CONNECT June 2010

1. CONNECT June 2010 Assessment of Stable Chest Pain NICE CG95 May 2010 Dr John BaylissMA FRCP j.bayliss@btinternet.com

2. Assessment of Chest Pain What is the Question ? • Is the chest pain due to myocardial ischaemia ?(? Inadequate perfusion...)= Need Functional Test for ischaemia:Stress Echo, Myocardial Perfusion Scan, MRI(Treadmill ExECG has poor predictive value...) • Is there coronary artery disease ?(?obstructive, that could be revascularised...)= need Anatomical test of coronary arteries:Coronary Ca++ score, CT angio, Invasive angio

3. Presentation with stable chest pain Diagnose stable angina based on one of the following: • Clinical assessment alone (typicality of chest pain) or • Clinical assessment plus diagnostic testingguided by the estimate of likelihood of CAD (risk factors, ECG) • functional testing for myocardial ischaemia • anatomical testing for obstructive CAD • Do not use exercise ECG to diagnose or exclude stable angina for people without known CAD

4. NICE Guideline: Chest Pain 2010 Making a diagnosis based on clinical assessment Stable Anginal pain is: • constricting discomfort in the front of the chest, or in the neck, shoulders, jaw, or arms • precipitated by physical exertion • relieved by rest or GTN within about 5 minutes Use clinical assessment and the typicality of anginal painto estimate the likelihood of CAD (see table): • 3 of the features above = typical angina • 2 of the 3 features above = atypical angina • 1 or none of the features above = non-anginal chest pain

5. NICE Guideline: Chest Pain 2010 • If chest pain is non-anginal: Exclude a diagnosis of stable angina ... • If chest pain is atypical or typical angina and likelihood of CAD is 10-90%, further diagnostic investigation is necessary. • If chest pain is typical angina and likelihood of CAD is >90%, further diagnostic investigation is unnecessary. Manage as angina.(invasive angiography then used not for diagnosis, but to plan revascularisation strategy

6. NICE Guideline: Chest Pain 2010 % people with CAD by symptoms, age, sex and risk factors

7. NICE Guideline: Chest Pain 2010

8. Example of CHD risk spreadsheet Clinical Risk of CAD v16 2010.xls

9. Implications • 12 lead ECGs in Primary Care: recording and interpretation... • Initial clinical risk assessment done by GP, but who decides which next investigation...? • No ExECG in RACPC for diagnosis of angina in new patients • Need to develop and ↑ capacity for • Stress echo • Coronary Ca++ score, Coronary CT

11. NICE Guideline: Chest Pain 2010

12. NICE Guideline: Chest Pain 2010

13. Assessment of Chest Pain

14. NICE Guideline: Chest Pain 2010 Key Priorities for Implementation: Presentation with stable chest pain Clinical assessment 1 • Take a detailed clinical history documenting: • the age and sex of the person • the characteristics of the pain, including its location, radiation, severity, duration, frequency, and factors that provoke and relieve the pain • any associated symptoms, such as breathlessness • any history of angina, MI, coronary revascularisation, or other cardiovascular disease and • any cardiovascular risk factors.

15. NICE Guideline: Chest Pain 2010 Key Priorities for Implementation: Presentation with stable chest pain Clinical assessment 2 • Carry out a physical examination to: • identify risk factors for cardiovascular disease • identify signs of other cardiovascular disease • identify non-coronary causes of angina (for example, severe aortic stenosis, cardiomyopathy) and • exclude other causes of chest pain • For people in whom stable angina cannot be diagnosed or excluded on the basis of the clinical assessment alone, take a resting 12-lead ECG as soon as possible. • Do not rule out a diagnosis of stable angina on the basis of a normal resting 12-lead ECG.

16. NICE Guideline: Chest Pain 2010 Key Priorities for Implementation: Presentation with stable chest pain • If the estimated likelihood of CAD is < 10% • first consider causes of chest pain other than angina caused by CAD. • Consider investigating other causes of angina, such as hypertrophic cardiomyopathy, in people with typical angina-like chest pain and a low likelihood of CAD (<10%).

17. NICE Guideline: Chest Pain 2010 Key Priorities for Implementation: Presentation with stable chest pain • If the estimated likelihood of CAD is 10–29%, offer CT calcium scoring as the first-line diagnostic investigation. • If the calcium score is: • 0: consider other causes of chest pain • 1–400: offer 64-slice (or above) CT coronary angiography • >400: offer invasive coronary angiography.If this is not clinically appropriate or acceptable to the person and revascularisation is not being considered, offer non-invasive functional imaging.

18. NICE Guideline: Chest Pain 2010 Key Priorities for Implementation: Presentation with stable chest pain • If the estimated likelihood of CAD is 30–60%, offer functional imaging as the first-line diagnostic investigation. • stress echocardiography or • myocardial perfusion scintigraphy with single photon emission computed tomography (MPS with SPECT) or • first-pass contrast-enhanced magnetic resonance (MR) perfusion or • MR imaging for stress-induced wall motion abnormalities. Take account of locally available technology and expertise, the person and their preferences, and any contraindications when deciding on the imaging method

19. NICE Guideline: Chest Pain 2010 Key Priorities for Implementation: Presentation with stable chest pain • If the estimated likelihood of CAD is 61–90%, offer invasive coronary angiography as the first-line diagnostic investigation if appropriate • If people have features of typical angina based on clinical assessment and their estimated likelihood of CAD is >90%, further diagnostic investigation is unnecessary. Manage as angina(invasive angiography then used not for diagnosis, but to plan revascularisation strategy)

21. Assessment of Chest Pain • Functional tests • ? Myocardial ischaemia as cause of pain • Exercise ECG (ExECG) • DobutamineStress Echo (DSE): wall motion ± perfusion • Nuclear Myocardial perfusion imaging (MPI-SPECT Thallium) • MRI imaging of wall motion abnormality or perfusion • Assessment of underlying CHD anatomy • Evidence of calcified atheroma in artery wall: • Coronary Calcium score (EBCT): = ? need to Rx • Evidence of coronary narrowing(s) • CT angiography • Invasive angiography : ? Revascularisation

22. Exercise ECG • Positive or Negative predictive value not as good as Stress Echo or MPI (or MRI) • Sensitivity 68%, Specificity 77%(TP/Dis+) (TN/Dis-) Pre-Test p Post-Test p by Symptoms if ExECG is POS NEG Non Anginal 20% 35% 5% Atypical  50% 70% 15% Typical Angina  80% 95% 45%

23. Stress Echo: Normal Rest Stress Long axis Short axis

24. Stress Echo: Anterior ischaemia Rest Stress Long axis Short axis

25. Myocardial perfusion (Thallium) imaging Ant Apex Ant Stress  Inferior Ischaemia Lat Septum Lat Inf Apex Inf Vertical Long Axis Horizontal Long Axis Short Axis Recovery

26. Assessment of Chest Pain • Functional tests • ? Myocardial ischaemia as cause of pain • Exercise ECG (ExECG) • DobutamineStress Echo (DSE): wall motion ± perfusion • Nuclear Myocardial perfusion imaging (MPI-SPECT Thallium) • MRI imaging of wall motion abnormality or perfusion • Assessment of underlying CHD anatomy • Evidence of calcified atheroma in artery wall: • Coronary Calcium score (EBCT): = ? need to Rx • Evidence of coronary narrowing(s) • CT angiography • Invasive angiography : ? Revascularisation

27. Coronary Calcium Score Calcium Score= amount of Ca++ in coronary walls 0 No (calcified) CAD 1-10 Minimal CAD 11-100 Mild CAD 101-400 Moderate CAD Over 400 Extensive CAD • Does not show stenoses • Radiation • Younger pts may have severe stenosis but not Ca++ (false NEG)

28. CT Heart

29. CT Angiography

30. CT Angiography

31. CT Angiography • CT coronary angio cannot show if any in-stent restenosis...

32. (Invasive) Coronary Angiography

33. Percutaneous Coronary Intervention (PCI)