The assessment and treatment of chest pain–both acute and chronic–is the focus of this conversation with guest Debabrata Mukherjee, MD. Dr. Mukherjee describes risk stratification, appropriate testing, and shared decision-making with patients with chest pain, as well as the importance of preventive care.
Welcome to Heart to Heart Nurses, brought to you by the Preventive Cardiovascular Nurses Association. PCNA's mission is to promote nurses as leaders in cardiovascular disease prevention and management.
Geralyn Warfield (host): I'd like to welcome our audience today for our conversation with Dr. Mukherjee, and I'm going to have him introduce himself to us.
Debabrata Mukherjee (guest): Hi. I’m Deb Mukherjee. I'm the chair of the Department of Internal Medicine at Texas Tech University Health Sciences Center at El Paso, Texas, and an interventional cardiologist by profession.
Geralyn Warfield (host): I'm hoping you can start off our conversation discussing with us the assessment and treatment of acute chest pain.
Debabrata Mukherjee (guest): Acute chest pain is a very common presentation in the emergency department, so appropriate evaluation, which is evidence-based, and not over-utilization of tests, is critical.
As with any medical condition, we start with history, physical exam, [00:01:00] to assess if it is cardiac chest pain, cardiac coronary chest pain, non-cardiac chest pain, non-coronary chest pain.
And we can do tests like ECG, biomarkers such as cardiac troponin, and—in certain individuals, particularly those that are intermediate to intermediate-high risk—appropriate testing, which may include stress testing, which may include anatomical testing such as CTA, and in the very high-risk patients who have ruled in for a heart attack, we do coronary angiography.
Geralyn Warfield (host): So, if one of our listeners is interested in finding out more about the delineation that they need to provide when they're seeing these patients with this kind of chest pain, to what kind of resources would you point them, or what kind of algorithm, for example, if one is available, could they use?
Debabrata Mukherjee (guest): So, one of the very useful risk scores to risk stratify this individual is a HEART score, which is very simple, five factors, and they can [00:02:00] Google it, use it online...an excellent resource. For more descriptions of other risk scores is the 2021 Chest Pain Guidelines: talks about the HEART score, the EDACS, the ADAPT, the modified ADAPT [mADAPT], and even the high sensitivity troponin-based risk score.
So, the two resources would be HEART score calculator online and the 2021 Chest Pain Guidelines for more detailed discussion on the individual risk scores.
Geralyn Warfield (host): So, can you give us an example of a case perhaps, that you have seen in clinical practice where you utilized this? Kind of, maybe, just some sample scores that you were able to access and utilize in your clinical diagnosis.
Debabrata Mukherjee (guest): Right. So, a few weeks ago I saw a 54-year-old woman with diabetes, hypertension, dyslipidemia. Came in with chest pain with some ECG changes, which were not quite ischemic, but not quite normal ECG, [00:03:00] normal biomarkers. And we used the HEART score and HEART score was calculated to be six, which puts her at intermediate risk.
So, she underwent stress testing and we found that she did have moderate to severe ischemia. Eventually underwent angiography, and a stent to her left circumflex artery. So, that's a good example.
With individuals with low-risk HEART score, we, we safely discharge from the emergency department or from the urgent care clinic, restratify them later with lipid profile, other testing to rule out diabetes and check for hypertension.
So, using a HEART score is a very effective way of risk stratifying. We call it clinical decision pathway into low risk, high risk, and intermediate risk.
Geralyn Warfield (host): So, in the case study that you just provided to us, how did you go about sharing with the patient about what the test results were going to mean in terms of next steps for her?
Debabrata Mukherjee (guest): That is an excellent question, Geralyn. [00:04:00] And shared decision making is key. We have many choices today. So, what I told her is that based on the clinical decision pathway, she's at intermediate risk, which is six—so, four to seven is intermediate risk. And I give her choices of the tests that we can do, which include CT angiography, stress imaging, to further risk stratify her.
And then we went over the risks, benefits of the test and the individual tests, including radiation contrast with some of the tests. And she decided because of the contrast issue, and she had a family history of kidney disease, to go with stress nuclear imaging. But it is key to discuss the risks, the benefits, the consequences, the test involvement of radiation or contrast to the individual patient, and make an educated decision between the clinician and the individual patient.
Geralyn Warfield (host): And I suspect in your clinical situation, you always have the possibility that family [00:05:00] members or caregivers are also present for that discussion. Do you change your discussion at any point for them? Do you, do have somebody on your team, for example, do follow up just to make sure there's, all their questions are answered?
Debabrata Mukherjee (guest): Right. We have a team of nurse practitioners who helps us follow these patients. Whenever possible, even though the patient is central to our decision making, we tend to, we try to involve, always, the caregivers, the spouses or family members, in the decision making.
Sometimes the patient is at a loss to make the decision because they're dealing with an acute condition. So, involving family members, and making sure the patient understands, and then following up later on, to make sure we are explained everything and they don't have any follow up questions before the particular test or even after the test is very important.
Geralyn Warfield (host): We're going to take a quick break and we will be right back.
Geralyn Warfield (host): We're back for more discussion about the [00:06:00] assessment and treatment of chest pain. And I'd like us to transition just a little bit from the acute chest pain examples that we've been discussing to chronic or stable chest pain. So, I'm hoping you could address those assessment and treatments, please.
Debabrata Mukherjee (guest): So, for chronic or stable chest pain, we also use pretest probability. And the pretest probability is based on their type of symptoms, chest pain versus dyspnea, the individual patient’s sex, men versus women. And based on those, certainly somebody old—say in their seventies—with chest pain has a 50 to 60% risk of having coronary artery disease, not including any other risk factors.
We can include other risk factors to determine the likelihood of coronary artery disease. We can do a coronary calcium score. We can do carotid atheroma or IMT testing. We can do ankle brachial index testing to further risk stratify or fine tune the risk. You can do lipoprotein(a) for the appropriate individuals. [00:07:00]
But basically, the symptoms itself, the type of symptoms, the sex of the patient, the age of the patient, can give you a very good idea of the likelihood of having coronary artery disease in these individuals.
Geralyn Warfield (host): And so in terms of your clinical practice, In terms of follow-up, are there any differences between the previous case study example that we just discussed before the break, and an example that you might have now in terms of, I realize there's a difference in testing, but as they are leaving your care and moving on to that next transition, wherever that might be, do you have any differences that you would have in these patients?
Debabrata Mukherjee (guest): I think the key for long-term follow up of individuals, either with acute or stable or chronic coronary artery diseases, is making sure we do everything to minimize their risk. Healthy lifestyle is important. Diet, exercise, making sure their cholesterol is adequately controlled. If they have diabetes, making sure their glycated hemoglobin is less than seven. Optimal control or blood pressure. These are [00:08:00] the things that save lives.
In acute coronary syndrome or acute chest pain, acute heart attack, doing revascularization certainly improves survival. But in stable coronary artery disease, the benefit is mostly symptoms. But in those individuals with stable coronary artery disease, if we can take care of their lipids, if we can treat their diabetes appropriately, their hypertension, that will save lives.
Geralyn Warfield (host): Is there anything else that you would like to share with our audience that I have neglected to ask?
Debabrata Mukherjee (guest): I think you've asked all the right questions. I you like to emphasize that an ounce of prevention is worth a pound of cure. Early on, even individual in their twenties, because in the United States we are seeing a lot of obesity in an adolescents and young adults.
So, healthy lifestyle, good diet, exercise, making sure folks know their blood pressure. Folks know if their diabetes, their lipid profile, at some point after they turn 25, making sure we do everything so [00:09:00] that they do not develop coronary artery disease or a heart attack 20, 30 years down the road.
Geralyn Warfield (host): And that prevention really is an important aspect of this. And just because you had your blood pressure checked, four years ago at some event, maybe at some clinic setting, you'd need to have it checked again.
Debabrata Mukherjee (guest): Absolutely.
Geralyn Warfield (host): That, that ongoing preventive care is important as well.
Debabrata Mukherjee (guest): Ongoing prevention care, you hit the nail on the head, is critical. Just because somebody had a lipid profile 10 years ago or five years ago, things change. Blood pressure changes, people develop diabetes. So regular checkups, regular—if necessary—basic blood work, but regular history and physical is key and not something that was done once in a while.
Geralyn Warfield (host): Sounds great. Just in case you haven't had an annual exam, now's your chance to make sure that you have that happen. We want to make sure we all stay healthy, and that includes our colleagues and our families as well as our patients.
Debabrata Mukherjee (guest): Well said.
Geralyn Warfield (host): Thank you ever so much for being here today. This is Geralyn Warfield, your host, and we [00:10:00] will see you next time.
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