Chest pain – the best test for the right patient

In this episode of PodMD, experienced cardiologist Dr Manuja Premaratne will be discussing the topic of chest pain – the best test for the right patient, including how a patient typically presents with chest pain, the most common causes, the different diagnostic tests available, the importance of choosing the right test, when to refer and more.


RACGP

  • Transcript
    Please note this is a machine generated transcription and may contain some errors.
    *As always, all in this PODMD podcast is intended for health professionals and the comments are of a general nature. Information given is not intended as specific medical advice pertaining to any given patient. If you have a clinical issue with one of your patients please seek appropriate advice from a colleague with expertise in the area.

    Today I’d like to welcome to the PodMD studio Dr Manuja Premaratne

    Manuja is one of Australia’s most well trained and highly qualified non-interventional cardiologists, being one of a few experts in all cardiac imaging modalities. He undertook his medical training at the University of Queensland. He completed his cardiology training at Wollongong and Prince of Wales Hospitals in NSW and an Echocardiography Fellowship at the Prince of Wales Hospital, one of Australia’s busiest units.

    This was followed by a 2-year Advanced Cardiac Imaging Fellowship at world renowned University of Ottawa Heart Institute. He is one of only 10 Australian cardiologists to be granted the United States’ board certification in Cardiac CT. He has received Awards from the American College of Cardiology and the American Society of Nuclear Cardiology as one of the 10 top researchers in the USA and Canada in Cardiac Imaging

    Today, we’ll be discussing the topic of chest pain – the best test for the right patient

    *We do hope you enjoy this podcast but please remember that the advice here is of a general nature and is not intended as specific advice about a given patient. The views and opinions expressed in this podcast are those of the doctor, not PodMD.
    If you do have a patient on whom you require specific advice, then please seek advice from a colleague with appropriate expertise in that area.

    Manuja, thanks for talking with us on PodMD today.

    Manuja: Thanks for having me.

    Question 1
    The topic of today’s discussion is chest pain – the best test for the right patient. Manuja, can you describe how a typical patient would present with chest pain?

    Manuja: Sure. Look. So look, one of the main things is chest pain is very common in terms of presentations to emergency departments and it’s one of the commonest things we deal with as Cardiologists. The sort of broad classification with chest pain is that there are two kinds we call acute and stable. The acute chest pain is the patient who comes to ED. Stable chest pain as the patient who presents to you know, their family doctor or to us in a clinic setting. So when you say someone like the typical chest pain, so the broad sort of picture that we have in what we’re all taught in, sort of the textbooks is the patient with chest pain or chest heaviness like an elephant sitting on my chest. Or brick on my chest and the pain goes down the arm or up the neck. So that’s what we usually think of as a sort of typical sort of chest pain

    These days, what we’ve also learned through research over the last few years is that certain patients present differently to that sort of typical picture. So for example, female patients. And have tiredness and fatigue. And they can often have sort of triggers of, like emotional sort of stress and events. Or often you have patients with diabetes who don’t get that sort of central sort of chest tightness or, you know. And so they have their chest pain is indifferent. So it is, while that is a predominant picture that central chest tightness and heaviness going down the arm. There are other sort of pictures we need to keep in mind.

    Question 2
    What are the most common causes of chest pain?

    Manuja: So the most the common cause of chest pain, from a heart point of view, what we’re worried about is ischemic heart disease. So cholesterol blockages in our, in our artery. So that’s the and ischemic heart disease costs like you know, the lead, the Heart Foundation statistics show that 50 people die of heart disease every day and then it cost the economy like $5 billion a year. So it is ischemic heart disease, one of the most commonest causes of chest pain.

    The other things you can have, like things like musculoskeletal chest pain is very common. Reflux is a common cause of chest pain, but often what we like to do is to rule out the rule out ischemic heart disease first, as that’s the most serious chest pain, the other sort of serious cause of chest pain that can be an emergency presentation or pulmonary embolus or clot in the lungs. You can have aortic dissections or a tear in the aorta, but those are rare causes, but those other causes that can lead to if you’re suspicious, suspect them, and you need to keep them top of mind, but the commonest causes are ischemic heart disease and gastroesophageal reflux. So those are the sort of top two sort of causes, abdominal and cardiac.

    Question 3
    Can you provide an overview of the different diagnostic tests available for evaluating chest pain?

    Manuja: Sure. So look, the broad classification of these tests are what we call functional and anatomical. What I prefer, so when I teach medical students, I say the way we, the way I like to think about it is in terms, one side gives us a directive visualisation of their arteries and if there’s any atherosclerosis and the other sort of test the functional test, it lets us gives us a likelihood of the likelihood of the presence of a significant stenosis.

    So, so anatomical test is like what we call a CT coronary angiogram. So that’s where you inject dye into the patient. And then you have an outline of the arteries and you can see if there’s any cholesterol build up. Functional testing is when you put a patient on a treadmill, you put in the heart under stress and you’re either looking for abnormal wall motion. So on an echo way, the way the abnormal heart movement or abnormal blood flow, as in with nuclear perfusion. So those are the 2 broad sort of classifications like anatomical and functional.

    Question 4
    Could you explain the importance of choosing the right test for diagnosing chest pain?

    Manuja: Sure. Look it is an important question both in terms of for the clinician in terms of getting the right answer, but also for the patient in terms of having an answer, giving an answer to what’s wrong with them. Thing that I would prefer to think about it in terms of what would make what would give you a bad result or actually you know not a proper answer. So for the perfect CT coronary angiogram, the first important thing is because it involves injection of contrast, is the patient allergic to iodine based contrast? Or and how is their renal function because contrast affects the kidneys, so usually we use a cut off as EGFR of 30. So usually we like to have a renal function that’s within three months. If it’s close to 30 just to see what it is.

    The other things for a perfect CT coronary angiogram that you want is a heart rate close to 60. So can they take beta blockers? It’s very important to hold your breath to get the lungs out of the way. So can they hold their breath for a few seconds? So that’s what generally makes a good CT coronary angiogram. For a good stress echo, so the most important thing is can they if you’re sending them for a treadmill based test, do they have make sure they don’t have any, like osteoarthritis of the knees or the back that precludes exercise. We like these patients to go for at least 10 minutes if they to get a good assessment of their heart rate and if you’re using stress echoes or ultrasound. Making sure that you’re not sending a patient who’s morbidly obese because the ultrasound wave has to go through all that fat. Go to the heart, and then come back out. So the more fat there is, the more degradation of the signal and the less clear the images.

    And for a perfusion scan, nuclear stress, we generally because it involves radiation and we don’t like to do it in younger patients, so generally I like to do a CT coronary angiogram first because it gives a visualisation of the arteries. I can see what’s going on in there and if there’s any atherosclerosis, it gives me a chance to start treatment versus the other tests, the functional. Test sure it gives me the likelihood of the significant blockage, but it doesn’t give me any information about. Is there any cholesterol buildup.

    Question 5
    Have there been any developments in testing in the last years or are there any in trials or development now?

    Manuja: So good question. In terms of the evidence base, so the evidence base has advanced a lot for CT coronary angiography. So in 2018, we had a study called the Scott Heart trial. So that’s where they looked. It was a randomised controlled trial in Scotland where they looked at CT coronary angiography versus the standard of care which is comparing it to exercise treadmill. And So what they showed was patients with the CTs who had a CT scan to investigate their symptoms of angina actually had a mortality benefit. So and so it was a very positive outcome for CT coronary angiography, so that has changed and that the and so the increasing evidence base for CTCA has led it to be classified as first line alongside stress echo and stress mibi, in terms of as first line investigations for chest pain.

    So the American College of Cardiology and all the other important societies in the world, they came out with the chest pain guideline in 2021 that showed CTCA is first line and. And so that was one of the main pluses for CTCA in terms of evidence. The other thing is the National Health Service. So the Nice guidelines in the UK in 2016, they were ahead of the curve and they made CTCA a first line for chest pain. Of a CTCA first line compared to and made functional testing second line.

    So those are the 2 main sort of big things because CTCA is relatively new compared to stress echo and nuclear scanning. So nuclear scanning and stress echo have been there since the 19. Nuclear imaging has been there since the 80s and stress ECHO has certainly been there since the late 80s and early 90s, so CTCA is a relatively new kid, but like it’s only been the scanner technology has only made it practical since the mid 2000s, so that’s why most of the newer evidence is focused towards CTCA.

    Question 6
    How do non-invasive tests like CTCA, electrocardiograms (ECGs) and stress tests compare to more invasive procedures like cardiac catheterization in terms of diagnosing chest pain?

    Manuja: Sure. So ideally you would do it like everyone would have a an invasive angiogram because that’s the sort of the what we say the gold standard. But it is a test that is invasive. It involves making a puncture. You know putting it, you know, cutting the skin, making a hole in an artery, putting a tube in and, you’re putting a tube in, you know into the heart. So it’s a test that has significant risks in terms of, you know, risks of stroke, risks of bleeding.

    So that’s why finding the non invasive test that’s good is very important. So I find CTCA is the closest in terms of to invasive coronary angiography, in terms of if it lets you visualise the actual cholesterol inside versus stress testing, which doesn’t. So stress testing will not give you an idea of someone has any atherosclerosis, so at least with the CT angiogram, even if there’s a little bit, I can tell the patient. Look, you have mild nonobstructive coronary artery disease. We should treat it because the evidence shows that even that mild disease can cause you trouble down the line.

    Question 7
    How do you approach the challenge of diagnosing chest pain in patients with atypical symptoms?

    Manuja: So a good question. Atypical symptoms do present a significant proportion of our practice and this is where I find CTCA so useful. CTCA and the injection of the dye gives you a complete outline of that coronary artery tree. So if they have a significant blockage. Then you’ve picked it up. If they don’t have a significant blockage and they have mild disease, it’s still positive news. I tell the patient because that means OK, you need to be on cholesterol treatment. We need to control your risk factors. We need to make sure that this mild disease stays mild. So for atypical symptoms, I find CTCA is very helpful and I would recommend it as first line for everyone out there.

    Question 8
    When should a GP refer?

    Manuja: So good question in terms of when to refer. I would generally say anyone with chest pain, you should refer, right. But the other thing is when someone presents with chest pain, I usually find that it gives you an opportunistic sort of chance to address other risk factors. You know, let’s so when someone comes in to see me with chest pain, I check their cholesterol. I say let’s do your lipids. Let’s let’s check your blood pressure and then let’s check your BMI. So it gives me. So I. Would say you should refer patients with chest pain to get it investigated. Because it could be something serious. Rule out something serious, but it would also gives you a good chance to look at all the other risk factors you know, check their cholesterol, check their blood pressure and check their BMI and give it gives you a chance to talk to the patient, you know, to address these other risk factors.

    Question 9
    What role does the GP play in the treatment of the condition?

    Manuja: Look, I would say our GP colleagues are one of the most important parts of the in the patient care for the patient with chest pain because they’re the first point of contact and they’re the main point of contact. So I would say look the important roles are in terms of recognising the patient with chest pain and then also sending them through to you know referring them to for the test. Now unfortunately, the current Medicare rules means that GPS can’t order a bulk bill CTCA, but you can still order a patient a CTCA just involves an out of pocket cost.

    So recognising the patient with chest pain, organising their test, referring as appropriate, and then also following on let’s say. If there is non-obstructive coronary artery disease on that CTCA, making sure that their LDL is well controlled, checking their risk factors such as hypertension, keeping a control on things like obesity. I find obesity these days is a big part of my practice in terms of I find it controlling obesity means that the cholesterol comes down, blood pressure gets comes down.
    So it’s rather that sort of central player that has a lot of tentacles in terms of control, sleep apnoea. So I find so that’s what I’m telling patients these days. You know, so it’s all finding someone a chest pain gives you the chest, not just to diagnose the cause of the chest pain, but also to check out other risk factors. So I would say those are that’s why the General practitioner is so important because as the main person of patient contact.

    Concluding Question
    Thank you for your time here today in the PodMD studio. To sum up for us, could you please identify the three key take home messages from today’s podcast on chest pain – the best test for the right patient?

    Manuja: 1. Chest pain can be investigated with direct visualization of the coronaries non-invasively. Patients should get a CTCA these days as first line
    2.Important to keep in mind patient characteristics that might contraindicate a test
    3.It is a good time to check on cardiac risk factors.

    Thanks for your time and the insights you’ve provided.

    Manuja: Thank you

*As always, all in this PODMD podcast is intended for health professionals and the comments are of a general nature. Information given is not intended as specific medical advice pertaining to any given patient. If you have a clinical issue with one of your patients please seek appropriate advice from a colleague with expertise in the area.