Case History 1 : Sorting out chest pain in general

practiceDr Albert Ko / GP Panel

Case Presentation 1Ascot Cardiology Symposium

Dr Albert Ko2013

Presenting Symptoms70 yrs old male with prolonged cough for 6 months Recent improvement with a 10 day course of ABAssociated with rhino-sinusitis and some postnasal

dischargeShortness of breath on exertion with reduced exercise

capacity The cough mainly started while he was away yachting

at the world championship in the US and won!

What would you do? Do nothing, offer reassurance that he is better than

most 70 years old

Refer to a respiratory physician

Refer to a cardiologist

Physical Exam and InvestigationsRegular pulse and normal heart soundsVery mild airflow obstruction on spirometryCXR showed atelectasis at the right lung base with

very mild cardiomegaly

Suggestions by the respiratory physicianExtended the AB for a further 11 daysOtrivine and Butacort nasal sprayFurther investigations such as?

Further InvestigationsBNP given the very mild cardiomegaly on CXR – 186

(normal <35 and clear cut LVF >400)Echocardiogram – Multiple regional wall motion

abnormalities with mild reduction in overall systolic function

Resting ECG – Symmetrical T inversion in the inferior and lateral leads (normal 6/12 ago)

ESE – Little improvement in LV contractility after 7 min of the Bruce Protocol and stopping due to SOB. He had no CP

Coronary Angiography

Treatment optionsMedical – Drug therapy

Surgical – CABG

PCI – Complex multi vessel disease with chronic total occlusion of both

the RCA and L Circumflex A

LAD – Pre/Post PCI

LCx – Pre/Post PCI

RCA – Pre/Post PCI

Presenting Symptoms54 years old Handyman with worsening SOB/cough

associated with a tight chest after working under a dusty and damp house

No CV risk factorsGiven 3 courses of AB – Roxithromycin with little

effectCXR – Possible pleural plaqueReferral to Respiratory Physician CT chest – Unremarkable

Further ActionsHe was not better and got to the stage where he

became very limited in his ET yet he still continued to work and took Panadol for it

Referred to Cardiology just prior to Christmas

ESE – Positive at 5 min with worsening CP and SOB associated with significant ST depression and wall motion abnormality

Coronary Angiography

Treatment Medical – Drug therapy

Surgical – CABG

PCI – Complex two vessel disease with LAD/diagonal bifurcation

stenosis and chronic total occlusion of the RCA

LAD/Diagonal Pre/Post PCI

RCA Pre/Post PCI

Discussion PointsSilent Ischemia – A proportion of patients never has

any chest pain SOBOE – Angina equivalent The merit of BNP in sorting out cardiac verse

respiratory cause of Cough and SOBGP referral to the appropriate medical sub-specialty

can often influence the treatment outcomePCI is non inferior to CABG in expert hands