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Chest pain - when it’s probably not traditional atheroma @Lwnurses #LWN #LearnWithNurses Michaela Nuttall RGN MSc Founder, Learn With Nurses Director, Smart Health Solutions Associate in Nursing, C3 Collaborating for Health Chair, Health Care Committee HEART UK Member, Nurses Working Party and Guidelines & Information Trustee, PoTS UKritish and Irish Hypertension Society @ thisismichaela431 peeps.. So far BHF 2020 In the UK more than 100,000 hospital admissions each year are due to heart attacks; that's 280 admissions each day or 1 every 5 minutes. More than 200,000 UK hospital visits each year are due to heart attacks. In the 1960s more than 7 out of 10 heart attacks in the UK were fatal. Today at least 7 out of 10 people survive. Chest pain…. Chest pain refers to pain in the thorax. It can be classified by cause (cardiac or non- cardiac). • Cardiac causes of chest pain include: • Acute coronary syndrome (unstable angina and myocardial infarction). • Stable angina. • Other cardiac causes, such as dissecting thoracic aneurysm, pericarditis, cardiac tamponade, myocarditis, acute congestive cardiac failure, or arrhythmias. https://www.nice.org.uk/guidance/cg95 Non cardiac causes Respiratory causes of chest pain include: • Pulmonary embolus, pneumothorax or tension pneumothorax, community-acquired pneumonia, asthma, or pleural effusion. Other causes of chest pain include: • Gastroenterological causes, such as acute pancreatitis, oesophageal rupture, peptic ulcer disease, gastro-oesophageal reflux, oesophageal spasm, or oesophagitis. • Musculoskeletal causes, such as rib fracture, costochondritis, spinal disorders (disc prolapse, cervical spondylosis, facet joint dysfunction), rheumatoid or psoriatic arthritis, fibromyalgia, or osteoporotic fracture. • Cancer (for example, lung cancer); herpes zoster; Bornholm disease; precordial catch (Texidor twinge); or psychogenic or non-specific chest pain • Postural Tachycardia SyndromeNICE Chest Pain Overview 2020NICE Chest Pain Overview 2020 What percentage of people involved in research about CVD are women? 38.2% 41.1% 42.7% 45.8% 49.9% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% What percentage of people involved in research about CVD are women? 38.2% 41.1% 42.7% 45.8% 49.9% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% The average delay between the onset of symptoms and arrival at hospital for men ranges between 1 hour 24 minutes and 3 hours 30 - what is it for women? 1 hour 31 minutes and 5 hours 30 minutes 1 hour 48 minutes and 7 hours 12 minutes 3 hour 48 minutes and 4 hours 12 minutes 7 hour 48 minutes and 12 hours 12 minutes 1 hour 31 minutes and 12 hours 12 minutes 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% The average delay between the onset of symptoms and arrival at hospital for men ranges between 1 hour 24 minutes and 3 hours 30 - what is it for women? 1 hour 31 minutes and 5 hours 30 minutes 1 hour 48 minutes and 7 hours 12 minutes 3 hour 48 minutes and 4 hours 12 minutes 7 hour 48 minutes and 12 hours 12 minutes 1 hour 31 minutes and 12 hours 12 minutes 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% What percentage of women get an initial diagnosis which is wrong when having a heart attack? 20% 30% 40% 50% 60% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% What percentage of women get an initial diagnosis which is wrong when having a heart attack? 20% 30% 40% 50% 60% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Why? • Not enough known • Clinicians' perspective • Angiograms not as effective in diagnosis heart disease in women • It might not be ‘traditional’ atheroma (next session) They told me I was just having • Lack of inclusion in research a pto the hospital with noaken urgency. • InequalitiesBut when it’s not ‘traditional’ atheroma PoTSSCAD (Spontaneous Coronary Artery Dissection) most commonly affects?SCAD (Spontaneous Coronary Artery Dissection) most commonly affects? SCAD • SCAD most commonly occurs between adolescence and late 60s • Many people with SCAD will have few or no traditional risk factors for heart and circulatory disease • 90% of those with SCAD are women • It can often occur during, or soon after, pregnancy • It’s thought that estrogen and progesterone weaken blood vessel walls, making more vulnerable to tearing - SCADhttps://www.saintlukeskc.org/condition/spontaneous-coronary-artery-dissection-scad Symptoms SCAD patients experience different symptoms; the most common are: • Central chest pain • Pain or numbness in one or both arms • Jaw pain • Back pain • Shoulder pain • Nausea • Sweating/clamminess • Difficulty breathing Diagnosis and treatment • ECG (electrocardiogram) Surgical intervention: – although ECGs can • stents, or coronary artery bypass surgery look normal in some SCAD patients Medical management: • Blood tests to assess Aspirin, statins? blood pressure pills and beta blockers Troponin levels • Angiogram Cardiac rehab • CT scan What might increase risk of SCAD? • Abnormalities of the blood So: vessels such as fibromuscular • Number 1 cause of heart attacks dysplasia (FMD) in women under 50 years of age • Inherited connective tissue • Number 1 cause of pregnancy- diseases such as Ehlers-Danlos related heart attacks syndrome or Marfan’s syndrome • Most individuals with SCAD are • Severe high blood pressure young, healthy, and active with • Extreme physical exercise no family history of heart disease • Severe emotional stress Ischaemia with Non-Obstructed Coronary Arteries INOCA • These are conditions where the blood supply to the heart is restricted even when there are no blockages in the coronary arteries. • Patients with INOCA can present at emergency care with symptoms of a heart attack yet are often told there is nothing wrong with their heart, partly because INOCA conditions often do not show up on usual tests, like ECG’s and routine angiograms. • Patients with INOCA can spend many years being sent home from emergency departments without diagnosis, without treatment and without help. Vasospastic angina (Variant/Prinzmetal’s) People experiencing vasospastic angina do not typically have episodes of angina during exercise. • usually occurs while at rest and in the early morning or late at night • is often severe, but can be variable and can also be mild (a sense of unease) • can occur in other locations in the body; the back, shoulders, neck, stomach and arms • can be eased through taking medication • some people can also experience nausea. Triggers • emotional stress • exposure to extremely cold weather or a sudden drop in temperature • hyperventilation • allergic reactions (usually severe reactions that result in histamine release, sometimes referred to as Kounis Syndrome) • inflammation of the coronary artery wall • smoking • some antidepressants • some anti-migraine drugs • use of the drug cocaine • high consumption of alcohol More common in women Especially around the time of menopause Treatment • Nitrates: These can be given • Lifestyle in sublingual tablets, oral tablets or capsules or • Management of other risk factors patches. • Calcium channel blockers: These include diltiazem, amlodipine, nifedipine and verapamil. Microvascular Angina (syndrome X) • May be more severe and last longer than other types of angina pain • May occur with shortness of breath, sleep problems, fatigue, and lack of energy • Often is first noticed during routine daily activities and times of mental stress Only 5% or coronary arteries are visible on angiogramInternational Heart Spasms Alliance Diagnosis & treatment • Calcium channel blockers. • Not always diagnosed • Beta blockers. • Nitrates like nitroglycerin. • Lack of awareness • nicorandil, ivabradine and ranolazine • MRI • Low dose imipramine • Stress echocardiography • Hormone replacement therapy (HRT), especially if • Acetylcholine provocation their chest pain is associated with hot flush.s during angiography Support, CBT, HypnotherapyPoTSPoTS Symptom Profile 3 Commonest symptoms Lightheadednes Fatigue Fast palpitations Altered circulationn Syn copee* Visuall greying Brain fog * Orthostatic headaches Acrocyanosisheadaches Exe rcise intolerance Chest painr pain Raised noradrenaline Sweating Tremulousness Nausea, vomiting Diarrhoea, abdo pain Sense of anxiety Poor sleep *Symptoms occur mostly when upright* Summary • Chest pain isn’t always traditional cardiac • Think of what else it might be • The inequalities are vast • It is acknowledged there is a lack of research in women • There is a movement for change, it’s going to take a while