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Wednesday, 18 June 2014

#ECGclass - Summer 3 - Aortic Stenosis and chest pain

Welcome! 
If you are new to ECGclass, b
efore we start, you may like to read this brief explanation of what it's all about:   #ECGclass and how it works

Each 'term' is spilt into 5 cases, launched a 2 weekly intervals.  

So here goes with the next case of this term!


Summer 3



A 49yr old man presents to you with a 6 month history of chest pain.

Sometimes this is triggered by exertion, sometimes at rest. 
It can be prolonged, often lasting several hours and on occasions, all weekend.
He considers himself fit and active, so he light-heartedly dismisses his symptoms, and works through his 'mild' discomfort, which is very localised in the left upper chest, without radiation. He has no arm pain, no dizziness, and no breathlessness. 
In fact, he has only presented under duress from his wife.

He is a non smoker, with no risk factors for IHD and not on any medication. 
On examination, as always, his BP is normal.  However, you do hear a systolic heart murmur at the left sternal edge.

You obtain an ECG below:


What are you thinking now?
What is your next step?



Update

You press him a bit further to try and establish more detail about his history...
His symptoms are indeed predictably triggered by exertion on every occasion these days, and whilst he considers them mild enough to continue exercising through, they will usually settle within a minute or two of resting. On the other hand, he also gets episodes which are totally unprovoked and out of his control which can be prolonged at rest.  

He admits that his symptoms have become more progressive in nature (in terms of both frequency and severity) since their onset, over the past 6months. 

He insists he has no dizzy spells, syncope, no palpitations and  no family history of heart disease. He has alwasy made healthy lifestyle choices and has no risk factors for IHD.

Have these new revelations altered your suspicions, or swayed the urgency of your management?



***

Discussion 

ECG :  Widespread T-wave inversion with chest pain at rest. 

It wouldn't be wrong to admit this man, on the basis of his rest pain, and ECG changes.  You can't reassure him that nothing adverse will happen if he stays at home. 
Is this acute coronary syndrome? 
Has he had a recent cardiac event with ongoing T-wave changes and unstable symptoms at rest? 
Was there a recent episode of pain that was more significant than the others?

On the other hand - he looks, and feels, quite well as he sits in front of you. He's clincially stable and given his dismissive nature, he may take some persuading to go in - but with rest symptoms he is at risk.


At very least, this presentation should prompt an urgent referral to the RACPC.  
In the meantime he should be started on aspirin, a beta-blocker and a statin and given GTN/999 advice. The referral should include a copy of his ECG and make note of the murmur
(Note: Not all RACPC are set up with ECHO facilities, so if this information is included with the referral, an "ECHO on arrival" request can be made by the clinician receiving the referral).

In this case scenario, the gentleman refused admission at time of presentation but an ECHO at RACPC confirmed severe Aortic stenosis.   As such, an  ETT was contraindicated.  

He required same day admission for monitoring, and an in-patient work up for diagnostic cardiac catheterisation to exclude coronary atheroma before dealing with his valve disorder. 

Aortic Stenosis as a cause of angina must not be missed

Aortic stenosis can cause cause anginal symptoms in people with healthy coronary arteries and it's management, is therefore, completely different.  Treating someone with antianginal therapy for "IHD", when they actually have undiagnosed aortic stenosis a). won't help them, and b). is indefensible. 
Severe anginal symptoms in an individual with low risk factors for coronary artety disease should always raise suspicion - but most importantly - examinination for a murmur should always be sought in those patients presenting with chest pain.  

Frequently, prolonged severe aortic stenosis gives rise to voltage criteria for LVH on the ECG. 

The above ECG shows no voltage criteria for LVH, and we know he is normotensive.

Below is another example of severe Aortic Stenosis, this time causing the typical 'strain' pattern seen with LVH:







Note the similarities in the two ECG's. 
However, in this second example, there is gross voltage criteria for LVH (fulfilled in Leads I, aVL, V1-6).  There is widespread T-wave depression, and typical of LVH,  T-wave inversion in the leads which face the left ventricle (i.e. leads I, aVL, v4-6).

T-wave inversion is also seen in leads V2 and V3.  This is suggestive of other pathology, such as co-existing coronary disease.



Lesson - Don't let the stoical nature of some patients disarm you! :-) 





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1 comment:

  1. Thanks Heather, enjoyed this class. I wonder if he might have had an altered pulse character on examination which might have helped to identify the valve problem?

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