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CHEST PAIN ASSESSMENT

CHEST PAIN ASSESSMENT. Jamil Mayet Consultant Cardiologist. Progression of the Atherosclerotic Plaque. Lumen. Lipid Core. Macrophages. Smooth Muscle Cells. Rupture and haematoma. Fibrous Cap. Thrombus. Lumen. Lipid Core. Platelets. Fibrous Cap. Lipid Core. Lumen. Unstable.

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CHEST PAIN ASSESSMENT

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  1. CHEST PAIN ASSESSMENT Jamil Mayet Consultant Cardiologist

  2. Progression of the Atherosclerotic Plaque Lumen Lipid Core Macrophages Smooth MuscleCells Rupture and haematoma Fibrous Cap Thrombus Lumen Lipid Core Platelets Fibrous Cap Lipid Core Lumen Unstable Stable

  3. Myocardial infarction • Overall MI death rate 30-40% • 50% deaths prior to hospital admission • MI is the first presentation of IHD in 50% of patients

  4. Unstable Angina 1,000,000 • UA is as serious a problem as MI • 2%–10% treated UA patients will experience an MI prior to discharge • As many as 5% die despite hospital treatment for UA • 30-day event rate (death or MI) is 20% despite conventional therapy 900,000 747,000 800,000 651,000 700,000 Number of patients 600,000 500,000 400,000 300,000 200,000 100,000 0 MI UA Discharge diagnosis 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

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

  6. Angina Pectoris • Stable 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; 26:643-8Kannel WB, Feinleib M. Natural History of angina in the Framingham Study. Prognosis and Survival. Am J Cardiol 1972; 29:154-62 • New onset angina • Death/MI 14% within 6 months Duncan B, Fulton M, Morrison SL et al. Prognosis of new andworsening angina pectoris. Brit Med J 1976; 1: 981-5

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

  8. Assessment of chronic chest pain • History of pain • Exertional • Likelihood of angina • Risk factors • ECG • ECG with provocation • Exercise ECG, nuclear scan, stress echo • Angiography for diagnosis

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

  10. Treatment of angina • Aspirin • Oral anti-anginals • Beta-blockers, nitrates, ca antagonists, nicorandil • Sub-lingual GTN • Secondary prevention

  11. History : The pain • >50% who describe one of these have anginal pain • Crushing • Heavy, pressure • Tight • 40% who describe one of these have anginal pain • Burning • Indigestion • 4 times risk of anginal pain if patient’s pain radiates to • Jaw or Shoulder or Arm

  12. Presentation ECG in acute coronary syndromes • Early mortality • LBBB 20% • Anterior ST elevation 12% • Inferior ST elevation 8% • ST depression 15% • Normal ECG 2%

  13. Initial ECG • UA AMI • Normal 43% 10% • T inversion 26% 14% • ST depression 20% 20% • ST elevation 45% • BBB 11% 11%? • Hamm Rouan • NEJM 1997 AJC 1989

  14. ECG • If 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 AMIor unstable angina • Early changes are subtle • Inexperienced doctors miss 20% significant abnormalities

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

  16. Defibrillation • Primary VF rate post MI 5% • 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

  17. Management of ACSGeneral principles • Risk stratification • Appropriate acute medical management • Identify 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 factors • Long term medical management; risk factor modification

  18. Thrombolysis for AMI • 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

  19. Therapeutic options • Antiplatelet Therapy • Aspirin, Thienopyridines, GP IIb/IIIa inhibitors • Anti-Coagulants • LMWH • Anti-Ischaemic Therapy • Beta-Blockers, Nitrates, Ca Antagonists, Nicorandil • Coronary Revascularisation • Secondary Prevention • Statins • ACE Inhibitors

  20. Effect of Anti-platelet Drugs on Vascular Events ( Death, MI, CVA) 25 37 36 38 Anti-platelet drugs 22.2 Placebo 20 18.4 17.1 4 23 14.4 15 13.5 10.6 9.2 10 6.9 4.85 4.46 5 0 Prior MI Acute MI Prior CVA / TIA Other risk Primary Prevention

  21. Hazard Rates for CV death, MI, CVACURE STUDY Month Lancet 2001;358:527-33

  22. Clopidogrel in ACSPCI - CURE Lancet 2001;358:527-33

  23. Troponin Positive (Death/MI 30 days)

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

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

  26. PTCA and stenting

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

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