Chest Pain: Assessment of Patients with Suspected Cardiac Chest Pain

Question 1

If you suspect someone has cardiac chest pain, what should you ask as part of the history?

Answer 1

1. Do they currently have chest pain?
2. When was their last episode and how long did it last for?
   
   • it amy indicate ACS if it lasts longer than 15 minutes.
3. Presence of CV risk factors?
4. Hx of IHD.
5. Where is the pain? - pain in the chest (e.g. arms, back or jaw)
6. N&V, sweating, SOB?
7. Exertional?

Question 2

What should your immediate management be for someone presenting with acute cardiac chest pain?

Answer 2

1. GTN spray
2. Aspirin 300mg
3. Only give O2 if sats <94% (Aim for sats of 88-92% if COPD- at risk of hypercapnoeic respiratory failure)
4. Perform an ECG.

Question 3

Describe the referral time frames and what should be done according to NICE if someone has ACS?

Answer 3

• Emergency admission
  
  • Current suspected ACS chest pain
  • Chest pain in the last 12 hours with an abnormal ECG or ECG not available.
• Refer to hospital the same-day for assessment
  
  • Chest pain 12-72 hours.
  • Chest pain in the last 12 hours but are now pain free with a normal ECG.
• Refer to hospital for either emergency or urgent same day assessment (Use clinical judgement)
  
  • Pain is resolved.
  • There are signs of complications.
• If suspected was >72 hours ago with no complications:
  
  • Perform full assessment - haemodynamic status, signs of complciations like pulmonary oedema or shock and signs of non-coronary cause like aortic dissection.
  • ECG
  • Troponin measurement before deciding upon further action
  • Use clinical judgement regarding urgency of the referral to secondary care.

Question 4

How do NICE define stable anginal chest pain?

How do they disctinguish between typical, atypical and non-anginal chest pain.

Answer 4

1. Constricting discomfort in the front of the chest, neck, shoulders, jaw or arms
2. Precipitated by physical exertion
3. Relieved by rest or GTN in about 5 minutes

• Patients with all 3 features have typical angina
• Patients with 2 of the above features have atypical angina
• Patients with 1 or none of the above features have non-anginal chest pain

Question 5

If they have typical angina symptoms and a risk of CAD >90%, what diagnostic tests do you need to do and how do you manage them?

Answer 5

They should be treated as having angina with no more diagnostic tests need to be done.

Question 6

What do you assume in men >70 years with typical or atypical anginal chest pain?

Answer 6

That they have a CAD risk of >90%

Question 7

What do you assume in women >70 with anginal chest pain but who are low risk?

Answer 7

Assume an estimate of 61–90%

Question 8

What do you assume in women >70 who have typical anginal chest pain but who are high risk?

Answer 8

Assume they have a CAD risk of >90%

Question 9

What are the 3 conditions that make someone high risk for CAD according to the complicated NICE table?

Answer 9

• Diabetes
• Smoking
• Hyperlipidaemia (Total cholesterol >6.47 mmol/L)

Question 10

If someone has an estimated likelihood of CAD of 61-90%, what diagnostic tests should be done?

Answer 10

Invasive coronary angiography

Question 11

If someone has an estimated likelihood of CAD of 30-60%, what diagnostic tests can be done?

Answer 11

Non-invasive Functional imaging, for example:

• Myocardial perfusion scan with SPECT
• Stress echocardiography
• First-pass contrast-enhanced magnetic resonance (MR) perfusion
• MR imaging for stress-induced wall motion abnormalities.

Question 12

If someone has an estimated likelihood of CAD of 10-29%, what diagnostic tests should be done?

Answer 12

CT calcium scoring.

Question 13

If someone has an estimated likelihood of CAD of <10%, what should be done?

Answer 13

Consider investigating other causes of chest pain (e.g. hypertrophic cardiomyopathy)

Question 14

For all people being investigated for angina, what should also be done?

Answer 14

Blood tests

• TFTs
• FBC - anaemia

Question 15

How do you interpret the CT calcium score in patients who have a CAD of 30-60%

Answer 15

• 0 = consider other causes of chest pain
• 1-400 - offer 64 slice CT coronary angiography
• > 400 - offer invasive coronary angiography.
  
  • If this is not acceptablethen offer non-invasive functional imaging.

Question 16

How does NICe define significant coronary artery disease (CAD)?

Answer 16

1. Significant coronary artery disease (CAD) found during invasive coronary angiography is ≥ 70% diameter stenosis of at least one major epicardial artery segment or ≥ 50% diameter stenosis in the left main coronary artery + Factors intensifying ischaemia.
2. Such factors allow less severe lesions (for example ≥ 50%) to produce angina:
   • Reduced oxygen delivery: anaemia, coronary spasm.
   • Increased oxygen demand: tachycardia, left ventricular hypertrophy.
   • Large mass of ischaemic myocardium: proximally located lesions.
   • Longer lesion length.
   • Factors reducing ischaemia.
3. Such factors may render severe lesions (≥ 70%) asymptomatic:
   
   • Well-developed collateral supply.
   • Small mass of ischaemic myocardium: distally located lesions, old infarction in the territory of coronary supply.

Question 17

What tests do we no longer do anymore to diagnose angina?

Answer 17

Exercise ECGs and MR coronary angiography.

Question 18

Here is the NICE table to roughly be familiar with Angina Risk Stratification and be roughly familiar with who is high or low risk.

Answer 18