likely
Other features which make a diagnosis of stable angina unlikely are when the chest pain is:
continuous or very prolonged and/or
unrelated to activity and/or
brought on by breathing in and/or
associated with symptoms such as dizziness, palpitations, tingling or difficulty swallowing.

32. Non-anginal chest pain
Consider causes of chest pain other than angina (such as gastrointestinal or musculoskeletal pain).
Only consider chest X-ray if other diagnoses, such as a lung tumour, are suspected.
Do not offer diagnostic testing to people with non-anginal chest pain on clinical assessment unless there are resting ECG ST-T or Q waves.
If a diagnosis of stable angina has been excluded, but people have risk factors for cardiovascular disease, follow the appropriate guidance, for example on cardiovascular disease prevention and hypertension.

33. Initial Investigations
For all patients:
FBC – ?anaemia
U+E’s, TFT’s and glucose
ECG – pathological Q waves
– LBBB
– ST/ T wave changes
CXR – only if alternative diagnoses suspected

34. Diagnostic investigations
First-line: 64-slice CT coronary angiography
Second-line: non-invasive functional testing
Third-line: invasive coronary angiography

35. Diagnostic investigations
First-line: 64-slice CT coronary angiography
Offer 64-slice CT coronary angiography if:
clinical assessment indicates typical or atypical angina, or
clinical assessment indicates non-anginal chest pain but 12-lead resting ECG has been done and indicates ST-T changes or Q waves.

36. Diagnostic investigations
For people with confirmed CAD (for example, previous MI, revascularisation, previous angiography):
offer non-invasive functional testing when there is uncertainty about whether chest pain is caused by myocardial ischaemia.
An exercise ECG may be used instead of functional imaging.

37. Functional Imaging Depends on local availability and expertise:
NICE guidance recommends:
MPS with SPECT or
stress echocardiography or
first-pass contrast-enhanced magnetic resonance perfusion or
MRI for stress-induced wall motion abnormalities.
Exercise ECG testing not recommended to diagnose or exclude stable angina for patients without known CAD
Exercise ECG testing is however recommended in patients with known CAD

38. Confirm diagnosis of stable angina or continue investigations
Confirm a diagnosis of stable angina and follow the recommendations in managing stable angina when:
significant coronary artery disease is found during invasive or 64-slice (or above) CT coronary angiography or
reversible myocardial ischaemia is found during non-invasive functional imaging.

39. What about treadmill testing?
Exercise ECG:
Exercise ECG is widely used for the non invasive detection of myocardial
ischaemia (usually due to obstructive CAD)
Exercise is used to induce stress with either treadmill and cycle ergometer devices, and ECG, blood pressure, heart rate and the development of chest pain and or other symptoms are monitored
Exercise testing is a low-risk investigation even in patients with known CAD, but serious complications occur in 2 to 4 per 1000 tests and death may occur at a rate of 1 to 5 per tests

40. ETT advantages The advantages of exercise testing:
Takes less than 1 hour to perform
It determines exercise capacity
It has a long history of use
Trained personnel are readily available
Myocardial ischaemia is assessed.

41. ETT disadvantages Disadvantages:
Does not localise the coronary territory of ischaemia
Lower sensitivity and specificities compared with other diagnostic tests
May be inappropriate in some patients, for example, in patients with pulmonary or peripheral artery disease and those patients who are unable to walk or pedal a cycle ergometer
Overall diagnostic performance weaker than DSE, MPS, perfusion MR
Less cost effective than other functional imaging modalities

42. CT Coronary angiography
Multislice CT coronary angiography has developed rapidly in recent years.
Pros
Highly effective in the diagnosis of anatomically significant CAD
Relatively low cost
Cons
Limited capacity in CT scanners
However, questions remain about the ability of multislice CT coronary angiography to accurately identify stenoses of functional significance (that is, those that are sufficient to cause angina) in people with stable chest pain.

43. Summary A good history is mandatory and leads your investigations
Examination rarely contributory in coronary disease
Making a diagnosis of stable angina caused by CAD in people with chest pain is not always straightforward
Diagnosis made by clinical assessment alone or
clinical assessment plus diagnostic testing

44. Further reading Chest pain of recent onset: assessment and diagnosis
NICE Clinical guideline (CG95)
Published March 2010
Updated November 2016