A 60-year-old hypertensive patient presents to the ED with chest pain. The pain came on very suddenly in the left chest whilst he was lifting a heavy plant pot. The pain is difficult to localize. The intensity has been constant and remains persistent. En route to hospital it has changed location to the left side of the lower thoracic back. He has recently had treatment for thoracic back pain from a chiropractor. He is sweating (looks unwell) and anxious but has no shortness of breath. Blood pressure is 160/90 mmHg, heart rate is 100 bpm and saturations are 99% on room air. The ECG does not show acute ST change. D-dimer is 1700 ng/mL (normal < 500 ng/mL), and troponin is awaited.
Based on the information available, what is the most likely diagnosis?
The question is designed to emphasize the importance of careful history to elicit the pre-test probability of a particular diagnosis. 75% of presentations to the ED with chest pain are of non-ischaemic aetiology. The history is highly suggestive of an aortic syndrome:
• sudden onset (no crescendo as in ACS);
• changing locations (reflecting propagation of dissection);
• strongly positive D-dimer (history does not suggest PE; negative D-dimer also has a high negative predictive value for aortic syndromes).
You review a 65-year-old male on the post-take ward round who has been referred by his GP with a 2-week history of exertional chest pain. There have been no episodes at rest and he has improved since the GP started him on bisoprolol 2.5 mg od. His resting ECG shows no ischaemia and troponin tests are negative. He has a family history of ischaemic heart disease but no other risk factors.
Which investigation would you recommend?
The history is very suggestive of stable angina and so the patient has a high likelihood of coronary disease (>90%). Therefore he should go directly to invasive coronary angiography. Exercise treadmill testing is no longer recommended by NICE for stratification of stable angina.
A 45-year-old woman presents with ongoing chest pain. Immediate observations reveal BP 140/80 mmHg, heart rate 90 bpm, and saturations 99% on room air.
What should you do next?
An ECG should be performed as soon as possible as prompt diagnosis of ST elevation MI is essential. Nevertheless, the majority of patients presenting with chest pain are of non-ischaemic origin and so the other treatments may not be necessary. If ACS is suspected, aspirin should be given first. Oxygen is not recommended in the chest pain algorithm unless saturations are <94% (aim 94–98% or 88–92% if COPD).
You review a 55-year-old woman in clinic who has been referred by her GP with recent chest pains. You feel that the nature of the pains is atypical for ischaemia although they are reproduced with exertion. She has no identifiable risk factors for ischaemic heart disease and the resting ECG is normal.
What would you recommend?
This patient has a low probability of coronary disease (10–29%) but may have atypical angina. CT coronary angiogram is the best rule out test.
Angiography of a patient who had redo coronary artery bypass grafting in 1987. He had three grafts and has a recurrence of angina.
The following RAO angiogram shows?
Anatomy common to angiography for graft studies. These images are a particularly good example as graft markers (radio-opaque circles) have been placed and show the graft positions relative to each other in LAO and RAO view. Right coronary artery grafts are placed above the native RCA on the aorta. The graft is best engaged in the LAO view with the catheter pointing towards the left of the field of view. In this case a stump is revealed at the point of the marker.
Left coronary system grafts (commonly diagonal, obtuse marginal, or intermediate. vein grafts to the LAD are now uncommon due to the LIMA) are placed sequentially above the native left coronary system. In the RAO view the grafts are engaged with the catheter pointing to the right of the field of view.
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