CHEST PAIN ASSESSMENTJamil MayetConsultant Cardiologist

Progression of the Atherosclerotic PlaqueFibrous CapLipid CorePlateletsThrombusRupture andhaematomaLumenLipid CoreSmooth Muscle CellsLumenFibrous CapLumenLipid CoreMacrophagesUnstableStable

Myocardial infarction

Overall MI death rate 30-40%50% deaths prior to hospital admissionMI is the first presentation of IHD in 50% of patients

Unstable Angina0100,000

UA is as serious a problem as MI2%10% treated UA patients will experience an MI prior to discharge As many as 5% die despite hospital treatment for UA30-day event rate (death or MI) is 20% despite conventional therapy MIUAWhite. Am J Cardiol. 1997;80:2B10B, Landau et al. N Engl J Med.1994;330:981993, Klootwijk et al. Lancet. 1999;353(suppl):1015, Balsano et al. Circulation. 1990;82:1726Number of patients651,000747,000200,000300,000400,000500,000600,000700,000800,000900,0001,000,000Discharge diagnosis

Stable Angina PectorisPrevalence1.1% in patients aged 30-592.6% in patients aged over 60

Angina PectorisStable anginaDeath/MI rate 3-4.6% per yearFry J. The natural history of angina in a general practice. J Roy Coll of Gen Pract 1976; 26:643-8 Kannel 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 monthsDuncan B, Fulton M, Morrison SL et al. Prognosis of new and worsening angina pectoris. Brit Med J 1976; 1: 981-5

Chest Pain Assessment

ChallengesMaking a correct diagnosis Early risk stratificationSymptom reliefOptimal treatment of high risk patients

Assessment of chronic chest painHistory of painExertionalLikelihood of anginaRisk factorsECGECG with provocationExercise ECG, nuclear scan, stress echoAngiography for diagnosis

Assessment of chest painAngiographyFor diagnosisFor assessing riskFor assessing suitability for PTCA / CABG

DO NOT UNDERESTIMATE THE LIFESTYLE RESTRICTION OF ANGINA

Treatment of anginaAspirinOral anti-anginalsBeta-blockers, nitrates, ca antagonists, nicorandilSub-lingual GTNSecondary prevention

History : The pain>50% who describe one of these have anginal painCrushingHeavy, pressureTight40% who describe one of these have anginal painBurningIndigestion4 times risk of anginal pain if patients pain radiates to Jaw or Shoulder or Arm

Presentation ECG in acute coronary syndromesEarly mortalityLBBB20%Anterior ST elevation12%Inferior ST elevation8%ST depression15%Normal ECG2%

Initial ECG UAAMINormal43%10%T inversion26%14%ST depression20%20%ST elevation45%BBB 11%11%? Hamm Rouan NEJM 1997 AJC 1989

ECGIf it shows changes which may be acute this objective information outweighs any clinical opinion that may have been gathered from history & examinationIf it is normal it has not helped. The patient may be having an AMI or unstable angina Early changes are subtleInexperienced doctors miss 20% significant abnormalities

Troponin for risk stratificationLindahl et al. NEJM 2000Troponin T

DefibrillationPrimary 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

Management of ACS General principles Risk stratificationAppropriate acute medical managementIdentify coronary anatomy in high risk patients; otherwise stress imagingPCI vs. CABG based on extent of coronary disease, LV function and presence of co-morbid factorsLong term medical management; risk factor modification

National Service Framework: Possible MI patients should be assessed professionally and, if indicated, receive aspirin and thrombolysis within 60 minutes of the call for helpThrombolysis for AMI

Therapeutic optionsAntiplatelet TherapyAspirin, Thienopyridines, GP IIb/IIIa inhibitorsAnti-CoagulantsLMWHAnti-Ischaemic TherapyBeta-Blockers, Nitrates, Ca Antagonists, NicorandilCoronary RevascularisationSecondary PreventionStatinsACE Inhibitors

Effect of Anti-platelet Drugs on Vascular Events ( Death, MI, CVA)13.510.618.46.94.4617.114.422.29.24.85Prior MIAcute MIPrior CVA / TIAOther riskPrimary Prevention0510152025Anti-platelet drugsPlacebo363837234

Hazard Rates for CV death, MI, CVA CURE STUDYLancet 2001;358:527-33Month

Clopidogrel in ACS PCI - CURELancet 2001;358:527-33

Troponin Positive (Death/MI 30 days)

Troponin +

5.819.6

3.711.3

6.619.4

6.921.7

1119

4.810.3

abciximab, tirofiban, lamifiban, lefradafiban

placebo

5.8

3.7

6.6

4.8

6.9

10.3

19.6

11.3

19.4

21.7

Troponin -

4.95.2

4.65.3

5.17.1

7.19.6

7.810.4

00

Placebo

abciximab, tirofiban, lamifiban

Asprin

11.16

1.372.07

1.392.59

1.84.16

asprin

Placebo

1.8

1.39

1.37

4.16

2.59

2.07

1.16

Diagramm1

0.70.330.17

0.510.510.3

0.520.480.3

0.530.450.27

1.20.80.5

0.550.60.3

0.530.50.3

0.250.20.1

Diagramm1 (2)

0.70.330.17

0.510.510.3

0.520.480.3

0.530.450.27

1.20.80.5

0.550.60.3

0.530.50.3

0.250.20.1

Tabelle1

placeboabciximab, tirofiban, lamifiban, lefradafibanPlaceboasprin

CAPTURE19.65.811.161

PRISMMed11.33.722.071.37

PRISMPCI19.46.632.591.39

PRISM+21.76.944.161.8

ParagonB1911

FROST10.34.8

placeboabciximab, tirofiban, lamifiban, lefradafiban

CAPTURE4.95.2

PRISMMed4.65.3

PRISMPCI5.17.1

PRISM+7.19.6

ParagonB7.810.4

FROST00

All pts0.70.330.17

Diabetes0.510.510.3

Smoker0.520.480.3

Age > 650.530.450.27

CK-MB1.20.80.5

ST depr.0.550.60.3

T invers.0.530.50.3

TnT pos0.250.20.1

Tabelle2

BraunwaldClass IIIB24 h30 Days6 mo.

5%15-20 %25 %

Heparin Vs LMWH in ACS Pooled data from TIMI IIB & ESSENCE TrialsEndpoint: Death/MI/Urgent Revascu;arisationAntman et al., Circ 1999;100:1602

IV Beta-Blocker & MI in Thrombolytic Era(TIMI-IIB)5.42.713.75.1Mortality (Rx in 2hrs)Reinfarction0246810121416Rate (%)iv Beta-BlockerControlp=0.01p=0.02

PTCA and stenting

Secondary Prevention / CommunicationAddress coronary risk factorsCommunication with primary care needs to be perceived as a hospital priorityFor patient safetyFor addressing secondary preventionFor building GP registries