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Heart Health:

Heart Health: spotlight on chest pain

Chest pain is a common presenting complaint for patients

in primary care and one of the most common reasons for

Casualty attendances in the UK. Early diagnosis and risk

stratification for patients with angina is particularly important,

because of the high incidence and poorer outcomes associated

with untreated cardiovascular disease. Patient assessment,

diagnosis and treatment options are summarised below by

Dr Ian Webb, Consultant Cardiologist.

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Diagnosis and risk stratification

The diagnosis of angina is broadly

supported by three different diagnostic

streams: (1) anatomical tests to assess

coronary anatomy (CT angiography,

invasive coronary angiography), (2)

anatomical assessment of heart muscle

damage, which in the presence of

pain is assumed to be ischaemic in

aetiology (echo or MRI), and (3) the

stress response of the heart to exercise

or pharmacological challenge (exercise

test, stress echo or stress MRI).

Cardiovascular risk is associated with

increasing disease burden, greater LV

dysfunction (reversible or non-reversible)

and greater levels of ischaemia on

testing. Furthermore, even when on

appropriate medication, key CV risk

factors remain crucially important

targets, with poorer outcomes in poorly

controlled diabetics, hypertensives

and those individuals with difficult

hyperlipidaemia disorders.

Diagnosis and interpretation of

screening tests carry several important

caveats: no test is 100% accurate; the

absence of ischaemia on stress does

not preclude a diagnosis of underlying

coronary disease, and vice versa, where

coronary disease is demonstrated

anatomically, this may clearly have

nothing to do with symptoms of non-

cardiac chest pain, irrespective of

coronary disease burden. For all these

reasons, the clinician must carefully

weigh up the evidence of their tests

against the individual’s symptoms and

their risk profile.

Patient assessment

Angina is a clinical diagnosis made after

detailed consultation and examination.

Angina pain may be ‘typical’ or ‘atypical’

based on the number of presenting

symptoms (NICE CG95), which include

(1) typical pain character, (2) typical

exertional precipitant and (3) typical

symptom alleviation (i.e. through rest

and s/l GTN).

Classical risk factors may augment

and support the clinical suspicion of

angina, but their absence clearly does

not preclude disease and the need to

investigate further. Conversely, even

where symptoms are non-cardiac,

traditional risk factors of increasing

age, diabetes, smoking history,

sedentary lifestyle, hypertension and

hypercholesterolaemia remain at the

forefront of primary prevention and

healthy hearts for the future.

Angina in the young (less than 40

years of age) is still uncommon, but

is on the increase in the UK due to

sedentary lifestyles, poor diet and

increasing levels of diabetes. Additional

considerations in this age group include

anomalies such as congenital valve

disease (e.g. bicuspid aortic valve with

severe stenosis), profound anaemia

and arrhythmias, all of which can

result in ischaemic-driven symptoms

in individuals without classical

cardiovascular risk factors or manifest as

atherosclerotic heart disease.