04. chest pain
TRANSCRIPT
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Chest Pain
Darrell Rubin, MD PhD
Department of Medicine
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Objectives
• Presentation of chest pain
• Evaluation of chest pain
• Acute coronary syndrome (ACS)
• Initial treatment
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A Chest Pain Case
A 65 year-old man with apast medical historysignificant for hypertensionand dyslipidemia presentsto the emergencydepartment after 2
episodes of chest pain.What do you want to knowabout the symptoms?
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A Chest Pain Case
Provocative/palliative factors
Quality
- character
- duration
- frequency
- associated symptoms
RadiationSeverity
Timing
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A Chest Pain Case
First episode – 6/10 exertional chest pain relievedwith rest
Second episode - occurred at rest and did notimprove until EMS was activated.
Associated symptoms - dyspnea and diaphoresis
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Perspectives
Resident’s perspective
• Admission
• Serial AMI panels• MONA
• Plavix, Heparin
• Statin, β- blocker,ACEI
• NPO
• Echo, stress, ± angio
Patient’s perspective
• Heart attack
• Heart attack
• Heart attack
• Heart attack
• Heart attack
• Heart attack
• Heart attack
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Glossary
Chest pain
Angina
Ischemia
ACS
Unstable AnginaNSTEMI
STEMI
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Angina
Definition
“… a discomfort in the chest or
adjacent areas caused bymyocardial ischemia, usuallybrought on by exertion and
associated with disturbance ofmyocardial function, butwithout myocardial necrosis."
Akbar et al JAMA 280(14): 1256, 1998
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Myocardial Ischemia
Definition
“… an imbalance between
myocardial oxygen supply andmyocardial oxygen demand..."
“Hurst’s The Heart” 12th edition
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Grading Angina
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Differential Diagnosis
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http://slidepdf.com/reader/full/04-chest-pain 12/33Clifford, et al JAMA 294(20):2623, 2005
Valuable History
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Acute Coronary Syndrome
Unstable Angina
NSTEMI
STEMI
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Definition
“… any constellation of clinical
symptoms that are compatiblewith acute myocardial
ischemia..."
Acute Coronary Syndrome
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Unstable Angina / NSTEMI
Definition
“… ST-segment depression or
prominent T-wave inversionand/or positive biomarkers ofnecrosis… in the absence of
ST-segment elevation and inan appropriate clinicalsetting..."
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Unstable Angina / NSTEMI(Unstable Angina)
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Unstable Angina / NSTEMI
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STEMI
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LBBB
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Physical Exam
T 36oC, P 85, BP 140/80, R 15, Pain 2/10
General – no distress
Neuro - A&O
CVS - normal inspection, PMI normal andnondiplaced, no heave, regular rhythm withnormal sounds, no murmers or rubs, JVP 7cm, radial and pedal pulses normal
Pulmonary - clear
Abdomen – nontender withouthepatomegaly
Extremities – no edema
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Chest X-Ray
Quality – exposure and rotation
Bony structures
Mediastinum
Heart
Costophrenic angles
Lung fields
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TIMI Risk Score
Antman et al JAMA 2000; 284: 835 - 842 www.timi.org
Age 65
3 CAD risk factors(FHx, HTN, chol, DM, active smoker)
ST deviation 0.5 mm
cardiac markers
Recent (24H) severe angina
HISTORICAL
PRESENTATION
RISK SCORE = Total Points (0 - 7)
Known CAD (stenosis 50%)
ASA use in past 7 days
1
1
1
1
1
1
1
POINTS RISK OF CARDIAC EVENTS (%)
BY 14 DAYS IN TIMI 11B*
0/12
3
4
5
6/7
RISK
SCORE
33
5
7
12
19
DEATH
OR MI DEATH, MI OR
URGENT REVASC
58
13
20
26
41 *Entry criteria:UA or NSTEMII defined as ischemic pain
at rest within past 24H, with evidence of CAD (ST segment
deviation or +marker)
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A Chest Pain Case
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AMI Panels
Creatine Kinase (CK) - 413 U/L (0-215)
CK-MB 7 and RI 2%CKMB <7 and RI <4% :Negative
CKMB <7 and RI >4% :Equivocal
CKMB >=7 and RI <4% :EquivocalCKMB >=7 and RI >4% :Positive
Troponin I 6.8 (0 – 0.06)
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A Chest Pain Case
CAD risk factors- + Family history- HTN- Dyslipidemia
Home meds- ASA 81 mg po daily- HCTZ 25 mg po daily
Biomarkers
- CK 413- MB 7 with index of 2- Troponin I 6.8
TIMI Risk Score- 5
Age 65
3 CAD risk factors(FHx, HTN, chol, DM, active smoker)
ST deviation 0.5 mm
cardiac markers
Recent (24H) severe angina
HISTORICAL
PRESENTATION
RISK SCORE = Total Points (0 - 7)
Known CAD (stenosis 50%)
ASA use in past 7 days
1
1
1
1
1
1
1
POINTS
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A Chest Pain Case
CAD risk factors- + Family history- HTN- Dyslipidemia
Home meds- ASA 81 mg po daily- HCTZ 25 mg po daily
Biomarkers
- CK 413- MB 7 with index of 2- Troponin I 6.8
TIMI Risk Score- 5
RISK OF CARDIAC EVENTS (%)
BY 14 DAYS IN TIMI 11B*
0/12
3
4
5
6/7
RISK
SCORE
33
5
7
12
19
DEATH
OR MI DEATH, MI OR
URGENT REVASC
58
13
20
26
41 *Entry criteria:UA or NSTEMII defined as ischemic pain
at rest within past 24H, with evidence of CAD (ST segment
deviation or +marker)
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Thygensen, et al JACC 50: 2173, 2007
Other reasons for Troponins
Heart failure
Pulmonary embolus
Renal failure
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Orders
• Admit to telemetry• MONA• Serial AMI panels
• Statin, β- blocker, ACEI
• Heparin IV or Enoxaparin• Clopidogrel and/or Eptifibatide• Echo• NPO• Stress test• Angiography
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Orders
• Admit to telemetry – monitor for arrhythmia
• MONA
– Morphine – Oxygen – Nitroglycerin – Aspirin
• Serial AMI panels
– Electrolytes, Cr, CBC, coags• Statin, β- blocker, ACEI
– Atorvastatin 80 mg po – Metoprolol 12.5 mg po q6 – Captopril 6.25 mg po q8
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Orders
• Anticoagulation – Heparin IV
– Enoxaparin sc
• Clopidogrel loading andmaintenance
• Eptifibatide loading and
maintenance
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Orders
• NPO after midnight
• Transthoracic echocardiogram
• Stress test – Exercise nuclear stress test
– Chemical nuclear stress test
– PET myocardial viability study
• Angiography ± PCI
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The Case
• NSTEMI
• Enoxaparin
• Clopidogrel load and maintenance
• TTE demonstrated EF 65% without wall motion abnormalities orvalvular dysfunction
• Coronary angiography demonstrated 95% right coronary artery
lesion
• PCI included a drug-eluting stent across the RCA lesion
• Discharged home with daily aspirin, clopidogrel, atorvastatin,
metoprolol, and lisinopril
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Summary
• Presentation of chest pain
• Evaluation of chest pain
• Acute coronary syndrome (ACS)
• Initial treatment