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Brian- Midlife (mid forties)Assessment of Chest Pain
Colin EdwardsCardiologist
Waitemata Health
Auckland Heart Group
August 2013
Introduction
CASE 1 Case 2
CHEST PAIN DISCUSSION
Which of the following statements are true?
QUESTIONS
ANSWERS
a) a, c, b) b dc) b cd) All the abovee) Non of the above
a) Acute pericarditis is characterised by global ST depression on ECG.
b) Myopericarditis is a benign condition and pts don’t require hospitalisation.
c) Ischaemic chest pain is usually focal and left sided, often radiates to the left armbut never to the right arm.
d) Patients with low CV risk (Framingham Risk Score) just about never have myocardial infarction (<5%).
e) An exercise treadmill test to a high workload is very accurate (>90%) in excludingflow limiting coronary disease in young patients
CASE 1
Presented to GP with acute severe chest pain
Upper respiratory tract infection 7-10 days ago
Brian – aged 45 yearsPM/SH – nilPrimary school teacher, coaches soccer and referee.
Focal, sharp, left sided, positional (worse on his back, relieved by sitting forwards)Restricted respiration.
CV Risk
Low CV risk
EXAMINATION
chest pain, sitting very still, tachypnoeic
HR=70bpm; BP130/80mmHg; Temp 37,4°C
JVP-not raised; shotty cervical lymph adenopathy
Heart sounds-muffled, ?? pericardial rubChest-pain on inspiration, no pleural rubAbdomen-normalPeripheries-normal
Clinical Assessment
?Pneumonia and Pleurisy or ?Pericarditis – complicating a recent viral infection
Admission ECG
Management
Contacted on-call cardiologist reviewed faxed copy of ECGECG - SR, early ST take-off globally Agreed likely acute pericarditis
Needs admission – CXR, echo- confirm diagnosisPain management
Acute Pericarditis – generally admitted for 24-48 hrs
ECG Changes - Acute Pericarditis
Global concave ST elevation – apart from AVR ST Depression AVRPR depression
CXR(AP)
CTR-55%
Investigations
ANA - neg
Viral serology – negCMV, EBVCoxsackie, HIV
DIAGNOSIS
CONCERNS: CK, TROPONIN
ECG changes + raised troponin Viral Myopericarditis
? Missing ACS (non-atheromatous) e.g. spontaneous coronary dissection
? At risk of developing fulminant myocarditis cardiogenic shock
Admit CCU – Urgent Echo
REASSURING
Mild LV dilatation, low normal LV systolic function
– no evidence of myocardial infarction
No pericardial effusion
Management
Inflammation and chest pain Brufen 400mg tds.
Offload the LV B-Blocker and ACE Inhibitor
Confirm the diagnosis by contrast CMR - 3 day wait
Management cont.
Good response to Brufen- pain free within 45 min.
D2- declined the 3rd dose of Brufen.
5pm Day 2 - recurrence of severe chest pain in CCU
Wanted to be discharge – told to wait for CMR
ECG
Repeat bedside Echo: unchanged
Vaso-vagal episode SBP = 60mmHg
CORONARY ANGIOGRAPHY
Contrast CMR
BTFE CINET2 SPIR
Late Gadolinium
LV Function LV-inflammation
Treatment at Discharge
Antifailure Therapy:Metoprolol 47.5mg/d, Cilazapril 2.5mg/d
No strenuous exercise 3-6months
Agreed to Brufen and Panadol X 10 days
? Additional anti-inflammatory Therapy? PrednisoneMassive inflammatory responseTo prevent recurrence
Treatment
Prednisone in acute pericarditis has been associated clinical relapse
COPE Trial (Circulation 2005 112 2012-2016):
RESULTS: Recurrence of acute pericarditis with colchicine 0.5mg bd x3months
120 pts with acute pericarditisRandomised to standard therapy vs standard therapy plus colchicine
Aspirin 650mg 6-8hrly x 7 to 10 days- taper over 4 weeksPPIColchicine 1g bd x 2 days, then 0.5g bd x 3 months
Admission 3 Months
LVEDV
(mls)
N-77-195
210 194
LVESV
(mls)
N 19-72
95 82
EF (%) 55 57
Clinically well24 hour holter - no significant arrhythmias
Sudden Death and Acute Myocarditis
Myocarditis accounts for up to 12% of unexplainedSudden Death in youngpatients
Died Suddenly at home initially thought to be due to MIPost mortem no coronary disease; acute myocarditis
Assessment of Chest Discomfort
Causes of Chest Pain in GP Practices
Musculoskeletal - 36%Gastrointestinal - 19%Cardiac - 16% (stable angina 10.5%, ACS-1.5%)Psychiatric – 8%Pulmonary – 5%Other – 16%
Description of Chest Discomfort
Ischaemic chest discomfort:DiffuseSqueezing, tightness, pressure, heavy weight on chest (elephant sitting on chest), like a bra too tight.
Ischaemic chest pain-radiates to the neck, lower jaw and teeth, both L + R arms. Radiation to the R arm is often more indicative of ischaemia
Ischaemic CP comes on gradually, usually lasts 5-10min.Circadian – more likely in the mornings due to sympathetic tone
Provocation and Palliation
Ischaemic Chest pain typically provoked by exertion, cold air, emotional stress.Relieved by rest and GTN spray.
Upper gastrointestinal pathology (peptic ulcer disease) discomfort with meals.Relieved by antacids, PPI.
Pericarditis /Pleurisy:Exacerbation with respirationPericarditis worse lying back, relieved by sitting up and leaning forwards
Case 2Brian at 44 yearsAvid golfer, attends gym 3 x per week, generally fit and wellPM/SH – nil of note, vasectomy
CV RISK
RISK FACTOR PATIENT
Family history early CAD YES-mother PCI @ 50yrs
Smoker No
Diabetes No, Hb A1c-38
Hypertension No BP=120/70mmHg
Lipid profile T Cholesterol 4.6HDL 1.2LDL 3.0Ratio 3.8
Main Complaint:Moving some paving stones- quite short of breath, pale and clammy, lasted 5-10minAttended Gym the following day – no power, had to stop the treadmill – saw his GP onthe way home
CV Risk
Low CV risk
Resting ECG
Exercise Treadmill Test13min30 Bruce Protocol
CTCA
Normal LV size and function
Normal coronary calcium score - 0 Agatson units
CT Angio: severe soft plaque at the ostium of the LAD
Coronary Angiography
Severe ostial LAD stenosis
Stent
CV Risk
Framingham Risk – limitations in assessing CV riskyoung pts, particularly with +ve family history.
CTCA is a very useful tool in more accuratelyassessing CV risk in the younger potentially high risk patient.
ETT – limited accuracy in assessing ischaemia in young and middle aged pts
CV Events versus CV Risk
MAJORITY OF EVENTS OCCUR IN HIGH AND INTERMEDIATE RISKPTS, BUT……
Which of the following statements are true?
QUESTIONS
ANSWERS
a) a, c, b) b dc) b cd) All the abovee) Non of the above
a) Acute pericarditis is characterised by global ST depression on ECG.
b) Myopericarditis is a benign condition and patients don’t require hospitalisation.
c) Ischaemic chest pain is usually focal and left sided, often radiates to the left armbut never to the right arm.
d) Patients with low CV risk (Framingham Risk Score) just about never have acute myocardial infarction (<5%).
e) An exercise treadmill test to a high workload is very accurate (>90%) in excludingflow limiting coronary disease in young patients
