Chest Pain Guide - A to Z of the NHS - Dr Gill

[Music] hello and welcome back to our a to z of the nhs we've managed to make it to letter c even if we might not have finished editing the b's yet but we're doing the recording nevertheless so andy welcome back we've got three c's to discuss today um the first one we're going to do is chest pain and i think i'm going to talk more about that as a hospital doctor when then we're also going to do crohn's disease and celiac and i think this is more in your territory so on this occasion i will swap to being the interviewer and you the interviewee so chest pain that that tends to be the thing that i actually see a lot of patients for and then bounce them on to you basically if it's chest pain and i'm concerned i'm not going to deal with that on the initial case so what's what's going to happen when i've seen a patient and i've been worried about chest pain and send them up to you at the hospital that's a very good question and i think you as a gp and you out there as the general public should have a very low threshold for sending patients to the hospital with chest pain because there are a group of very serious causes which we'll talk about in a minute but many of those serious causes need treatment that can really only happen in a hospital now you say having a very low threshold i think that would be probably something really useful to delve into now because i hear from lots of patients say they're worried to go to the hospital because of covert at the moment what would you say if someone has chest pain i understand that when a pandemic and i understand that covert is bad and it's dominating the press at the moment but people still have heart attacks or as we call them myocardial infarctions and clots in the lungs that we call palmly emboli or pes and these are two very very serious conditions and both often present as chest pain so if you ever have chest pain you may have one of those and they really can only be sorted out in hospital so i would encourage you to come to the hospital if you can't get to your gp or if you can get to your gp you may want an assessment there first but i think most of the time people with a rapid onset of bad chest pain should come directly to the hospital and in all ways we will look after you when you come to the hospital we're streamlining patients who we think might have coronavirus and all those other patients who need our care it's a safe environment still so back to your question of what happens well patients with chest pain are prioritized so that's the first thing you don't sit in the queue in the waiting area as soon as we hear those two words that we're all slightly worried about chest and pain together you get put in an accelerated system you have an ecg an electric recording of the heart very quickly and depending on what that shows you'll either be put into the resuscitation area which is where we put the sickest patients or what's called majors which is an area where people have major medical problems so we've we've got you know the the approach when the patient's in we know where they're going to go but what are we going to do for that patient who's you know gripping their chest and they feel like they've got a rhinoceros sat on it well having had a quick look at the ecg which will tell you fairly quickly whether the patient's having a heart attack or not you would then proceed to doing a couple of things first of all you'd almost certainly put some oxygen on them and you would put a needle in a vein in the arm we call this a ventron and this is because we may need it later on to give you drugs with so that's the very first thing that would happen one of the things that we're looking for is a section of the ecg complex probably everybody's seen it on the television when it does that and these blips have stages about five stages and one stage is called the st segment and if that is raised that is highly suggestive of a heart attack a myocardial infarction that there are other causes and with what you're saying on the ecg those changes there's some are as medics were very good at giving sort of nice touchstone names and one of the names that i have heard with regard to ecg's when we have these very large raised portions when someone's having an mi they can be called tombstones and i think that gives an idea of how severe these things can be and why we desperately want to see patients with chest pain so that we can work out all the other causes and hopefully reassure them it's not a heart attack yeah absolutely i have heard that phrase i must admit i i don't use it myself and i i wouldn't recommend us using it i think it's a bit of a grey's anatomy type phrase even if it is used in america it doesn't mean that we have to um i'll tell you a little bit about what happens next after that initial assessment the junior doctor who sees you or sometimes maybe a nurse a specialist cardiac nurse would take a history that means ask questions and then examine you because people don't just have heart attacks that's not the only cause of chest pain i've got on my crib sheet here at least 20 causes and we go through history and examination to find out the cause of the pain as well as the ecg we normally do two other tests including a chest x-ray and one of my favorite tests that we talked about which is arterial blood gases you'll remember them james won't you yes i remember the sort of vampiric look in your eyes as you thought back to doing them so um what i thought i might do now is talk about how we decide the cause of the chest pain um and in broad terms there's four groups there's uh the big group that everybody's heard about that people tend to focus on which are the cardiac or or heart causes and of those there's four that we see on a reasonably regular basis heart attacks are myocardial infarction something called a dissection of the aorta and then something called pericarditis and myocarditis now i'm not going to go through all of these today but i would like to talk about the heart attacks and the second thing a dissection if that's all right because from from my memory of medical school with that we've got we can actually sometimes get hints what might be going with the patient with the way they describe the pain haven't they absolutely absolutely um so when someone is having a heart attack we actually use the phrase myocardial infarction and we lump that with two other things stable angina and unstable angina into a group phrase called acute coronary syndrome or acs and the clue to that is the type of pain it's often described as a heavy central chest pain radiating down the left arm whereas the pain of a dissecting aortic aneurysm is a more severe pain and usually radiates through into the back i've heard it described as a tearing sensation as opposed to that heavy weight of the myocardium it is it is described as that but actually these words are not terribly helpful in clinical practice because what's tearing to you is heavy to me and we have different pain thresholds so i think it's more where the pain is and i quite often ask the patient how would you grade the pain between 0 and 10 when 10 is having a baby and one is a mild headache and sometimes that helps you decide how bad a pain is or not so they are a couple of the important cardiac causes of chest pain the heart attacks the acs are diagnosed with an ecg and with a blood test called trop t to diagnose a dissecting aneurysm you actually need a big test you actually need a ct scan and that's another reason why i think patients with chest pain should go to a big hospital because they will have a ct scanner there so for example in warwick hospital where i've spent a lot of the time we've got all that same kit but we go to different departments you guys are really lucky you've actually got a ct scanner in the a e department separated by one door absolutely we're very lucky in our hospital in coventry it was a purpose-built hospital that opened in 2006 and actually there is as you say a ct within the emergency department so it means patients can go from the ambulance through recess and into the ct scanner so we can make a diagnosis of an aortic dissection in half an hour for example whereas another hospital that would take a few hours i'd like now to talk about the respiratory causes of chest pain um there's quite a few the main ones that i'd like to focus on today are pulmonary embolus and pneumothorax and the reason i've chosen those two is because they're important they're dangerous they can kill you and there are very effective treatments a palm embolus is a clot in the lungs they're relatively common there are risk factors like being a woman like being overweight like being on the pill but anybody can have a pulmonary embolus now i think i think it's important to say we haven't checked scripts we knew what we were talking about at this point you say that they're relatively common this week i have had a lady who has been overweight who'd come back from a flight and has a pulmonary embolism just this week isn't that astonishing and i promise you viewers that is not a setup uh my story for palmy embolus is a rather sad one actually it was a young woman i looked after 15 plus years ago she was very overweight she had young children and she had a fracture she fractured her ankle just walking she tripped and fractured her ankle and about 10 days later she had a rapid onset of chest pain came up to the hospital and unfortunately she had what's called a saddle embolus that is when somebody has a huge blood clot in both of the main pulmonary arteries and we call it a saddle emboli because when we put the patient in the ct scanner it looks like a saddle sitting across there when we slice it in half with the radiogram with the radiogram what is this 1700 when we slice it in half with the ct scanner the patient was discussed with me it was about eight o'clock at night when the registrar clicked that it might be a palm endless and i said get a ct scan immediately and that happened but unfortunately we were too late and the patient was transferred to itu and died about two o'clock in the morning so that was a very very sad day for me because i was the consultant responsible for her i was in charge of the take um but you know bad things happen in medicine sometimes it's actually interesting what we're saying about patients coming in and we use the history to get a lot of the diagnosis and we can confirm in other ways with patients who've got coronavirus at the moment they sound the things that they describe sound sometimes like a pulmonary emboli and when we do the tests you know looking at their sat the abg's they appear to have a pomona enemy but they haven't had them when we've put them in the ct scanner one of the things that we have found is that these patients are getting micro emboli so we've gone from one extreme the saddle embolus this colossal clot blocking the big arteries to these micro emboli blocking the small arteries which is why we are evolving with our knowledge of covid even at the moment but i think it's also right in saying that covert is a great pretender and can present as almost anything um so it can for example lead to myocarditis that can lead to chest pain and as you say it can lead to a polymer is a significant one as well as the micro permeable that could present as chest pain so covid is now entering our differential for chest pain quite importantly at the hospital i'll move on to pneumothorax and pneumothorax normally presents as a sudden onset of chest pain in a young person particularly a tall slim person stop looking at me like that like yourself james uh so i i would be a ladies and gentleman unlikely to have a pneumothorax the important thing about pneumothorax or collapsed lung is it's very treatable with a thing called a chest train so it's very important to make the diagnosis um and the other reason i wanted to mention it is there are only three causes of a sudden onset of chest pain so pains can come on either gradually rapidly or bang like a bus hitting you and those three are pneumothorax aortic dissection and rupture of a major abdominal viscous such as a peptic ulcer or the esophagus which i now like to to move on to right i think we'll move on to the third group of causes which are gi or gastrointestinal causes i've already mentioned perforation of a peptic ulcer in the stomach for example or the esophagus that can present as a sudden onset of chest pain but also we have gourd gord which stands for gastroesophageal reflux disease and this is basically when you have hiatus hernia and because of our hiatus hernia acid refluxes back up the esophagus causes inflammation in the low esophagus and pain that's actually a big one i see an awful lot at work people coming in with straightforward reflux and there was a guy who won a nobel prize a few years ago for finding one of the calls as you said a hiatus hernia is a mechanical problem that's really quite difficult for us to treat but quite commonly it's due to a bug h pylori and the guy who won the nobel prize for it he thought this bug is causing reflux and causing people to get chest pain like that couldn't get anybody to pay attention to it so he cultured up h pylori drank the flasks caused huge stomach ulceration which nearly ruptured didn't quite die thankfully proved his point and won a nobel prize for it and that's basically where people such as myself now give out ameprazole and a couple of antibiotics all the while to treat this infection and what was a killer because this bug would cause ulcers and could uh rupture is now quite run on the mill to the degree that after christmas it may have been just too much good living um i was getting a bit of reflux and you know burden of knowledge things began to percolate in my head so i actually tested myself from h pylori thankfully everything was fine and it resolved when i stopped basically living on a diet of chips for a week but you know it is something that is a low level cause that can have a really high level uh problem there are a couple of other gi causes i think we should always entertain one is pancreatitis which is a very nasty disease sometimes called the internal burn often due to gallstones and to something that my mother has which is surprisingly common which is esophageal contraction she seems to have a hyper excitable esophagus sometimes it's called the corkscrew esophagus and it tightens and causes chest and abdominal pain and uh i've done a bit of reading about it before this talk and apparently it's surprisingly common particularly in the elderly have you seen any patients with that i must confess i haven't but i imagine that getting a barium swallow where we get the patient to swallow a material that shows up white on an x-ray i bet that would look quite interesting when she's having that because we'd probably see that in a constricted appearance when she had an episode so my third group of uh chest pains are the dreaded other now whenever there's a list of problems in medicine there's always an other and the bottom of the other is always lupus or tb or something like that and sure enough in other we have we have a few of those i prefer the phrase other than musculoskeleta which is the traditional way of classifying the other bit of chest pain because musculoskeletal is only one of the causes of other what are these other causes well an important one is rib fractures i've seen that many times particularly in the elderly and that may be a presentation of metastasis so it's an important thing is to investigate rib fractures in the elderly and also it can give us a more severe form of what you've already mentioned on pneumothorax absolutely so if you have a rib fracture and the sharp bit of the fracture points into the lung you can have a pneumothorax as well and certainly you see that in people who've had a road traffic accident another cause of chest pain uh in the other group is trauma and as an ex-rugby player um you won't be surprised to know a lot of people have trodden on me and when they tread on you they damage ribs they damage muscles and also you can sprain muscles and that i think is a cause of muscular seizure chest pain a couple of others one is herpes zoster so sometimes chest pain can be the presentation of zoster that will come out two or three days later have you ever seen that james in your general practice oddly enough it tends to be more over the winter and we'll normally have probably three four cases of people who come in and again with the history they'll say they're getting a burning sensation but it tends to be quite near the surface and we get them to take off their clothes and we'll often see this bright red line of vesicles fluid-filled spots and that's the the shingles the herpes zosters come forth for whatever reason causing that severe pain uh yeah and those patients don't tend to come up to hospitals but i have seen a few patients come in with chest pain and then the rash appears the next day for example another couple of causes uh before we finish one is uh thoracic pain i've seen this misdiagnosed a few times where somebody has a thoracic spinal problem that presents as chest pain and i've seen tb mist particularly in asian people which has presented as chest pain and that's another reason when you have a patient with chest pain and the chest pain has gone on for four weeks you don't know the cause they look a bit unwell it's always worth doing a ct or perhaps an mri have you ever seen that in your practice at all i haven't seen it in the practice but when i was a junior doctor we did have a patient that had spinal tb with another colleague ravi gowda it was one of the bits that really put him on a pedestal for myself when you're treating crohn's which we'll come to in a moment you must make sure a patient does not have tb you've got to do chest x-rays you've got to do various blood tests before you can give them a medication called anti-tnf tnf alpha the reason being is if you give a patient with tb this medication you will kill them dr gowda had a patient who he thought had tb and he couldn't prove it he spent weeks and weeks sampling scanning x-ray nothing came back and he applied to the gmc for permission to give the guy tnf alpha he put a loaded gun against his head and fired it his tb flared they got a sample put the antibiotics directly into his spine saved the guy's life that is amazing as you know i've also worked with dr gowdan he's one of my heroes too and i've had similar patients where he's made an amazing difference to them in fact he saved their lives so wherever you are ravi well done uh final cause of chest pain is panic attack um now panic attacks are very common uh we all have them i've had them occasionally when i was younger you may have had one yourself at some point i have just when i think about what i'm going to have to do in the edit but anxiety can lead to hyperventilation anxiety can also lead to panic attacks uh and in my experience they're more common in men i don't quite know why i have this idea that when men get anxious when men somatise that means a symptom that is psychological becomes some is from a greek or latin word greek word meaning body and when they somatise their pain they often somatize their pain to their chest and get chest pain but i would stress that psychological causes or functional causes of chest pain should only be diagnosed once you know the patient has not had a myocardial infarction upon limb with a dissection etc etc in other words a panic attack is a diagnosis of exclusion and what you say there i think that we have to make a balance because excess investigations can cause harm but ruling out all of those big things and having that information to hand and carefully explain it to the patient can be a hugely powerful treatment in its own right and i think it's not wrong for you as a gp to send a particular young person to hospital chest pain you're 90 sure it's a functional it's a psychological problem but you're not absolutely sure and it's perfectly reasonable for you to ask us to rule out serious cardiac and respiratory courses and then when the patient returns to you a week later you can say to them you've been hospital you've had the test you had a drop tea a d diamond they even did a ct scan and they're all normal and then it's easier for you to introduce the possibility that the pain may be function as we call it well actually the lady i mentioned who i caught the pe with last week she was okay in herself and that was kind of how we sent her up to the hospital i explained to her that it looks like a duck it sounds like a duck and it's quacking like a duck but actually you're quite young and i know that's the platypus is out there so i'd like you to go up to the hospital so that they can tell us that actually this isn't a blood clot and i'm just barking up the wrong tree unfortunately it was a blood clot but we had her in the right place in order to check that that's a a great story i feel i've got to come up with another story about somebody with chest pain and i've just thought of one a patient i looked after again 15 plus years ago a tall man such as yourself james a slim man and he presented by driving past our hospital and had a sudden a sudden onset of throat and upper chest pain and a very astute junior doctor examined him carefully and heard a murmur a rare murmur called aortic regurgitation and that is due to an abnormal a leaking aortic valve and when i asked him to present the patient to me he said he wasn't sure what was wrong with him he had a feeling there was something going on we didn't know what it was the ecg was nearly normal but he had this rather odd murmur i went to see the patient examine the patient confirm they had the murmur and immediately i thought it was a dissection of their order and what happened next was pretty incredible first of all the surgeons came to see that that's the cardiothoracic surgeons they agreed that it was likely on the history we did a rapid ct confirmed the diagnosis and the patient was in theater two hours later what was amazing was uh that after the theater the patient came back had a bleed went back to theater they repaired the bleed and the patient walked out of hospital two weeks later and i was with the dissection with a dissection wow so the diagnosis was really made by a various junior doctor who examined the patient carefully nice well i think that's a good point to leave our chest pain journey on so thank you very much for that andy and you can join us below as we now go on to further seas with crohn's and celiac disease [Music] you