Chronic cardiac chest pain

Abstract

Complaints of chest discomfort and pain is one of the most common causes of patients seeking help in primary care with 20 –40% of the general population affected by chest pain during their lifetime. The incidence of unspecific chest pain ranges from 10 in the 20 –29 yr old to 30 per 1000 person-years in the 70– 79 yr old, 1 and in any given year, one-fifth of the population will experience chest pain. Although the majority of cases are benign and short lived, with only a minority of patients consulting their doctor, acute new or new-onchronic chest pain still accounts for an estimated 700 000 annual emergency department attendances and a quarter of medical emergency admissions in England and Wales. 2 With 8% of men and 3% of women aged between 55 and 64 and 14% of men and 8% of women aged between 64 and 74 suffering from angina, 3 medical staff will repeatedly encounter patients with chest pain. At the acute presentation, it is important to establish the presence of ischaemic heart disease, such as acute coronary syndrome (ACS), warranting urgent medical or surgical intervention. Whereas treatment of newly diagnosed coronary artery disease (CAD) and angina follows wellestablished medical and surgical pathways, a number of patients with established angina, however, fail to respond to medical therapy or are unsuitable for surgical intervention. Such refractory angina is defined as chronic when lasting more than 3 months. Chronic refractory angina is characterized by reversible myocardial ischaemia in the presence of progressive CAD difficult to control by a combination of medical therapy, percutaneous coronary intervention (PCI), and coronary artery bypass graft surgery (CABG). 4 Additionally, the patients often have impaired left ventricular function, renal impairment, and diabetes. Although it would be anticipated that this group of patients would become even smaller with continued advancements in medical technology, data suggest a continued European yearly incidence of 30–50 000 chronic refractory angina patients. 4 Even after coronary revascularization, surveys suggest between 19% and 38% of the patients remain troubled by angina 12 months after intervention. 5 As some of these patients will present in chronic pain clinics and for noncardiac surgery, anaesthetists will be required to assist in their management.