Practical view to chest pain(Medical therapy and disposition)

Presented by Dr. Mani Mofidi

Rasoul Akram Complex

Case scenario

• A 75 y/o male came to the ED with 2 episodes of retrosternal resting chest pain radiated to left arm from 1 hours ago, now resolved.

• PMH & FH: DM, his father died by heart attack in age of 60

• DH: ASA 80 mg/d, Metformin 500 mg/bid

• ECG: no ST-T changes

• BP: 115/75 mmHg, PR: 90/ min

What is your decision about this patient?

Goals …

• Focused assessment (targeted history, Ph.E, Biomarkers)

• Risk stratification (find high risk patients)

TIMI risk score• Age >= 65• Aspirin use in the last 7 days• At least 2 angina episodes within the last 24 hrs• ST changes of at least 0.5mm on admission EKG• Elevated serum cardiac biomarkers• Prior coronary stenosis >= 50%• At least 3 risk factors for CAD: - Hypertension

- Current smoker

- Hypercholesterolemia

- Diabetes

- Family history of CAD

Score Interpretation

pppCalculated TIMI riskscore

Risk of >= 1 primary end point in 14 days

Risk status

0 or 1 5% Low

2 8% Low

3 13% Intermediate

4 20% Intermediate

5 26% High

Primary treatment

• O2 if o2 sat < 94%

• Aspirin

• Nitroglycerin sublingual or spray

• Morphine

• Serial ECG & biomarkers• Consider noninvasive diagnostic tests

Very low risk for adverse events

• Patients younger than 40 y/o with non-classical presentations and no significant past medical history

• Serial biomarkers and 12-lead ECGs are normal.

• These patients may be discharged directly from the

ED/CPU if appropriate outpatient testing can be arranged

within 72 hours.

Low risk for adverse events

• Possible ACS, serial ECGs and biomarkers are normal

• ASA• Nitroglycerin sublingual up to 3 times at 3 to 5 min

interval, if pain persisted try IV rout 10 μgm/min• Β-blockers (metoprolol, 25 to 50 mg/d PO)• Morphine (2 to 5 mg) • Use the last 3 drugs if ongoing pain exists

Intermediate risk for adverse events

• Rest pain, now resolved• New onset of pain (at least class II severity within last 2

months) • Crescendo pattern of pain• Ischemic pattern on ECG

High risk groups

• Recurrent angina at rest or with low-level activities despite intensive medical therapy

• Elevated cardiac biomarkers (TnT or TnI)• New or presumably new ST-segment depression• High-risk findings from noninvasive testing• Hemodynamic instability, pulmonary edema• PCI within 6 months• Prior CABG or MI• Reduced LV function (LVEF less than 40%)

Early invasive strategy is preferred (in 48 h)

Treatment of intermediate and high risk patients

• ASA• Clopidogrel• Antithrombin• Nitroglycerin• Β-blocker

Aspirin

• 160-323 mg

• Contraindications: allergy (asthma), active bleeding, platelet disorders

• Use concurrent antacid or H2 antagonist to reduce side effects

Clopidogrel

• Loading dose 300 to 600 mg

• Contraindication: active bleeding

Antithrombin

• Heparin: Bolus of 60 units/kg (max, 4000 units) followed by infusion of 12 units/kg (max, 1000 units) titrated to a PTT 1.5 to 2.5 * control

• Enoxaparin: 1 mg/kg SC every 12 h, if GFR < 30 cc/min the dose should be reduced to 1 mg/kg/d

B-blocker

• Metoprolol (25 to 50 mg/d PO)

• Should start within 24 hours after hospitalization

• Contraindications: bradycardia, severe LV dysfunction, heart blocks, hypotension, active COPD & asthma, at risk for cardiogenic shock (age > 70, SBP < 120 mmHg, sinus tachycardia > 110/min)

Nitroglycerin

• First try sublingual or spray 3 times by 3 to 5 min interval

• With persistent pain, hypertension or signs of heart failure continue with IV route 10 μgm/min

• Contraindications: hypotension, extreme bradycardia (< 50 beat/min), RV infarction, recently received sildenafil

ACE-inhibitors

• After STEMI & NSTEMI (within 24 h)

• When hypertension persists after treatment with nitroglycerin and B-blocker

• LV dysfunction or CHF

Back to the case …

New rest pain now resolved

• Age >= 65• Aspirin use in the last 7 days• At least 2 angina episodes within the last 24 hrs• ST changes of at least 0.5mm on admission EKG• Elevated serum cardiac biomarkers• Prior coronary stenosis >= 50%• At least 3 risk factors for CAD: - Hypertension

- Current smoker

- Hypercholesterolemia

- Diabetes

- Family history of CAD

Back to the case …

• New rest pain now resolved

• Age >= 65• Aspirin use in the last 7 days• At least 2 angina episodes within the last 24 hrs• ST changes of at least 0.5mm on admission EKG• Elevated serum cardiac biomarkers• Prior coronary stenosis >= 50%• At least 3 risk factors for CAD: - Hypertension

- Current smoker

- Hypercholesterolemia

- Diabetes

- Family history of CAD

• Intermediate risk

• ASA• Clopidogrel• Antithrombin• Nitroglycerin• Β-blocker

• Intermediate risk

• ASA (not loading dose)• Clopidogrel• Antithrombin • Nitroglycerin• Β-blocker• antacid• cardiology consult for admission

References

• Braunwald’s Heart Disease 20012

• Rosen’s Emergency Medicine 2010

• Tintinalli’s Emergency Medicine 2011

• AHA 2010