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Newly diagnosed angina

An HGV driver's 'chest pains' may be angina ­ Dr Melanie Wynne-Jones discusses

An HGV driver's 'chest pains' may be angina ­ Dr Melanie Wynne-Jones discusses

Case history Mr Jones is 54, overweight and an HGV driver. He says he has started getting central chest tightness, particularly when loading his lorry. He thinks it might be muscular, but it sounds more to you like angina.What else do you need to know from your history and examination?These should include discriminatory questions to help you rule in/out angina or alternative diagnoses such as musculoskeletal pain, bronchospasm or oesophageal reflux. There may also be symptoms or signs of hypertension, heart failure or valvular disease. Cardiac ischaemia is notoriously difficult to exclude without investigation.You need to consider and advise on Mr Jones's risk factors such as family history, ethnicity, smoking, alcohol and recreational drug use.

You should also check his:

  • urine·
  • blood pressure·
  • BMI·
  • lipid profile ·
  • LFTs (in case a statin is required)·
  • blood glucose ·
  • FBC (anaemia can trigger angina)·
  • thyroid function if appropriate (hypothyroidism ditto)·
  • renal function.

A normal resting ECG does not exclude ischaemic heart disease.What should you do next?Mr Jones needs an exercise tolerance test and cardiology opinion1. Most areas have a rapid-access chest pain clinic that will see patients within two weeks; fax a referral, using the local proforma if there is one, and send test results as they become available.

Your explanation to Mr Jones will depend on whether you strongly suspect angina or feel it is unlikely, but it needs to be ruled out. Provided there is no contraindication to the use of aspirin, he may benefit from taking 75mg dispersible aspirin daily until the diagnosis is clear. You may wish to co-prescribe a proton-pump inhibitor, particularly if oesophageal reflux is a likely alternative diagnosis. Mr Jones should also have a glyceryl trinitrate spray, both in case of emergency and as a therapetic trial. You will need to explain when and how to use it, warn him about possible headache or dizziness, and advise him to call 999 if it does not relieve his chest pain within 10 to 15 minutes. It is important he understands the reason for this as patients often wait too long before calling an ambulance.

He should also be advised to contact the surgery if his symptoms deteriorate before his appointment. Depending on his symptoms or the presence of hypertension you may also want to prescribe a ?-blocker, PPI or other medication, or ask him to monitor his peak flow readings.

What are the implications of a diagnosis of CHD for Mr Jones?

His licence will be revoked if he has continuing symptoms, whether or not he is receiving treatment2. Re-licensing may be permitted when free from angina for at least six weeks, provided that exercise test requirements can be met and there is no other disqualifying condition. For group one drivers (non-occupational drivers of cars or motorcycles), driving must cease if symptoms occur at rest or at the wheel, and may recommence when satisfactory symptom control is achieved. The DVLA need not be notified, but drivers should inform their insurance companies.Although the diagnosis is not yet certain, Mr Jones should stop driving his HGV until it is confirmed or refuted and his symptoms are fully controlled. This may take longer than two weeks, and if his employer cannot assign him alternative duties, you may need to issue a Med3 sicknote along the lines of 'possible angina ­ being investigated'.

If Mr Jones does not yet wish to inform his employer, in the short-term you could write something more vague such as 'chest pains' or 'awaiting hospital tests'.Mr Jones is likely to be worried about possible effects on his life expectancy, his employability and his usual activities, including smoking, alcohol, exercise, any booked holidays and sex. He may or may not mention these concerns; you should explore whether they need to be discussed now or later. You could print off a patient information leaflet3 from your practice computer or suggest he contacts the British Heart Foundation4.

How will Mr Jones affect your QOF points?

Part of GPs' contract with the NHS includes a quality and outcomes framework; points (and cash) are awarded for achieving targets across several disease areas including coronary heart disease5. Achieving points is important both for individual patient care and because QOF money represents a large chunk of practice income.If the diagnosis is confirmed, Mr Jones should be added to the practice's CHD register (Read code G3), thus increasing the practice prevalence.

Anyone with a diagnosis of CHD made after 1 April 2003 should have an exercise tolerance test; it is important that the date of the diagnosis precedes that of the ETT (beware delays in letters and coding). There are also points for recording smoking cessation advice, blood pressure, lipid levels and appropriate medication including aspirin and influenza vaccination, plus points for achieving cholesterol and blood pressure targets.Most GP computer systems flag patients' records to show which targets are relevant/ have been missed. As a practice employee, you will be expected to keep an eye out for these, and take any necessary action.Many practices delegate CHD recording and follow-up to administrative staff and specially trained practice nurses; you will need to find out how this is organised in your practice.

Melanie Wynne-Jones is a GP in Marple, Cheshire

Key points

  • Anyone with symptoms suggestive of new angina should be referred for investigation·
  • Patients with angina (and practice staff) should be advised to call 999 if ischaemic-type pain lasts more than 15 minutes·
  • Secondary prevention of established CHD includes attention to risk factors and the appropriate use of medication·
  • Well-organised chronic disease management improves individual patient care and maximises QOF points

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