1. CHEST PAIN ASSESSMENT Jamil Mayet Consultant Cardiologist

2. Progression of the Atherosclerotic Plaque Fibrous Cap Lipid Core Platelets Thrombus Rupture and haematoma Lumen Lipid Core Smooth Muscle Cells Lumen Fibrous Cap Lumen Lipid Core Macrophages UnstableStable

3. Myocardial 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 patientsMI is the first presentation of IHD in 50% of patients

4. Unstable Angina 0 100,000 UA is as serious a problem as MI UA is as serious a problem as MI 2%–10% treated UA patients will experience an MI prior to discharge 2%–10% treated UA patients will experience an MI prior to discharge As many as 5% die despite hospital treatment for UA As many as 5% die despite hospital treatment for UA 30-day event rate (death or MI) is 20% despite conventional therapy 30-day event rate (death or MI) is 20% despite conventional therapy MIUA 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 Number of patients 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

5. Stable Angina Pectoris PrevalencePrevalence –1.1% in patients aged 30-59 –2.6% in patients aged over 60

6. Angina Pectoris Stable anginaStable angina –Death/MI rate 3-4.6% per year Fry J. The natural history of angina in a general practice. J Roy Coll of Gen Pract 1976; 26:643-8 Kannel WB, Feinleib M. Natural History of angina in the Framingham Study. Prognosis and Survival. Am J Cardiol 1972; 29:154-62 New onset anginaNew onset angina –Death/MI 14% within 6 months Duncan B, Fulton M, Morrison SL et al. Prognosis of new and worsening angina pectoris. Brit Med J 1976; 1: 981-5

7. Chest Pain Assessment ChallengesChallenges –Making a correct diagnosis –Early risk stratification –Symptom relief –Optimal treatment of high risk patients

8. Assessment of chronic chest pain History of painHistory of pain –Exertional Likelihood of anginaLikelihood of angina –Risk factors ECGECG ECG with provocationECG with provocation –Exercise ECG, nuclear scan, stress echo Angiography for diagnosisAngiography for diagnosis

9. Assessment of chest pain AngiographyAngiography –For diagnosis –For assessing risk –For assessing suitability for PTCA / CABG DO NOT UNDERESTIMATE THE LIFESTYLE RESTRICTION OF ANGINADO NOT UNDERESTIMATE THE LIFESTYLE RESTRICTION OF ANGINA

11. Treatment of angina AspirinAspirin Oral anti-anginalsOral anti-anginals –Beta-blockers, nitrates, ca antagonists, nicorandil Sub-lingual GTNSub-lingual GTN Secondary preventionSecondary prevention

12. History : The pain >50% who describe one of these have anginal pain CrushingCrushing Heavy, pressureHeavy, pressure TightTight 40% who describe one of these have anginal pain BurningBurning IndigestionIndigestion 4 times risk of anginal pain if patient’s pain radiates to Jaw or Shoulder or Arm

13. Presentation ECG in acute coronary syndromes Early mortalityEarly mortality –LBBB20% –Anterior ST elevation12% –Inferior ST elevation8% –ST depression15% –Normal ECG2%

14. Initial ECG UAAMI Normal43%10%Normal43%10% T inversion26%14%T inversion26%14% ST depression20%20%ST depression20%20% ST elevation45%ST elevation45% BBB 11%11%?BBB 11%11%? Hamm Rouan NEJM 1997 AJC 1989 NEJM 1997 AJC 1989

15. ECG If it shows changes which may be acute this objective information outweighs any clinical opinion that may have been gathered from history & examinationIf it shows changes which may be acute this objective information outweighs any clinical opinion that may have been gathered from history & examination If it is normal it has not helped. The patient may be having an AMI or unstable anginaIf it is normal it has not helped. The patient may be having an AMI or unstable angina Early changes are subtleEarly changes are subtle Inexperienced doctors miss 20% significant abnormalitiesInexperienced doctors miss 20% significant abnormalities

16. Troponin for risk stratification Lindahl et al. NEJM 2000 Troponin T

17. Defibrillation Primary VF rate post MI 5%Primary VF rate post MI 5% Success of DC Shock 90%Success of DC Shock 90% National Service Framework: People with symptoms of possible MI should receive help from appropriately trained person with a defibrillator within 8 minutes

18. Management of ACS General principles Risk stratificationRisk stratification Appropriate acute medical managementAppropriate acute medical management Identify coronary anatomy in high risk patients; otherwise stress imagingIdentify coronary anatomy in high risk patients; otherwise stress imaging PCI vs. CABG based on extent of coronary disease, LV function and presence of co-morbid factorsPCI vs. CABG based on extent of coronary disease, LV function and presence of co-morbid factors Long term medical management; risk factor modificationLong term medical management; risk factor modification

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

21. Therapeutic options Antiplatelet TherapyAntiplatelet Therapy –Aspirin, Thienopyridines, GP IIb/IIIa inhibitors Anti-CoagulantsAnti-Coagulants –LMWH Anti-Ischaemic TherapyAnti-Ischaemic Therapy –Beta-Blockers, Nitrates, Ca Antagonists, Nicorandil Coronary RevascularisationCoronary Revascularisation Secondary PreventionSecondary Prevention –Statins –ACE Inhibitors

22. Effect of Anti-platelet Drugs on Vascular 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 MIAcute MIPrior CVA / TIAOther riskPrimary Prevention 0 5 10 15 20 25 Anti-platelet drugs Placebo 36 38 37 23 4

23. Hazard Rates for CV death, MI, CVA CURE STUDY Lancet 2001;358:527-33 Month

24. Clopidogrel in ACS PCI - CURE Lancet 2001;358:527-33

25. Troponin Positive (Death/MI 30 days)

26. Heparin Vs LMWH in ACS Pooled data from TIMI IIB & ESSENCE Trials Endpoint: Death/MI/Urgent Revascu;arisation Antman et al., Circ 1999;100:1602

27. IV Beta-Blocker & MI in Thrombolytic Era (TIMI-IIB) 5.4 2.7 13.7 5.1 Mortality (Rx in 2hrs) Reinfarction 0 2 4 6 8 10 12 14 16 Rate (%) iv Beta-Blocker Control p=0.01 p=0.02

29. PTCA and stenting

30. Secondary Prevention / Communication Address coronary risk factorsAddress coronary risk factors Communication with primary care needs to be perceived as a hospital priorityCommunication with primary care needs to be perceived as a hospital priority –For patient safety –For addressing secondary prevention –For building GP registries