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Tuesday, 27 November 2012

The NICE Chest Pain Guidelines


The NICE Chest Pain Guidelines.

There is a lot of understandable confusion over the NICE chest pain guidelines.

It is true that when the 2010 guidelines were first launched, they created quite a stir, even amongst cardiologists, who struggled to agree on their interpretation.

Possibly, the biggest mistake NICE made, was to launch the "Management of New Onset Chest Pain Guidelines" almost 18 months before they updated the  "Management of Stable Angina" guidelines. These two guidelines are clearly designed to be interpreted in conjunction, and this delay led to considerable confusion.

The second mistake, was not to recognise the importance of 'prognostic' information in patients with angina, such as can be gained from an exercise ECG.


To clarify - there are two relevant Guidelines which need to be considered in conjunction.

1.  The Management of Chest Pain of Recent Onset - CG95 March 2010

2. The Management of Stable Angina CG126 - Updated July 2011

Diagnosing Angina

The first guideline (CG95) is all about diagnosis, in a patient presenting with new onset chest pain.

Pages 1-9 deal mainly with "unstable" chest pain (such as may occur at rest, without any triggers) and is suggestive of Acute Coronary Syndromes, and the management thereof.
Pages 10 onwards, deal with the management of newly presenting, but "stable", chest pain - i.e. the patient is well at the time of presentation and the symptoms are often predictable, short-lived and well-tolerated.  This is the section we will deal with here.

The guideline stresses that in many cases, a diagnosis of angina can be made clinically.
In these circumstances, exercise ECG's are not required to make the 'diagnosis'.  So, for example, those with classical symptoms, and a Coronary Artery Disease risk (CAD risk) likelihood of  >90% don't need further diagnostic tests. You can be pretty confident that they have angina.
But...The guidelines fail to point out, that an Exercise ECG can offer very important prognostic information, and help stratify that risk. For example, an exercise tolerance of >6 minutes of the Bruce protocol, before being limited by pain or ST changes, puts a patient with angina in a very good prognostic/low risk group.

According to NICE CG95 (The Management of Chest pain of recent onset) a diagnosis of angina can be excluded if the pain does not fulfil any of the following 3 criteria:

1. A constricting discomfort in the front of the chest, neck, shoulders, jaw or arms
2. Precipitaed by physical exertion
3. Relieved by rest - or GTN if tried - in under 5 minutes.

NICE goes on to define:
  • Typical Angina - as a pain which fulfils all three criteria (3/3)
  • Atypical Angina - as a pain that fulfils two of the three criteria (2/3)
  • Non-Angina - as a pain that fulfils one, or none, of the criteria. (0-1 /3)
The management of patients who only fulfil 0-1 of these criteria, no longer needs to follow the above guidelines. In other words, a pain which is "continuous or prolonged at rest, unrelated to activity, aggravated by breathing, or associated with other symptoms" is unlikely to be angina, and other causes should be considered.  

If 2 or more of these criteria are fulfilled, then we should go on to calculate a % CAD risk score (see below) to tell us the likelihood that this patient's symptoms are the result of significant underlying coronary disease.  Usually, this risk assessment is calculated at the RACPC, where patients can then be directed onwards to the most appropriate investigations. 

The RACPC

There are two common conditions worth mentioning, which often pop up at the RACPC as a cause  of chest pain.

Anaemia? 
When referring a patient to RACPC, it's always worth checking their FBC, renal function and lipid profile results before they get there.  Nothing more awkward than a patient arriving in clinic and looking up their FBC to find an Hb on 7g/dl and explaining that is the cause of their chest pain and no further cardiac tests are indicated.  

Aortic Stenosis?
Also - always check for murmurs in patients presenting with chest pain.  Aortic stenosis as a cause for angina should not be missed.  The management of this condition is completely different to that of coronary artery disease.  Any murmur should be clearly mentioned in the referral letter so that arrangements can be made for an ECHO on arrival, as part of the assessment. 


At the RACPC, the patient will be assessed with the following considerations in mind

1.  The history
2.  The risk factors
3.  Is the pain angina or not? (If not - what's the cause?) Can the diagnosis be made on clincial grounds, or are more tests needed?
4.  Is there any underlying IHD (if so - what's the prognosis? ) Consider further functional/anatomical tests.
4.  Who should be considered for revascularisation? (based on 3 + 4)

Don't be disheartened, as a GP, if your patient attends the RACPC and is discharged with a diagnosis of "non-cardiac chest pain".  It's not meant as an insult!
Firstly, don't forget, as GP's we have under 10 minutes to take a detailed history, examination, check risk factors, arrange tests, consider all the implications, share all that with the patient, and finally, read code every aspect of the consultation.
In the RACPC, the clinician has team of cardiac technicians, and sometimes up to 45 mins per patient, to establish a detailed history. Also, patient's stories do sometimes change! (Tell me about it - I have seen that with my own patients, whom I later felt embarrassed to have referred when assessed again by myself at RACPC!).

Secondly, The RACPC does have an another important role.  A number of clearly non-cardiac patients, need enhanced level reassurance to enable them to move forward, thus preventing the ongoing psychological morbidity associated with worry. Not to mention, repeated emergency admissions with non-cardiac chest pain.

At the RACPC  a % CAD score is calculated, but only those with chest pain which sounds suggestive of ischaemia.  Based on this score,  further tests of cardiac function are then offered to clarify any uncertainty in diagnosis.

Assessing Risk - What is the CAD risk score?

The CAD risk score estimates the percentage of people estimated to have Coronary Artery Disease according to age, sex, risk factors and typicality of symptoms.

Once the risk is assessed, the CAD score table (provided in the NICE guidelines) is used to assess the PRE-TEST likelihood of CAD.  A web-based alternative to using this numeric CAD scoring chart has been kindly provided by Dr Mark Dayer of The West Hertfordshire Hospitals:  Coronary Risk Assessment Dukes Score .
This on-line Tool is so quick and easy to use, most cardiologists find it far preferable to the numeric chart. 

  • If CAD risk <10% - Easy. Consider other causes of chest pain, or, if symptoms are classically angina, then consider other (non ischaemic) causes of angina  e.g. HOCM
  • If CAD risk >90% - Easy.  The guidelines state "Treat as stable angina without need for further diagnostic tests".  In other words, you've successfully made the diagnosis clinically, and continue to treat in accordance with the NICE Management of Stable Angina Guidelines (CG127).    True.  But they may still benefit from a prognostic test (see below).
  • If CAD risk is between 10-90% then other diagnostic tests many be indicated. This section is then divided into 3 further sub-groups. (see below)

For %CAD risk is between 10 and 90% The patients are subdivided into 3 groups:

          CAD risk 10-29%  - Offer CT calcium Scoring
          CAD risk 30-60%  - Offer non-invasive functional imaging (Stress ECHO/MIBI etc)
          CAD risk 61-90% -  Offer angiography, if acceptable, and if PCI is being considered.

This is not rocket science. Anyone can calculate the CAD risk score. True, if a GP has a confident grasp of the chest pain guidelines, and has open access to all the available cardiac imaging tests, then perhaps they could confidently manage all patients appropriately without the need to refer, until surgical intervention is required.  In reality, I don't think many GP's have open access for these tests, nor have the time or resources to take on this role from secondary care.

Arguably, those patients who would not chose to accept any surgical intervention, if offered, (PCI or CABG), and are well controlled on medical therapy, don't really need referral either. Like any health discussion, this is a decision which needs to be taken together, with their GP, after appropriate counselling and knowledge-sharing. It may be an entirely reasonable choice.
Would you want an angiogram/PCI even if all your symptoms are controlled on medication?
Some will. Some won't.


A word of note. The CAD % risk is a predictive score only. 
(It is based on a small research study of only 1030 patients between 1983 and 1985, at Dukes University Medical Centre, USA.  Of the 1030 patients, 168 underwent Angiography.)

What's more, the NICE risk score does not include other factors such as HDL, FH and ethnicity and in many ways this is disappointing. 


So Why Do An Exercise ECG?

NICE Say: "Do not use an exercise ECG to diagnose or exclude stable CAD"

But ... nothing stops us from choosing to use it once we've made a clinical diagnosis, yet want some prognostic information.


ETT are useful to
  • Assess or trigger symptoms (arrhythmias, valvular heart disease)
  • Assess exercise capacity
  • Provide prognostic information - e.g for DVLA
A sensible report from the RACPC might read something like this:

"Thank you for referring this 49yrs gentleman with a clinical diagnosis of atypical angina (i.e. Short-lived constricting left chest and arm pain, which has an inconsistent relationship to exertion). He managed 9 minutes of the Bruce protocol today before developing symptoms. There were no ST segment changes. If he does indeed have angina, today's test puts him in a good prognostic group. 
I note his various risk factors for IHD. 
His CAD risk score calculated  today is 45%.  In accordance with NICE guidelines, to help clarify the diagnosis, we will arrange another non-invasive test of cardiac function, such as a stress ECHO, and write with the results. 
In the meantime, he has been advised about lifestyle choices and the use of GTN/999 for prolonged symptoms".

Who needs Intervention?

Once angina has been diagnosed, the second guideline, Management of Stable Angina (CG126) comes into play.

According to NICE CG126, if a patient on optimal therapy (Note: This is defined as being on only one, or two, anti-anginal medications) and is still getting symptoms, then further intervention (PCI or CABG) should be considered.
So - even if you confidently diagnose Angina clinically in GP land, and start a beta-blocker of your choice -  unless symptoms are completely controlled, they may still need some further input via the RACPC.

In practice, when patients arrive at RACPC with classical ischaemic symptoms, they have often already been started, quite appropriately, on anti-anginal therapy by their GP. The RACPC therefore, is already in a position to consider if their symptoms are well controlled on treatment, or if further intervention may be required.

So, in summary, The Acute Trusts should not be selling all their Treadmills.  Not just yet anyway.

Simple?

Hope that helps, and that I haven't confused everyone even more.
H :-)


Acronym Guide:
NICE National Institute of clinical excellence
CG Clinical Guideline
ACS Acute Coronary Syndrome
CAD Coronary Artery Disease
RACPC Rapid Access Chest Pain Clinic


Management of Recent Onset Chest Pain

Today's #ECGclass is looking at the management of recent onset chest pain. 
This case comprises of  6 questions, with updates after each. 
It's requires a bit more interaction than usual (!),  so if you're feeling brave, please do use the hashtag #ECGclass and join in.  
It's a bit drawn out, so we'll see how we do for time, but may spread the updates out over a couple of days.  

Keep posted as the case evolves!

Remember there are no right or wrong answers and everyone's opinion is valid. 
Do feel free to join in, and most important of all, have fun! :-)

OK. Here goes....

Case 17

A 52 yr old gentlemen comes to see you complaining of intermittent chest pains for the past 3 weeks.

Q1. What do you want to know?

Please use the  #ECGclass to ask anything else you want to know about this man's symptoms.

Update 1
You establish that prior to 3 weeks ago, he was symptom free and quite active for his age.
Over the past 3 weeks he has noticed a dull left chest discomfort, which is very mild, but comes on after 5 minutes of walking. This is quite reproducible each time he walks, but only lasts a couple of minutes once he stops and rests.
Sometimes it travels upwards, to both his shoulders and arms.
It has never come on at rest, or overnight.

Q2. Is there any other information you want to know?
Please use the #ECGclass 

Update 2
You want to establish some information about his risk factors.
He not is on any medication, has never smoked,  and is not overweight.
He has not had any blood tests for several years.
He has no family history of significant IHD (<65yrs in women or <60yrs in men).
In more recent years, he has suffered with a bit of indigestion after meals, but not sufficient to require any treatment.

You examine him.  His heart sounds her normal (no murmurs), and his BP is 132/76. His pulse is regular and strong at a rate of 78/min.
There is no chest wall or epigastric tenderness.

Q3. What now?

Update 3
Based on his symptoms, you make a clinical diagnosis of Angina.
You explain your thoughts to him, and start him on Aspirin, a beta-blocker and a Statin with some GTN and 999 advice.
You explain you would like to refer him the the Chest Pain clinic (RACPC) to get further information on the severity of any coronary heart disease.
Meanwhile you arrange an ECG, and some bloods to rule out secondary causes of angina (FBC, glucose, TFTs, lipids, U&E's and eGFR)

His resting ECG is below:




Q4.  If his Cholesterol level comes back at 5.8 mmo/l, use the information you have so far to to work out the % probability, that his presenting symptoms are a result of significant underlying IHD.  
Hint: Use the useful tool calculator below, kindly provided by West Herts Hospitals, to calculate his CAD risk probability (This on-line tool is just a simplified version of 'Table 1' - the CAD risk chart provided in the NICE 2010 chest pain guidelines):

 Coronary Risk Assessment Tool

(N.B. Don't confuse this with the 10yrs CVD risk score (eg Framingham) we frequently use to consider need for Primary Prevention strategies, in an asymptomatic person. This Coronary Risk Tool is ONLY for use with patients who present, with ischaemic sounding chest pain).

Next,  using the link below, refer to the NICE 2010 Clinical Guidelines for 'Chest Pain of Recent Onset'  (CG95) and determine what is the next most appropriate investigation?

For quick reference, refer to pages 12-14:

NICE 2010 Management of Chest Pain of Recent Onset - CG95

Please use the #ECGclass to share your findings.

Update 4
He attends his appointment at the RACPC within 42hrs of your referral. The team there get the same consistent history, and agree with your clinical diagnosis of angina. He is already feeling some benefit since starting on the beta-blocker, but hasn't had chance to trial the GTN yet.
The baseline ECG, above, is noted to be normal.

His CAD risk score is calculated at 74%.

On the basis of NICE guidelines, he is offered a Diagnositic Angiogram the following week.
His response to medically therapy can be reviewed when he attends for his angiogram, to consider the need for further intervention at that stage.

In the meantime, he is offered an Exercise ECG to help give prognostic information and risk stratification.
(In accordance with NICE, ETT should not be offered to people in whom a clinical diagnosis of angina has not been made. ETT, with its poor sensitivity and poor specificity, has NO role in the diagnosis of  IHD. It is certainly not a screening test for angina, but offers useful prognostic information, once a diagnosis has been made).

On the treadmill, he develops chest pains after only 3 minutes of the Bruce Protocol, and by 4 minutes he has the following exercise ECG trace:



Q5.  What do you think of the ST segments?  Just describe what you see. 
         
ST segments should be described in relation to the baseline - i.e. baseline, elevated or depressed?
       
Furthermore, as you recall from last week, elevated ST segments can be described as convex (eg STEMI),  saddle-shaped (eg pericarditis) or upsloping (e.g.. Bengin high take-off).

Likewise depressed ST segments can be 1. Upsloping ( often normal on exercise),  2. Horizontal (ischaemic)  or  3. Downsloping (more severe ischaemia).

So #ECGclass - what do you think??


Update 5
In general, symptoms coupled with 2mm of horizontal ST depression on Exercise ECG, is indication of significant ischaemia, and the test should be stopped.
(Without any symptoms, 3mm horizontal ST depression is the diagnostic threshold for the test should be stopped).

The above ECG shows significant, horizontal ST depression, which is widespread.
Inferior leads: Lead II looks a little upsloping, but leads III and aVF have 2mm of horizontal ST depression.
Lateral Leads V4-V6: There is 3-4mm of horizontal ST depression
aVR: You might also have noticed the elevation pattern seen in aVR.

This 'reciprocal' ST pattern in lead aVR during in an ischaemic ECG, in considered a high risk sign, and usually suggests major vessel disease.

The fact that these changes have been triggered in under 6 minutes of exercise, makes this a STRONG POSITIVE TEST and puts him in a high risk group.
The treadmill is stopped and his ECG is monitored further in recovery.

Now look what happens as he rests:


Q6.  What do you think of the above ECG changes (after 6 minutes of rest)?

Update 6
Despite his pain settling within 1-2 minutes of resting, his ST changes have continued to progress.
See how they are now downsloping inferolaterally, with flipping of the T waves.
That nasty, sinister,  reciprocal change in aVR persists.
So despite him feeling fine, his heart is still struggling. Assuming we haven't triggered an ACute Coronary Syndrome on the treadmill, these changes will almost certainly return to baseline over then next 10-15 minutes.

A week later, this man's Angiogram confirmed major vessel disease, which was not correctable by PCI. He was referred for urgent CABG. Of course, even very severe IHD such as this, cannot be ruled out  by his perfectly normal resting ECG.


Thank you so much for your time and for joining in.
The end.
Phew.

In the light of several comments received during this #ECGclass, it is clear there is still a lot of uncertainty and confusion over the NICE chest pain Guidelines.
In view of this, I have added another blog for those interested, (see next) in an attempt to help clarify things.
H. :-)











Monday, 26 November 2012

#ECGclass Case 17


Today's #ECGclass is looking at the management of stable recent onset chest pain. 
This case comprises of  6 questions, with updates after each. 
It's requires a bit more interaction than usual (!),  so if you're feeling brave, please do use the hashtag #ECGclass and join in.  
It's a bit drawn out, so we'll see how we do for time, but may spread the updates out over a couple of days.  

Keep posted as the case evolves!

Remember there are no right or wrong answers and everyone's opinion is valid. 
Do feel free to join in, and most important of all, have fun! :-)

OK. Here goes....

Case 17

A 52 yr old gentlemen comes to see you complaining of intermittent chest pains for the past 3 weeks.

Q1. What do you want to know?

Please use the  #ECGclass to ask anything else you want to know about this man's symptoms.


Update 1
You establish that prior to 3 weeks ago, he was symptom free and quite active for his age.
Over the past 3 weeks he has noticed a dull left chest discomfort, which is very mild, but comes on after 5 minutes of walking. This is quite reproducible each time he walks, but only lasts a couple of minutes once he stops and rests.
Sometimes it travels upwards, to both his shoulders and arms.
It has never come on at rest, or overnight.

Q2. Is there any other information you want to know?
Please use the #ECGclass 


Update 2
You want to establish some information about his risk factors.
He not is on any medication, has never smoked,  and is not overweight.
He has not had any blood tests for several years.
He has no family history of significant IHD (<65yrs in women or <60yrs in men).
In more recent years, he has suffered with a bit of indigestion after meals, but not sufficient to require any treatment.

You examine him.  His heart sounds her normal (no murmurs), and his BP is 132/76. His pulse is regular and strong at a rate of 78/min.
There is no chest wall or epigastric tenderness.

Q3. What now?


Update 3
Based on his symptoms, you make a clinical diagnosis of Angina.
You explain your thoughts to him, and start him on Aspirin, a beta-blocker and a Statin with some GTN and 999 advice.
You explain you would like to refer him the the Chest Pain clinic (RACPC) to get further information on the severity of any coronary heart disease.
Meanwhile you arrange an ECG, and some bloods to rule out secondary causes of angina (FBC, glucose, TFTs, lipids, U&E's and eGFR)

His resting ECG is below:


Q4.  If his Cholesterol level comes back at 5.8 mmo/l, use the information you have so far to to work out the % probability, that his presenting symptoms are a result of significant underlying IHD.  
Hint: Use the useful tool calculator below, kindly provided by West Herts Hospitals, to calculate his CAD risk probability (This on-line tool is just a simplified version of 'Table 1' - the CAD risk chart provided in the NICE 2010 chest pain guidelines):


(NB Don't confuse this with the 10yrs CVD risk score (eg Framingham) used to consider Primary Prevention in an asymptomatic person. This CAD risk tool is ONLY for use with patients already presenting with ischaemic sounding chest pain).

Now refer to the NICE 2010 Clinical Guidelines for 'Chest Pain of Recent Onset'  (CG95 - Link below) and determine what is the next most appropriate investigation. 
Use pages 12-14 of the NICE guidelines (link below):

NICE 2010 CG95 - Management Chest Pain of Recent Onset

Now Please use the #ECGclass to share your findings!


Update 4
He attends his appointment at the RACPC within 42hrs of your referral. The team there get the same consistent history, and agree with your clinical diagnosis of angina. He is already feeling some benefit since starting on the beta-blocker, but hasn't had chance to trial the GTN yet.
The baseline ECG, above, is noted to be normal.

His CAD risk score is calculated at 74%.

On the basis of NICE guidelines, he is offered a Diagnositic Angiogram the following week.
His response to medically therapy can be reviewed when he attends for his angiogram, to consider the need for further intervention at that stage.

In the meantime, he is offered an Exercise ECG to help give prognostic information and risk stratification.
(In accordance with NICE, ETT should not be offered to people in whom a clinical diagnosis of angina has not been made. ETT, with its poor sensitivity and poor specificity, has NO role in the diagnosis of  IHD. It is certainly not a screening test for angina, but offers useful prognostic information, once a diagnosis has been made).

On the treadmill, he develops chest pains after only 3 minutes of the Bruce Protocol, and by 4 minutes he has the following exercise ECG trace:



Q5.  What do you think of the ST segments?  

Remember - Just describe what you see. 
         
ST segments should be described in relation to the baseline - i.e. baseline, elevated or depressed?
     
Furthermore, as you recall from last week, elevated ST segments can be described as convex (eg STEMI),  saddle-shaped (eg pericarditis) or upsloping (e.g.. Bengin high take-off).

Likewise depressed ST segments can be 1. Upsloping ( often normal on exercise),  2. Horizontal (ischaemic)  or  3. Downsloping (more severe ischaemia).

So #ECGclass - what do you think??


Update 5
In general, symptoms coupled with 2mm of horizontal ST depression on Exercise ECG, is indication of significant ischaemia, and the test should be stopped.
(Without any symptoms, 3mm horizontal ST depression is the diagnostic threshold for the test should be stopped).

The above ECG shows significant, horizontal ST depression, which is widespread.
Inferior leads: Lead II looks a little upsloping, but leads III and aVF have 2mm of horizontal ST depression.
Lateral Leads V4-V6There is 3-4mm of horizontal ST depression
aVR: You might also have noticed the elevation pattern seen in aVR.

This 'reciprocal' ST pattern in lead aVR during in an ischaemic ECG, in considered a high risk sign, and usually suggests major vessel disease.

The fact that these changes have been triggered in under 6 minutes of exercise, makes this a STRONG POSITIVE TEST and puts him in a high risk group.
The treadmill is stopped and his ECG is monitored further in recovery.

Now look what happens as he rests:


Q6.  What do you think of the above ECG changes (after 6 minutes of rest)?


When you've had a go - see next blog for the full discussion and outcome!

Monday, 19 November 2012

Acute Chest Pain and ST changes - Full Discussion.

#ECGclass Case 16


This 64yr old man presents to his GP, with chest pain.

His pains are sharp, transient, and very localised to a finger point area in the left chest.
The pains have been present for 2-3 months and are positional in nature. (Better when he lies on either side, or sits upright. Worse on lying down on his back).
They are not aggravated by exercise, breathing or coughing.

The pains are never exertional in nature, despite him maintaining a fairly active lifestyle.

Cardiovascular and respiratory examination are normal. He seems well.

You obtain the following ECG:
(Apologies for the poor quality - this is an old one - but don't worry, we're looking for 'patterns' here, not detailed measurements)


Clinically he seems well, and has no pain, at the time of examination. 

What do you do next?
Anything you want to know?

Please Tweet #ECGclass any thoughts you have, or further questions, you may want to know.
Do you want any further information or tests? 

Update 1

When he comes back to your room, having had his ECG with the nurse, he asks you if it looks OK?
He then discloses that although he had't been worried about his chest pain, (he thinks it is 'muscular'), he decided that he ought to get checked, as he had a coronary stent inserted several years ago, for single vessel IHD disease. He has been symptom free since then.

Does this change your interpretation of the ECG?
Is there anything you want to ask?

You note a suggestive ST elevation Pattern in the Inferior leads and in the V2-V6 lateral leads.

What are your thoughts on this?
(Remember to simply describe what you see).

Update 2
Firstly, let's study the inferior leads:   II, III and aVF 
How would you describe the ST elevation in these leads?

(You may find it useful to refer back to The July 16th blog entitled "Different patterns of ST elevation").

Update 3
Now let's study chest Leads : V2-V6 
How would you describe the ST elevation in these leads?
Does it look the same as the Inferior leads?


Discussion

Leads II,III and aVF
This pattern of ST elevation looks slightly U-shaped, or saddle-back.
It's not the classic convex pattern associated with STEMI's.
If it had been more widespread, and his symptoms had been more classical of Pericarditis, then this would have been a consideration. If ever in any doubt, and you have time to investigate (i.e a well-ish patient with a non-acute presentation, like this man) then a CRP would be helpful. (A normal CRP is rare in pericarditis).
This man's symptoms, however, are long standing, and not classical of pericarditis. Coupled with his very localised saddle-back ST pattern, this makes a diagnosis of pericarditis unlikely.

Chest leads V2-6
There appears to be perhaps 1mm of 'upsloping' ST elevation. This is Typical of HIGH TAKE OFF (otherwise known as Benign Early Repolarisation).

This gentleman (quite appropriately, given his history) was referred to the local RACPC where all investigations, including Exercise ECG and ECHO were normal.

It is likely that the ECG changes seen above, are all 'normal' for him.

It was agreed that his own diagnosis, of musculoskeletal chest pain, was probably correct.



Would your accurate interpretation of this ECG have altered your management plan?


No - probably not! 

In accordance with the 2010 NICE Chest Pain Guidelines (CG95), his chest pains are, by definition,  "Non-Cardiac" in nature, and therefore 'no further investigations are indicated'. 
However, if I'd seen him in my GP role, with that ECG and past history, I'd probably still have referred him for RACPC assessment.  If he'd seemed at all unwell at the time of presentation, I may even have been tempted to admit him. Hard to say without the patient in front of you. 

What is the likelihood that a patient's chest pain, is cardiac in origin?

For people presenting with stable chest pain, suggestive of ischaemia, there is a really useful online CAD (coronary artery disease) risk calculator kindly provided by the West Hertfordshire Hospital Cardiology department:

http://www.westhertshospitals.nhs.uk/WHC/risk-duke.html

This tool allows a calculation of the "likelihood" that the patient sitting in front of you, with chest pain, has symptoms arising from coronary arterial disease. This is the basis of the "Dukes score" table seen in the NICE 2010 chest pain guidelines. 
It is used in RACPC's all the time to determine the most appropriate next step in investigation. Equally, it could be used by any clinician wanting to confirm appropriateness for referral. 

N.B. This calculator is for people presenting with ischaemic sounding chest pain, and should not be used for people with non-cardiac chest pain (as defined by NICE). 
Neither should it be confused with the 10 yr CVD Risk Calculators, used for Primary Prevention decisions, in people without symptoms. 


Any questions?
Thank you. :)







#ECGclass - Case 16

#ECGclass Case 16 

This 64yr old man presents to his GP, with chest pain.

His pains are sharp, transient, and very localised to a finger point area in the left chest.
The pains have been present for 2-3 months and are positional in nature. (Better when he lies on either side, or sits upright. Worse on lying down on his back).
They are not aggravated by exercise, breathing or coughing.

The pains are never exertional in nature, despite him maintaining a fairly active lifestyle.

Cardiovascular and respiratory examination are normal. He seems well.

You obtain the following ECG:
(Apologies for the poor quality - this is a really old trace - but don't worry, we're looking for 'patterns' here, not detailed measurements)

Clinically he seems well, and has no pain, at the time of examination. 

What do you do next?
Anything you want to know?

Please Tweet #ECGclass any thoughts you have, or further questions, you may want to know.
Do you want any further information or tests? 


Update 1

When he comes back to your room, having had his ECG with the nurse, he asks you if it looks OK?
He then discloses that although he had't been worried about his chest pain, (he thinks it is 'muscular'), he decided that he ought to get checked, as he had a coronary stent inserted several years ago, for single vessel IHD disease. He has been symptom free since then.

Does this change your interpretation of the ECG?
Anything you want to ask?

You note a suggestive ST elevation Pattern in the Inferior leads and in the V2-V6 lateral leads.

What are your thoughts on this?
(Remember to simply describe what you see).


Update 2
Firstly, let's study the inferior leads:   II, III and aVF 
How would you describe the ST elevation in these leads?

(You may find it useful to refer back to The July 16th blog entitled "Different patterns of ST elevation").


Update 3
Now let's study chest Leads : V2-V6 
How would you describe the ST elevation in these leads?
Does it look the same as the Inferior leads?


When you've had a go,  you'll find the full discussion on the next blog!

Monday, 12 November 2012

An Irregular pulse in a young man - #ECGclass case15

#ECGclass case 15

A usually fit and active, 30yr old man comes into see you complaining of intermittent dizzy spells over the past few weeks.

Examination of the cardiovascular system is normal. His pulse is strong, but you detect a slight irregularity. His BP is 108/72.
There is no significant family history of young heart disease, or sudden cardiac death.

However, he is visibly anxious, so you offer to do an ECG.

You get the following trace:



What comments can you make?
Are there any other tests you want?

Please use the #ECGclass to post any questions/comments you'd like to make. 
Remember, everyone's opinion is valid, and many ECG's are open to debate.

Update
The first comment to make is that this isn't a 12 lead ECG and you may want to see the full 12 leads chest leads in order to interpret properly.
However, within the limitations of a 3 lead ECG, what comments can you make?

Is it regular? Or Irregular?
Are there any P waves?
If so, are the P all conducted? 
What about the QT interval?

Update
You also request blood for FBC and Thyroid function, both of which are normal.
He is not on any medication, and has no significant past medical history.

On review, he still seems very anxious, and you ask him more specifically about his concerns.
He tells you he is worried about his heart and blood pressure, because he is under enormous pressure at work. He feels he is coping poorly with the unreasonable demands of his job, but he is under a lot of financial strain, and has no other work options.

Discussion


In a history such as this, in a young man, the main indication for the ECG - other than reasurrance - is to rule out an inherited channelopathy such as Brugada syndrome or Long QT syndrome; or even HOCM. 

There are no ECG features here suggestive of Brugada syndrome or HOCM, but as 12 lead ECG would be better fro these purposes.
The QT interval is just on the borderline of normal limits (max 11 small squares, or 0.44secs). However, as this rhythm is a little bradycardic, the corrected QT interval will actually be shorter, and so well within normal range. 
This is a normal QT interval. We'll cover long QT syndrome another week.

Within the confines of this 3 lead ECG, we can say the ECG shows sinus rhythm.
Normal P waves are present in front of every QRS complex.  Every P wave seen is conducted. 
The PR interval is constant and of normal duration (3-5 small squares, or 0.12 - 0.20sec).

The P wave and QRS morphology is constant, in any one lead. 
I agree with those of you who thought the P waves looked a bit notched in lead III (and maybe II) - but I suspect these are normal. They are certainly clearly seen, and look normal in Lead I. 

If you are ever in doubt about the presence or  morphology of P waves, the best lead to study the P wave is usually V1, so again, a 12 lead view would be helpful here. 

The P wave rate, however, varies in a cyclical fashion, giving a cyclical variation in the QRS pattern. 


This ECG shows SINUS ARRHYTHMIA.

This arrhythmia is usually a normal finding, especially in children and young adults. There is cyclical variation with respiration.  Heart rate increases during inspiration (Reduced vagal tone, with acceleration of the SA node discharge), and decreases during expiration. 
The arrhythmia may be abolished at faster heart rates, such as during exercise etc.  

It is likely that this man'a symptoms are a result of his current stress, and he needs strongly reassuring about his normal heart trace and BP, then his real issues can be addressed. 

The lesson here is once again about confidence. No tricks - It's a normal ECG, and we need to be confident enough to be able to say that.
Well done all! 

Thank you. :)





#ECG class - Case 15

#ECG class - Case 15

A usually fit and active, 30yr old man comes into see you complaining of intermittent dizzy spells over the past few weeks.

Examination of the cardiovascular system is normal. His pulse is strong, but you detect a slight irregularity. His BP is 108/72.
There is no significant family history of young heart disease, or sudden cardiac death.

However, he is visibly anxious, so you offer to do an ECG.

You get the following trace handed over from the new treatment room nurse:



What comments can you make?
Are there any other tests you want?

Please use the #ECGclass to post any questions/comments you'd like to make. 
Remember, everyone's opinion is valid, and most ECG's are open to debate/discussion. There are no wrong answers, just describe what you see. 


Update
The first comment to make is that this isn't a 12 lead ECG and you may want to see the full 12 leads chest leads in order to interpret properly.
However, within the limitations of a 3 lead ECG, what comments can you make?

Is it regular? Or Irregular?
Are there any P waves?
If so, are the P all conducted? 
What about the QT interval?


Update
You also request blood for FBC and Thyroid function, both of which are normal.
He is not on any medication, and has no significant past medical history.

On review, he still seems very anxious, and you ask him more specifically about his concerns.
He tells you he is worried about his heart and blood pressure, because he is under enormous pressure at work. He feels he is coping poorly with the unreasonable demands of his job, but he is under a lot of financial strain, and has no other work options.



See next blog for the full discussion on this case!