Chest Pain: Non-Cardiac

Question 1

List the classical symptoms /presentation of cardiac chest pain

Answer 1

sensation in chest of squeezing, heaviness, pressure, weight, vice like aching, burning, tightness
radiation to shoulder, neck jaw, inner arm, epigastrium, band like discomfort
relatively predictable
lasts 3-15 min
abates when stressor is gone or nitroglycerin taken

Question 2

List the symptoms /presentation of atypical non-cardiac chest pain

Answer 2

pain that is pleuritic sharp, prickling, knife like, pulsating, lancing, chocking
involves chest wall, is positional, tender to palpation, can be inframamary; radiation patterns highly variable
random onset
lasts seconds, minets, hours, or all day

Question 3

Cardiac enzymes - sensitivity and specificity

Answer 3

High sensitivity troponin
• Excluding NSTEMI
– Negative troponin at 6 hours (<0.04)
– Negative Troponin (<0.04) taken at admission (0 hours) and at 3 hours or rise <0.03
• False positives
– 2% of population have an elevated hs-cTn
– Stable CAD, Renal failure, LVH, pulmonary hypertension, CCF.

Sensitivity & Negative predictive value
• At admission the HS-cTn has a sensitivity of 82.3% and a negative predictive value of 94.7% for ruling out MI.
• At 3 hours the sensitivity is 98.2% and negative predictive value is 99.4%
• Combining the initial result with the serial change at 3 hours improves the sensitivity and positive predictive value

Question 4

What does a negative troponin mean?:

Answer 4

• A positive troponin with a suitable history diagnoses a STEMI (with ECG ST elevation) or NSTEMI (without ST elevation).
• A negative troponin excludes STEMI / NSTEMI but does not completely exclude the presence of IHD (ACS). Patients can have unstable coronary plaques, dynamic ECG changes and a negative troponin. These patients are at high risk of developing myocardial infarction and can be falsely reassured.
• A patient with continuous chest pain of considerable duration (>30 mins) with a negative troponin is unlikely to have an ACS but may have incidental coronary artery disease.

Question 5

Subclassifying the chest pain groups: STEMI

(ECG and trop +ive) how is it diagnosed and managed?

Answer 5

• Recognize ECG
• Primary PCI
• easy

Question 6

Subclassifying the chest pain groups: NSTEMI (trop +ive) how is it diagnosed and managed?

Answer 6

• Correctly interpret biochemistry.
• Exclude less likely causes of +ive trop.
• Urgent elective PCI
• Primary PCI if unstable
• easy

Question 7

Subclassifying the chest pain groups: Chest pain with ECG –ive and trop – ive - how is it diagnosed and managed?

Answer 7

• Clinically difficult
• Typical/ atypical features in
history
• Risk factors (including age)
• Pitfalls:
• Avoid over investigation of non cardiac pain
• Avoid false reassurance of significant coronary pathology

Question 8

Post acute phase - long term management of STEMI

Answer 8

Pharmacology
• Aspirin
• Clopidogrel or Prasugrel • Statin
• Β blocker
• ACE inhibitor

Non pharmacology
• Echo (to assess LV function) • Cardiac rehabilitation
• Driving instructions

Question 9

Providing clarity of diagnosis for non- anginal chest pain

Answer 9

• Non invasive
• CT coronary angiography
• myocardialperfusionscintigraphywithsingle photon emission computed tomography (MPS with SPECT)
• stressechocardiography
• contrast-enhancedmagneticresonance(MR) perfusion or MR imaging for stress-induced wall motion abnormalities.
• Invasive
• Coronary angiogram