Investigating severe interscapular pain

I welcome the article on investigating severe interscapular pain by
Haydar et al. and commend the authors on their coverage of this subject. I
would like to make 2 comments.

First, the utility of the ECG, and of a
careful history and examination, is somewhat underplayed in the article
and further imaging is frequently not required if the ECG is diagnostic. A
presentation with interscapular pain is perhaps more likely to require
imaging than with anterior chest pain, and the balance of the 3 diagnoses
put forward (MI, dissection, PE) will vary according to this.

Second, the
authors mention myocardial perfusion imaging. This is an excellent test
for detection of acute coronary syndromes in patients with non diagnostic
ECGs but uptake is low in this country due to constraints on time and
equipment use. The study simply requires administration of the tracer at
rest during pain, and imaging at a later stage depending on urgency. This
only requires 15 to 20 minutes; the 4 hours mentioned in the article is
for a stress-rest study as performed in patients without resting symptoms.

Competing interests:
Dr Harbinson is immediate ex-president of the British Nuclear Cardiology Society