Introduction to chest pain day

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Introduction to chest pain day

• NWL GP training course
• Iqbal Malik/Jamil Mayet
• 2009

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The course

• 4 days teaching
• Log book
• 1000 word case by day 3- 10th September
• Day 4 7th October
• 4000 word case by 4th November exam day
• viva on exam day

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Q1 Which one of these twins is a smoker?
a
b
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Atherosclerosis
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Atherosclerosis
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Atherosclerosis
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Pathophysiology
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Pathophysiology
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Prevalence (BHF figures)

• 1.5 million people with angina in the UK
• UK has one of the highest death rates from CHD in
  the world
• 1 MI every 2 minutes in the UK
• 50 fatal
• Treatment aims
• Relieve symptoms
• Minimise risk of acute coronary syndromes

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NSF

• Std 9 urgent assessment of angina
• Std 10 hospital systems for assessment and
  treatment, and risk reduction
• Continuing in the community

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Break the ice
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Case histories in primary care
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Q What is the correct duration of therapy for
clopidogrel after ACS?

• A 1 week
• B 1 month
• C 6 months
• D 12 months
• E Life

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A What is the correct duration of therapy for
clopidogrel after ACS?

• A 1 week
• B 1 month
• C 6 months
• D 12 months
• E Life

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Case 1

• 48y Indian businessman
• Routine review of CHD reports all well
• ... maybe slight tightness in chest lt5min
  duration (new in last 6w)
• Due to go on a business trip next week
• Risk factors?
• Coronary angioplasty aged 43 for angina
• Type 2 Diabetes 5y (good control)
• Essential hypertension (130/84)

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Case 1

• Current medication
• Aspirin 75mg od, Atorvastatin 40mg od, Gliclazide
  160mg od, Metformin 850mg tds, Amlodipine 5mg od,
  Lisinopril 20mg od
• Investigations?
• HbA1c 6.9, Cholesterol 3.3 (HDL 0.9mmol/l),FBC,
  TFTs, UE normal
• Resting ECG
• normal

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Case 1

• Initial management?
• Refer for exercise ECG
• Add Atenolol 50mg od (cardioprotective), what
  about Clopidogrel?
• Advise re acute chest paingt15min duration and
  999
• What advise would you give about travel to USA
  next week (appointment for ETT unlikely before
  this)?
• Patient went to USA (against advise) collapsed
  had a CABG x 4 now well but insurance??

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Conclusions

• Important to investigate and treat
• Plumbing is not the whole solution
• Iqbals patented NHS heart tablet
• Aspirinstatin
• ACEIbeta blocker
• (clopidogrel)

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Case 2

• 66y caucasian lady
• c/o slight retrosternal tightness and sob walking
  200yds but does not stop her. Feels anxious as
  brothers both died MI 60s. 4w history
• Risk factors Brothers IHD.
• Examination CVS, BP gt160/100
• Investigations FBC, ESR, TFTs, fasting glucose,
  Cholesterol, CholHDL ratio,Creatinine

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Case 2

• Initial management
• (working diagnosis likely angina)
• Resting ECG (normal)
• Start aspirin, start statin, Start Amlodipine 5mg
  ? GTN spray.
• Refer RACPC and arrange review.
• Give advise on tel 999 if acute chest paingt15min
  and take 300mg aspirin

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Case 3

• 34 year old women from Afghanistan
• 4 year history of atypical chest pain.
• Pain occurring every 2 to 3 months in left chest,
  burning, heart thumping and looks pale, lasts 3-4
  minutes.
• S/B respiratory team-NAD
• Very anxious about pain.
• No risk factors

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Case 3

• No medication
• Investigations
• CXR n
• Respiratory n
• ECG n
• Further investigations??

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Strategy in primary care

• Good history
• think atypical angina presentation especially in
  diabetic patient (silent ischaemia), S.E Asians,
  women.
• Distinguish from unstable angina!!
• Assess Risk factors.
• CVS examination including xanthalsma, BP
• Basic Investigations
• FBC, fasting glucose, Total Cholesterol, Ratio,
  TFT, LFts,Creatinine electrolytes,Resting ECG

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Strategy continued

• If angina suspected initiate prevention
• Aspirin 75mg , Statin ( high dose?)
• Consider anti-anginal
• Refer to RACPC.
• If unstable angina urgently refer to AE
• Alarm symptoms of MI and 999

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Conclusions

• Important to investigate and treat
• Plumbing is not the whole solution
• Iqbals patented NHS heart tablet
• Aspirinstatin
• ACEIbeta blocker
• (clopidogrel)