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My approach to chest pain

September 7, 2019 Andrew To
Severe coronary non-calcified atherosclerosis with severe stenosis, on CT coronary angiography

Severe coronary non-calcified atherosclerosis with severe stenosis, on CT coronary angiography

Chest pain assessment

  • History and context

  • Risk profile

  • Why did the patient come today?

  • One or two tests

 The history of chest pain

  • It concerns mismatch of oxygen supply and oxygen demand

  • Typical history would include (i) predictable pattern, (ii) effort related, (iii) relieved by rest, (iv) progressing over time

 Tests?

  • High risk symptomatic – straightforward, ETT/ESE/Angio

  • High risk asymptomatic – unclear

  • Intermediate risk – difficult, but may require a combination of tests

  • Low risk symptomatic – CTCA or functional test

  • Low risk asymptomatic – no test

Tips

  • Interpretation of any test should be in the context of the clinical history and pre-test probability

  • The pattern of a symptom is more important than the absolute severity.

  • There is a reason they came today.

  • Bad things never go away; they get worse.

  • Risk is a changing variable. Risk is a lifelong continuum.

  • Family history is unmeasurable.

The European Society of Cardiology recently updated their chronic coronary syndromes (chronic stable angina) in 2019. Here is the link. Figure 2 is particularly useful to expand on the tests. 

Author: Dr Seif El-Jack

In Coronary artery disease, Cardiac Investigations, Myocardial infarction Tags coronary artery disease, chest pain, Risk assessment, exercise stress ECG, stress echcoardiography
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