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Chest Pain
Dr. Shamim NassrallyBSc (Hons) MB ChB MRCP(London)
Clinical Teaching Fellow
Objectives
By the end of this session you should be able to:
• Recognise Acute Coronary Syndrome (ACS)
• Initiate appropriate investigation and management of ACS
• Be able to calculate and interpret TIMI scores
• Recognise Acute Myocardial Infarction and use appropriate investigation to confirm the diagnosis
Acute Block 8
• Week 4– Tutorial 1
– Intro Simulation
– Experience in ED/AMU
– Medical Rotation in Junior Phase
• Revision/Putting it all together/Ask the “silly” questions
Chest pain
• SOCRATES
• Identify most likely system involved– Cardiac
– Pulmonary
– Gastrointestinal
– Musculoskeletal
– Neurological (Psychiatry)
Chest pain
• SOCRATES
• Identify most likely system involved– Cardiac
– Pulmonary
– Gastrointestinal
– Musculoskeletal
– Neurological (Psychiatry)
Cardiac Chest pain
• Coronary Artery disease (CAD)
• Ischaemic Heart disease (IHD)
• Atherosclerotic Heart Disease
• Essentially plaques made of cholesterol and calcium build up in the coronary arteries reducing cardiac muscle perfusion
Synonyms
Pathophysiology
Terminology
Angina UA NSTEMI STEMI
ACS
Angina Unstable Angina
• Exertional
• Relieved by rest
• ± ECG changes ( ST depression, T wave inversion)
• Troponin negative
• Can occur at rest
• Crescendo
• ± ECG changes ( ST depression, T wave inversion)
• Troponin negative
NSTEMI STEMI
• Troponin +ve
• ± ECG changes (ST depression/ T wave inversion)
• Troponin +ve
• ST elevation
• New onset LBBB
Cardiac Chest Pain (typical)
• Site :
• Onset:
• Character:
• Radiation:
• Associated Features:
• Timing:
• Exacerbating & Relieving Factors:
• Severity:
Cardiac Chest Pain (typical)
• Site : Retrosternal
• Onset: Sudden, Crescendo, Exertional
• Character: Dull, Squeezing, Tightness
• Radiation: Throat/Jaw, Shoulder
• Associated Features: Dyspnoea, Autonomic Sx
• Timing: Exertion, Meals, Rest. Duration
• Exacerbating & Relieving Factors: Exertion/Rest
• Severity: Subjective – but usually severe
Common risk factors
• ?
Common risk factors
• Hypertension
• Hypercholesterolaemia / Dyslipidaemia
• Diabetes Mellitus
• Smoking
• Age
• Male
• Family History of early CAD
• Obesity/ Physical Inactivity
Examination
Examination• Unremarkable physical examination
• Obesity
• Cholesterol deposits: arcus, xanthoma, xanthelasma
• Tar stains, nicotine stains
• Signs of peripheral vascular disease
• Acute LVF, New murmur of MR or VSD
• Cardiogenic shock
Investigations
• ?
Investigations• Electrocardiogram!!
• Blood tests– Full Blood Count
– Urea and Electrolytes
– Lipid Profile
– Clotting screen
– Blood sugar
– Troponin*
• Chest radiograph
Investigations (2)
• Transthoracic echocardiography (Handheld/Portable/Departmental)
• Exercise tolerance test
• Stress echocardiography
• Coronary angiography
• Further cardiac imaging – Cardiac CT/MR
Troponin
• Proteins released into the blood stream following muscle injury
• Different isomers of troponin
• Troponin T and I are specific for cardiac muscle
• More specific than CK
• Levels start to rise after muscle damage but only peak after 12 hours
Management : ACS
• STEMI
• NSTEMI / UA
• Angina
Management : STEMI
• ?
• NB: 2/3 criteria– New onset LBBB
– ST elevation of 2mm in 2 contiguous chest leads or 1mm in 2 limb leads
– Chest pain
Management : STEMI
• ABC approach
• Analgesia: opioid based (Morphine 10mg IV)
• Oxygen: 15L via NRM
• Nitrate: GTN spray
• Aspirin 300mg PO stat
• Clopidogrel 600mg PO stat
• Primary percutaneous angioplasty
Thrombolysis
• Use of clotbusting agents such as streptokinase or tissue plasminogen activators such as alteplase
• Now superceded by primary PCI
• Only for Acute myocardial Infarction within 2 hours
• Used if not possible to get access to percutaneous angioplasty
Management : NSTEMI
• ?
Management : NSTEMI / UA• ABC approach
• Analgesia: opioid based
• Oxygen: 15L via NRM
• Nitrate: GTN spray
• Aspirin 300mg PO stat
• Clopidogrel 300mg PO stat
• LMWH e.g. 1mg/kg Enoxaparin BD SC
• GTN infusion for pain
• Percutaneous angiography (within 48hours) ± angioplasty/ coronary bypass
TIMI risk score
Post Event management• Lifestyle modification
– Smoking cessation
– Dietary changes
• Secondary prevention
– ACE-I
– Beta-Blocker
– Statins
• Cardiac rehabilitation
• Risk of further events and associated morbidity e.g. arrhythmias and heart failure
Questions
Summary• ACS is a spectrum from Unstable Angina to STEMI
• UA/NSTEMI managed differently to STEMI
• TIMI risk score predicts outcome
• Use the ABCDE approach
• Perform the initial Ix and Rx
• Ask for help early, inform the Cardiologists early
• Primary angioplasty has revolutionised the area
• Don’t forget post MI management