Hippocrates and Chest Pain

"Life is short, the art long, opportunity fleeting, experiment treacherous, judgment difficult"

So wrote Hippocrates, father of medicine, some 2400 years ago in his book of Aphorisms. Most of that statement still holds today, except we live about twice as long on average.

Judgement remains difficult, especially when it comes to investigating patients with heart disease. Speakers during a well-attended session today at ESC heard from Dr Bax (Leiden, Netherlands) who explained how he approaches non-invasive imaging in the patient with chest pain. We need to search not only for evidence of atherosclerosis, but also coronary stenoses and their functional consequences. We must always be mindful of Bayesian effects. If the pre-test probability of disease is either very high or very low, then imaging (except coronary angiography) is of little use. I could add prognosis to his list of requirements of an imaging test.

Imaging is going to feel the cold wind of the global financial crisis - according to James Thomas of the Cleveland Clinic, at least in US. The rapid rise in imaging tests over the last 10 years have brought many benefits but at huge costs, both financial and in some cases worrying radiation exposure levels (see NEJM last week).

So we may be forced to rationalise our approach to the 45 year old man with atypical chest pain, positive family history, normal resting ECG and a non-diagnostic exercise test.

What would you do to investigate him? Straight to cath? CT angio? Perfusion imaging? Stress echo? Perhaps the one-stop-shop of cardiac MR?

Sometimes too many options are a bad thing. Although when it comes to Tapas I disagree....