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Approach to Chest Pain and Angina Part I Diagnosis and Risk Stratification

Approach to Chest Pain and Angina Part I Diagnosis and Risk Stratification. Mirek Otremba – Revised 2007. References. ACC/AHA Guideline on Chronic Stable Angina ‘02 Circ. 1999; 99:2829-2848 Update in JACC 2003; 41:159-168 www.acc.org CCS Consensus on Chronic Ischemic Heart Disease

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Approach to Chest Pain and Angina Part I Diagnosis and Risk Stratification

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  1. Approach to Chest Pain and AnginaPart IDiagnosis and Risk Stratification Mirek Otremba – Revised 2007

  2. References ACC/AHA Guideline on Chronic Stable Angina ‘02 Circ. 1999; 99:2829-2848 Update in JACC 2003; 41:159-168 www.acc.org CCS Consensus on Chronic Ischemic Heart Disease Can J Cardiol 2000; Vol 16 no. 12: 1515-1535 Chronic Stable Angina NEJM 2005; 352: 2524-34 Noninvasive tests in patients with stable CAD NEJM 2001; 344: 1840-1845

  3. Objectives • How to make the diagnosis of angina or CAD • When to order further testing to make the diagnosis of angina • When to order further testing to determine prognosis (risk stratification) • To understand the limitations of various tests

  4. Clinical Scenario A healthy 50 yr old man experienced 15 minutes of sharp, epigastric, left sided chest pain while mowing the lawn. He stopped and the pain resolved in 5 min. The pain did not radiate and there was no diaphoresis or dyspnea. Does this patient have angina? How would you classify his symptoms? (ie typical, atypical angina, or non-cardiac chest pain)

  5. Classification of chest pain • Typical angina • Atypical angina • Noncardiac chest pain • Substernal chest discomfort with characterstic quality and duration • Provoked by exertion or emotional stress • Relieved by rest or NTG Meets 2 of the above characteristics Meets one or none of the typical characteristics

  6. Classification of severity of angina C C S • Class I • Class II • Class III • Class IV No angina with ordinary physical activity Angina with strenuous/prolonged exertion Early-onset limitation of ordinary activity (2 blocks/1 flight) Worse after meals, in cold temp, or emotional stress Marked limitation of ordinary activity Inability to carry out any physical activity without angina Angina occurs at rest

  7. History and Physical You next ask about risk factors… To increase pre-test probability • Lipids, DM, HTN, smoking, and Fam. Hx • Plus a past hx of PVD, or Stroke …his father had an MI at the age of 50 yrs, and he is unaware of his lipid status.

  8. History and Physical You perform a focused physical looking for signs of heart disease or a non cardiac source of chest pain. On examination he is moderately obese (BMI 30), with a BP 140/80, and HR 80. The cardiac and chest exam is normal. His CBC, lytes, ECG and CXR are all normal What is his pre-test probability of CAD?

  9. Pre-test likelihood of CAD

  10. Is the DIAGNOSIS established after the Hx/Px and initial tests? Does the pt fit into one of the following? • Noncardiac c/p and low pretest prob… • Diagnosis of angina is established (high pretest prob) • Diagnosis is still not clear…(intermediate pretest prob) • No further testing needed. • Pt does not have angina • No further diagnostic testing needed. • Pt needs risk stratification for prognosis • Consider the following tests to make a diagnosis…

  11. Diagnosis of CAD You decide to classify his chest pain as atypical, and estimate his pre-test probability of CAD as intermediate ( 65%) Is this high enough to give him a diagnosis of CAD and start treatment? How would you confirm the diagnosis?

  12. Diagnostic Tests for CAD • ECG Exercise Stress Testing (GXT) • Stress test plus imaging (nuclear or echo) • Pharmacologic testing (dipyridamole-MIBI, or Dobutamine-MIBI/Echo) • Angiography (gold standard test) What test is the most appropriate for him?

  13. DIAGNOSTIC TestsACC/AHA Guidelines Circ. 1999; 99:2829-48 Exercise ECG (GXT) for diagnosis • Class I • Pts with intermediate pretest prob. (with normal ECG) • Class IIa and IIb • Suspected vasospastic angina • Pts with high or low pretest prob of CAD • Class III • Baseline ECG abn. (LBBB, paced ECG, WPW, >1mm ST depression) Click here to see theACC/AHA classification system

  14. Diagnostic Tests Stress imaging studies (nuclear or echo) • Class I • Pts with intermediate pretest prob. and abnormal ECG • Class II • Pts with low or high pretest prob. and abn. ECG Pts unable to exercise… use pharmacological stress • Dypyridamole sestamibi or • Dobutamine echo/sestamibi

  15. Test Characteristics ofNon-invasive testing …for occlusive CAD

  16. 2D ECHO What about rest ECHO in the diagnosis of chest pain or CAD? Class I • Pts with signs of AS or HOCM • Pts with findings of CHF • Class III • Pts with none of the above findings • i.e. routine echo is not indicated in the dx of angina

  17. Angiography (Gold standard) How about angiography for diagnosis? • Class I • Pts who have survived sudden cardiac death • Class II • Pts with uncertain dx after noninvasive tests • Pts who cannot undergo noninvasive tests • Class III • Pts who “want to know” but are low prob.

  18. Diagnostic Testing You decide to order a routine treadmill test. • Exercise time: 10 min (~10 METS) • Symptoms: fatigue, no chest pain. • HR and BP response: appropriate (80% predicted HR) • ECG response: 1mm down sloping ST-segment depression in 3 leads at peak exercise. How do you interpret this result? Does he have CAD? (what is post test probability) What is his Prognosis?

  19. Interpreting Exercise Tests 4 components to interpreting a stress test 1. Symptoms (angina) during or after the test 2. ECG changes during or after exercise ST depression > 1mm 80ms after J point ST elevation 3. Hemodynamic response to exercise (HR and BP change) 4. Workload in METs Need to consider all 4 parts when interpreting test • For prognosis: • workload in METs is more important than ST changes • Use the Duke Treadmill Score to calculate risk/prognosis

  20. Our patient: Fagan Nomogram Post-test probability of CAD = 85% DTS score = 5 (formula and interpretation later)

  21. Clinical symptoms may not predict coronary artery disease burden Similar for women

  22. Risk Stratification

  23. Risk Stratification Once the clinical diagnosis of angina is probable or confirmed then the pt needs risk assessment The choice of test is based on the pt’s ECG and physical ability • Normal ECG – may use GXT (click to see AHA) • With an abnormal ECG use stress imaging • If unable to exercise use pharmacological stress • For some patients angiography may be the best initial test (click to see AHA)

  24. DTS = [exercise time (mins)] – [ 5 x ST segment deviation (mm)] – [ 4 x angina index ] Duke Treadmill Score (DTS) 0 no angina 1 angina occurs 2 angina reason for stopping test

  25. Imaging in risk stratification • Nuclear Imaging • Normal imaging predicts good prognosis (<1 %/yr) • Stress Echo • A negative test predicts a low risk for future events

  26. Risk dictates management Our Patient: DTS 5 = Low Risk Annual mortality = 0.25% • Predicted annual mortality < 1 % • can be managed medically • Pts with mortality 1-3 % / yr • consider either cath or exercise imaging study for further risk assessment • Pts with mortality >3 % / yr • should be referred for cath.

  27. Summary • Start with the Hx and P/E • estimate the pre-test probability of CAD • Decide whether the patient needs testing • to make a diagnosis of CAD or • the diagnosis established clinically, but need testing to determine prognosis. • Make decisions about therapy • medical vs. PCI/CABG • based on the patient’s risk assessment

  28. THE END

  29. ACC/AHA Classification System Class I: Conditions for which there is evidence and/or general agreement that a given procedure or treatment is useful or effective. Class II: Conditions for which there is conflicting evidence and/or divergence of opinion about the usefulness/efficacy of a procedure or treatment. Class IIa: weight of evidence/opinion in favor of usefulness ClassIIb: Usefulness less well established Class III: Conditions for which there is evidence and/or general agreement that the procedure/treatment is not useful/effective and in some cases may be harmful. Go Back

  30. Exercise Testing for Risk Stratification Exercise Testing for risk stratification and prognosis • Class I • Pts undergoing initial evaluation • Pts with significant change in symptoms • Class III • Pts with severe comorbidity and not appropriate for revascularization Go Back

  31. Angiography for Risk Stratification Angiography for risk assessment • Class I • Pts with CCS III or IV angina • Pts with high risk noninvasive tests • Pts with angina and CHF or poor LV function • Class III • Pts with angina responding to medical Tx and low risk or normal stress test Go Back

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