Referring in to the Chest pain pathway: The Primary Assessment

1. Referring in to the Chest pain pathway: The Primary Assessment Dr Ivan Benett Dr 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 primarycare physician each year because of chest pain symptoms. • 1-3% ofall primary care consultations. • ≈5% ofvisits to emergency departments, • ≈40% of emergencyadmissions are due to chest pain. RuigomezA et al. Chest pain in general practice: incidence, comorbidity and mortality Family Practice 2006 23(2):167-174 Dr Ivan Benett GPwSI Cardiology

3. Causes of chest pain presenting to primary careVerdon 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 Cardiology

4. Ruigomez A et al. Chest pain in general practice: incidence, comorbidity and mortality Family Practice 200623(2):167-174 13 740 patients with a first diagnosisof unspecified chest pain and 20 000 age- and sex-matched controlsidentified from the UK General Practice Research Database. Dr Ivan Benett GPwSI Cardiology

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 Cardiology

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 Cardiology

7. Primary Assessment History Examination & Investigation Q-Risk Pulse & BP Auscultation – Listen to the Heart for murmurs FBC , fasting BS & lipids, U&Es, TFTs ECG • 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. RISK STRATIFICATION Dr Ivan Benett GPwSI Cardiology

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 Cardiology

9. Hi = High risk = diabetes, smoking and hyperlipidaemia (total cholesterol > 6.47 mmol/litre). Lo = Low risk = none of these three. Calcium score Reassurance Invasive angiography No need for further diagnostic tests Functional Imaging 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 Dr Ivan Benett GPwSI Cardiology

10. Chest Pain Gateway Dr Ivan Benett GPwSI Cardiology