Chest Pain

Dr. Shamim NassrallyBSc (Hons) MB ChB MRCP(UK)

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

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

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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

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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

Troponins

Troponin

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

Troponin

Management : ACS

STEMI NSTEMI / UA

Angina

Management : STEMI

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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 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 with 1-3

hours of event Used if not possible to get access to

percutaneous angioplasty

Management : NSTEMI

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Management : NSTEMI / UA

ABC approach Analgesia: opioid based Oxygen: 15L via NRM Aspirin 300mg PO stat Clopidogrel 300mg PO stat LMWH e.g. 1mg/kg Enoxaparin BD SC GTN infusion for pain Percutaneous angiography (with 48hours) ±

angioplasty/ coronary bypass

TIMI risk score

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

Angina

Managed as OP, initially medically Anti-platelets, anti-anginals, risk factor/

lifestyle modification May require bypass surgery or angioplasty

Summary

ACS is a spectrum from Angina to STEMI UA/NSTEMI managed differently to STEMI TIMI risk score predicts outcome Use the ABCD 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

Questions?