Question 1

How should a general practitioner judge the complexity of a coronary artery disease case, which determines whether the patient is managed locally or referred abroad?

Dr. Biswarup Purkayastha · Accepted Answer

Complexity is generally determined by the workup. The markers to watch are troponin and creatine kinase. If the enzymes are very high or keep rising, or if symptoms are worsening beyond 72 to 96 hours of conservative treatment (antiplatelet medication, or thrombolysis where PCI is not available) and have not returned to normal, make a specialist referral so that a specialist can perform an angiogram and determine the severity of the disease.

Question 2

A man in his late thirties has had two years of episodic sharp chest pain with breathlessness and weakness, relieved by rest or nitroglycerine. Two ECGs (one showing borderline bradycardia), two echocardiograms, liver and renal function, a full blood count and a 24-hour Holter were all essentially unremarkable, and CT coronary angiography is not available at our hospital. What should the next step be?

Dr. Biswarup Purkayastha · Accepted Answer

This is a man with two years of chest pain that comes on exertion and goes away at rest, with an unremarkable blood workup, but one ECG picked up some bradycardia. I suspect right coronary artery disease, which is extremely tricky to pick up on a blood workup or even on CT. What he needs is an invasive coronary angiogram.

If that is not possible, put him on aspirin 150 mg with clopidogrel 75 mg once a day, and a statin of at least 40 mg once a day to stabilise the coronary plaque. Check his cardiac enzymes during his next episode of chest pain. A rise in enzymes without an ECG change classifies him as unstable angina, which is an acute coronary syndrome and needs urgent specialist assessment.

He is young, does not smoke or drink, but has a strong family history: his mother died of a cardiac illness. Having a coronary angiogram is cardinal in his management. If the lesion is fixable with a stent, it should be stented; if not, a surgical specialist should interpret the angiogram and decide between bypass, stenting or medication alone. Even if this patient is sent abroad, the first thing he should get is a coronary angiogram.

Question 3

Can you say more about coronary artery disease in menopausal women?

Dr. Biswarup Purkayastha · Accepted Answer

Women before 45 are quite different: high oestrogen levels and regular menstrual cycles give them phenomenally good cardioprotection. Normally a woman has about one-eighth the chance of heart disease that a man has. After menopause, around 40 to 45, her risk is still about half that of a man, so it has increased four times.

The presentation is also very different. These women present over a longer period, a few days, and may say they have a flu-like illness with a little tightness in the chest, which can be mistaken for a common cold and treated with over-the-counter medication. Any woman above 45 with a few days of uneasiness should be probed for coronary disease. The best test here is a CT coronary angiogram: women have a lower calcium load, so CT coronary angiography has a very good positive predictive value for coronary artery disease in women. They come with a longer and softer history, perhaps only occasional tightness in the chest rather than severe pain, and rather than giving them over-the-counter medication, consider coronary angiography.

Question 4

How do you manage angina in a patient who is HIV positive?

Dr. Biswarup Purkayastha · Accepted Answer

It is standard practice. A patient with HIV and angina needs an angiogram done under a universal-precautions pathway. If he has coronary artery disease, it is stentable and it is also operable. Any JCI-accredited hospital has a protocol in place to properly segregate these patients and provide the right care; in our hospital we have a protocol to isolate them, put them through the pathway and provide the correct treatment, whether PCI and stenting or coronary artery bypass. People living with HIV are not discriminated against in receiving this treatment.

Question 5

Is there a direct relationship between pectoralis muscle spasm and coronary artery disease, and if so, what is the first-choice management?

Dr. Biswarup Purkayastha · Accepted Answer

Pectoralis muscle spasm is often misdiagnosed as cardiac chest pain. We differentiate cardiac from non-cardiac chest pain by the enzymes: non-cardiac chest pain has no elevation of cardiac markers, so a pectoralis spasm will always return a negative troponin test, and you can be fairly sure it is not coronary artery disease. Coronary artery disease per se is not related to pectoralis muscle spasm, so I would not say there is a first-choice management for a direct link. Non-coronary chest pain is treated with non-steroidal anti-inflammatory drugs. If the patient has coronary artery disease, evidenced by raised enzymes or another finding, go down the angiography pathway and decide between angioplasty (PCI) and coronary artery bypass grafting.

Question 6

Can you elaborate on the relationship between optimal nutrition and coronary artery disease?

Dr. Biswarup Purkayastha · Accepted Answer

Optimal nutrition is a high-protein, high-fibre, low-fat, low-carbohydrate diet. As a preventive measure beyond the age of 40, have regular blood work and see your GP perhaps once every three months to keep a watchful eye on the disease. Be vigilant about lifestyle habits: walk regularly and exercise for more than two hours a week, which is about half an hour every weekday, and manage stress well. With the right physical effort, the right diet and good stress management, you can prevent coronary artery disease about 80% of the time before it reaches the point of needing an intervention, whether surgery or PCI.

Question 7

What alternatives could replace a frozen elephant trunk (FET) procedure?

Dr. Biswarup Purkayastha · Accepted Answer

FET is a very specific procedure for aortic dissection, used to prevent a re-entry tear, and in today's practice it is almost mandatory. If it has not been done in the first place, the options are a hot elephant trunk, which has fallen out of favour, or EVAR (endovascular aortic repair), which seals off the re-entry tear so that the repaired dissection does not extend beyond it. In the thoracic aorta EVAR is quite easy because there are no major branches arising from it. In the abdominal aorta, where the major abdominal vessels such as the coeliac trunk and the superior mesenteric, renal and inferior mesenteric arteries arise, you need patient-specific imaging: CT images of all the major vessels are sent to a stent-graft manufacturer, who designs a patient-specific graft with branches at the right levels. The graft is then deployed through the groin by whoever in your hospital does this work, a cardiologist, cardiac surgeon or interventional radiologist.

Question 8

An elderly diabetic patient with end-stage renal disease, on haemodialysis for three and a half years and taking aspirin and atorvastatin, presented with a week of intermittent chest pain and was admitted with a non-ST-elevation MI. What should the next steps be?

Dr. Biswarup Purkayastha · Accepted Answer

He has had a non-ST-elevation MI, so he needs antithrombotic treatment and a plan for coronary angiography. Keep him on a single antiplatelet, aspirin, and add anticoagulation. Unfractionated heparin suits him better than low molecular weight heparin, because it is not cleared by the kidneys and its effect can be monitored and reversed; I would give it three times a day for at least two weeks. Once the symptoms settle, in a couple of weeks, a coronary angiogram is done, timed around dialysis, which will clear the contrast. Then we decide whether he is for stenting or for coronary artery bypass grafting. An elderly diabetic who has had an MI is not the ideal patient to put straight onto the operating table; for frail older patients who need a quick fix, stenting is often a very good option to buy time and get them through.

Question 9

Can coronary spasm affect or cause pectoralis muscle spasm?

Dr. Biswarup Purkayastha · Accepted Answer

In a word, no. Pectoralis muscle spasm is picked up by a localised range-of-motion test: moving the arm, for example getting the hands behind the back, aggravates a pectoral spasm, while angina is not affected by lifting the arm or moving it back. Coronary spasm has to be differentiated from pectoralis muscle spasm, even in a resource-constrained setting. A coronary spasm needs treatment; a pectoral spasm needs patient education and non-steroidal anti-inflammatory drugs.

Question 10

The same patient scored 10% on the RFCL (risk factor-weighted clinical likelihood) model. How should that be interpreted?

Dr. Biswarup Purkayastha · Accepted Answer

RFCL is an extremely old scoring system; we don't use it any more, because it gives too many false negatives. It does not replace clinical judgement in a symptomatic patient. Once disease has been shown on CT or an angiogram, the SYNTAX score grades its anatomical complexity. Follow up the patient, send him to the nearest facility with CT coronary angiography and share the report with us.

Live Discussion with Dr. Biswarup Purkayastha