Investigation of Chest Pain in Men Rural Health West Annual Conference Perth 20 th March, 2016 Ben King Investigation of Chest Pain in Men Rural Health West Annual Conference Perth 20 th March, 2016 Ben King One good reason to also focus on men What do we know about assessing chest pain in men? Lots Most published cardiovascular trial data includes as much as 60-70% male participants Males are more likely to have invasive investigation and management Allowing for more invasive therapies, males have slightly improved outcomes in coronary disease Note: There are documented gender differences in plaque characteristics in MI patients Page 3 Page 4 Important issues in chest pain with men Diagnostic techniques Cases New technologies High sensitivity troponin CTCA Stress MRI FFR/OCT Opportunities for screening Recent developments in management on ischaemic heart disease Bio-resorbable vascular scaffold Duration of dual anti-platelet Case 1: Recently retired Mr M 66 year-old farmer, dragged in by wife for a check-up due to family history of premature IHD Wife claims Mr M looks puffed and distressed on exertion Mr M attributes it to the heat and his age When pushed, There s no pain, just a little discomfort maybe a little tight Background: BMI 29; ex-smoker; hernia repair 1999 BP 154/85; normal heart sounds; clear chest How should Mr M be investigated and followed up? (a) Referral (b) Exercise Stress Test (c) Test for risk factors (d) Stress Imaging (e) CTCA Page 5 Page 6 1
What if Mr M had this ECG? And what if Mr M had this ECG? Page 7 Page 8 Stable chest pain but abnormal resting ECG Some rest ECGs are diagnostic of ischaemia even in exertional CP Stress ECG becomes quite non-specific Stress imaging significantly increases specificity and sensitivity Gives functional assessment CT coronary angiogram has high sensitivity and good specificity Gives anatomical assessment Diagnostic angiography (+/- intravascular imaging) gives gold standard anatomical assessment and can be supplemented by fractional flow reserve for functional assessment Used to plan revascularisation Stress echocardiography Non-invasive Exercise or pharmacological stress No radiation; no contrast Limited by acoustic windows (body habitus, COPD, ) Gives additional data on valves, etc. Sensitivity 74-97%; Specificity 64-86% Marwick T, Heart, 2003 Page 9 Page 10 Abnormal stress response on echo Myocardial Perfusion Scan Non-invasive; no contrast Exercise or pharmacological stress Significant radiation Not subject to acoustic windows, but has risk of matched ischaemia, etc. Can overlook subendocardial disease Sensitivity 87-89% Specificity 73-75% Only available in nuclear medicine facilites Page 11 Page 12 2
CT Coronary Angiogram Non-invasive but uses nephrotoxic contrast; modest radiation Ideally needs slow regular heart rate for good imaging Anatomical not functional information Reasonable spatial resolution but limited in heavy calcification Can diagnose non-obstructive atheroma May diagnose extra-cardiac disease (e.g. aortic disease, COPD) SCOT-HEART study CTCA increases certain dx of coronary disease and decreases certain dx of angina Very high negative predictive value Only available at select locations PROMISE trial did not show difference in clinical outcomes compared with functional imaging studies CT coronary angiogam Page 13 Page 14 Emerging techniques Stress MRI Contrast stress echo Intravascular imaging IVUS Ocular Coherence Tomography Ocular Coherence Tomography Page 15 Page 16 Troponin Case 1: 35 year-old smoker with heavy chest pain New assays are highly sensitive for myocardial injury Keep in mind definition of MI (Thygesen, et al. Eur Heart J 2007) Type 1 relating to plaque rupture; occlusive coronary disease in ACS Type 2 secondary ischaemia of increased demand /reduced supply of O 2 Type 3 death prior to biochemical analysis Type 4/5 procedure-related evidence of myocardial injury Only available in certain laboratories Rule out ACS at 2-3 hours (normal 250%; elevated 50%) Must consider renal disease, sepsis, anaemia, PE, CCF Troponin I/T Sensitivity 72% 94% Specificity 95% 73% High Sensitivity Troponin Al Saleh et al. CMAJ 2014 Troponin negative at 6 hours Pain became postural NSAIDS Screen for inflammatory disease +/- Echo Page 17 Page 18 3
Case 2: 71 year-old diabetic with weeks of mild exertional chest tightness and shortness of breath Case 3: 54 year-old well controlled HT and dyslipidaemia presents with 2 episodes of 45-60 minutes burning CP Stress imaging will give assess LV function; viability and ischaemia Coronary angiography will appraise revascularization options Moderate risk individual for coronary disease Age; Gender; Recurrent CP; HT; cholesterol Symptoms not typical but consistent with angina ECG most in keeping with early ischaemia Treat for IHD and refer for angiography etc. (?inpatient) Page 19 Page 20 Case 4: 51 year-old football coach with epigastric pain on exertion Case 5: 70 year-old hypertensive with tearing pain from chest to back Low-moderate risk individual with (partially) atypical pain and normal ECG Correct demographic for Exercise ECG If pain is predictable on exertion, EST will be positive on symptomatic grounds CTCA will assess latent or clinically significant coronary artery disease Functional imaging can be limited in ruling out disease in typical clinical circumstances from multi-vessel; small/branch vessel disease, etc. ECG demonstrates inferior STEMI with complete heart block History raises concern of aortic dissection Check BP both arms / radio-radial delay Check CXR for widened mediastinum Rule out dissection before giving heparin, thrombolysis, etc. Page 21 Page 22 Case 6: 60 year-old overweight smoking tourist with sudden pleuritic chest pain and breathlessness Summary approach to chest pain Atypical pain in high risk individual Abnormal ECG but not ischaemic - CTPA Page 23 Parsonage et al. MJA 2013 Page 24 4
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