APPROACH TO PATIENT WITH CHEST PAIN & ACUTE CORONARY SYNDROME

Presented by: Siti Nur Hamizah

INTRODUCTION Any pain, pressure, squeezing, choking, numbness

or any other discomfort in the chest, neck, or upper abdomen, and is often associated with pain in the jaw, head, or arms.

Because of common/overlapping neural pathways, many conditions, both cardiac and extra-cardiac can result in chest pain.

Cardiac pain is mediated through upper 5 thoracic ganglia and spinal roots, but ramifications from adjoining spinal roots always exist.

Therefore pain in the chest may originate from any structure in thorax and upper abdomen innervated through lower cervical to D6/D7 spinal roots

EVALUATION OF CHEST PAIN:

Try to find the nature & cause of chest pain through CLINICAL HISTORY.

A) Acute/short lived/ongoing B) Recurrent & episodic C) Persistent Details on pain:

Site of pain, localized/diffuse, with radiation if any Intensity & character of pain Precipitating & relieving factors Any relationship with meals &posture & Any effect of local pressure, or variation with breathing,

coughing & movements of cervical spine &shoulder joints.

IN GENERAL: Chest pain/discomfort is unlikely to be due to

coronary artery disease if: Localized to region under left nipple/in skin/soft

tissue Localized to small area (<2-3 cm), anginal pain

tend to be diffuse. If chronic & persistent/ recurring and

momentary\chest pain is sharp, pricking, or stabbing

Or varies with posture/breathing and coughing Present for several hours but not accompanied

by appropriate ECG changes.

DIFFERENTIAL DIAGNOSISCardiac Non-Cardiac

Coronary artery diseaseMIPericarditismyocarditisPulmonary embolism

Less common causes:Aortic dissectionAneurysm of thoracic aortaSevere aortic stenosis

GIT disorder:a)Esophageal disorder like esophagitis or esophageal motility disordersb) Peptic ulcerc)Biliary diseased)Pancreatitis

Musculoskeletal disorder:Costochondritis, rib #,RadiculopathyPsychogenic chest pain

Lungs/ pleura: Bronchospasm pulmonary infarctPneumoniaPneumothoraxpulmonary embolismtuberculosis.

Neurological:Prolapse intervertebral discHerpes zosterThoracic outlet syndrome

ACUTE CORONARY SYNDROME Encompasses all acute phase of Coronary Heart Disease

> Unstable angina + NSTEMI + STEMI which usually present with acute chest pain at rest or on minimal exertion

Pathogenesis:

CLINICAL FEATURES

• Symptoms: prolonged cardiac pain-chest, throat, arms, epigastrium or back. Anxiety, fear of impending death,nausea and vomiting, breathlessness, collapse, syncope.

• Signs: pallor, sweating, tachycardia-(sympathetic activation) vomiting, tachycardia-(vagal activation), hypotension, oliguria, cold peripheries, narrow pulse pressure, raised JVP, third heart sound, quiet first heart sound, diffuse apical impulse, lung crepitations, fever, complication signs->mitral regurgitation, pericarditis.

• Unstable angina is characterised by new onset or rapidly worsening angina, angina on minimal exertion, or angina at rest in the absence of myocardial damage.

• In contrast, MI occurs when symptoms occur at rest and there is evidence of myocardial necrosis, as demonstrated by an elevation in cardiac troponin or creatinekinase-MB isoenzyme

INVESTIGATION

ECG Plasma cardiac markers-> CK-MB, cardiac

troponins T and I (4-6 hours, remains elevated for up to 2 weeks).

Other blood tests: leucocytosis, elevated ESR and CRP

Chest x-ray Echocardiography

IMMEDIATE MANAGEMENT: THE FIRST 12 HOURS• Analgesia-to lower adrenergic drive-> reduce vascular

resistance, BP, infarct size, susceptibility to ventricular arrythmias.

• Antiplatelet therapy- 300mg aspirin daily+ clopidogrel(600mg-150mg-75mg)

• Anticoagulants- unfractionated heparin, fractionated heparin or a pentasaccharide.

• Antianginal therapy- sublingual glyceryltrinitrate (300-500mcg), IV nitrates, IV beta-blockers.

• Reperfusion therapy: primary percutaneous coronary intervention(PCI), thrombolysis.

LATE MANAGEMENT OF MI

Lifestyle modificati

on

• Cessation of smoking, regular exercise

• diet

Secondary

prevention drug therapy

• Antiplatelet therapy, b-blocker, ACEI/ARB

• Statin ,aldosterone receptor antagonist

Devices and

rehabilitation

• Implantable cardiac defibrillator

COMPLICATIONS OF ACUTE CORONARY SYNDROME• Arrythmias- ventricular fibrillation, atrial

fibrillation, bradycardia.• Ischaemia• Acute circulatory failure• Pericarditis• Mechanical complications- rupture of

papillary muscle, rupture of interventricular septum, rupture of ventricle.

• Embolism

THANK YOU.