acute chest pain medicos notes-com
TRANSCRIPT
ACUTE CHEST PAIN
ACUTE CORONARY SYNDROMES
CAUSES• Angina & MI•Muskuloskeletal pain• Esophagitis & Esophagial spasm• Pleurisy• Pneumothorax• Costochondritis• Aortic dissection• Pancreatititis & Cholecystitis• Root pain• Pericarditis• Fibromyalgia•Mediastinitis
APPROACH
• Asess general condition sick/not sick• Check vitals• Short history• Quick examination• Severe pain give Morphine/Pethidine(C/I Br Asthma)• Get ECG Done• S/L Sorbitrate/Aspirin 325mg
Suspect Cardiac Pain in• >40yrs,male• Post menopausal • C/C smoker• DM/HTN• Obese• Sedentary
• TYPICAL CARDIAC PAIN• ANGINA EQUIVALENTS
PHYSICAL FINDINGS• Apprehensive look, Angor amini• Sweating, cold skin,Hypotension,• Tachy/Bradycardia,Arrythmias• Wide/Narrow pulse pressure• Dyskinetic Apex• S3,S4,Apical sys murmur• Pericardial rub• Basal creps
IHD
c/c stable anginaACS
UA NSTEMI STEMI
ACS
60% UA 40%MI
2/3NSTEMI 1/3STEMI
PATHOPHYSIOLOGY
1. A/C plaque change2. Dynamic obstruction (vasospastic)3. Progressive mechanical obstruction4. INCREASED myocardial O2 demand5. Decreased supply of O2
UA & NSTEMIUA Presents as
•Rest angina >10 minutes•Severe & new onset angina•Crescendo angina
NSTEMI•Above features + evidence of
myocardial necrosis
ECG
1. Labile ST Segment depression2. T Inversion3. Transient ST Elevation
Cardiac Specific markers
1. Myoglobin- first to rise (with in 2 hrs) less value2. Troponin I- has got prognostic
value,PREFFERED MARKER
3. CPK-MB-4. LDH 1NOT elevated in Pts with UA
Rx of UA / NSTEMI
GOALS
1. Prevention of Thrombus2. Restoration of coronary blood flow3. Reduction in myocardial o2 demand
• Supplemental o2• Morphine SO4
1. Reduces pain2. Causes venodialatation3. Arteriolar dialatation4. Vagotonic effect5. Useful in pul edemaDosage – 2 -4 mg Iv Rpted every 5 mts or until S/E ensue S/E – Hypotension,Nausea, vomitting,Apnea,Urinary retention
Antiplatelet therapy
1. Aspirin-325 mg non enteric chew stat if no c/I . Later 150 mg /day
2. Clopidogrel- 300mg stat & 75 mg / d3. Combination – ecospirin + clopidogrel4. Gp 2 b 3a antagonists
1. Absciximab2. Epifibatide3. tirofiban
Anticoagulant therapy
1. UFH – 50 – 60 IU/kg Max (5000IU) IV bolus----->12IU/kg/hr (Max 1000) aPTT Titrated to 1.5 to 2.5
2. LMWH-1. Dalteparin(Fragmin)2. Enoxaparin
Heparin induced thrombocytopenia3. PLT Count Dec after 5 – 7 days4. Occurs in 1 – 3% people5. LEPIRUDIN & ARGATROBAN used instead
Anti ischemic Rx
• Nitrates – NTG 0.5 mg s/l,Sorbitrate 5 mg s/l
C/I – Hypotension,
1. RVMI2. Tachycardia >100bpm
• BETA Blockers• Metoprolol 12.5 1 BD,Atenolol 25 1 OD,Carvedilol 3.125 1 BD,Betaxolol• Decreases myocardial o2 demand• C/I – Hypotension,
HR <60 bpmMarked 1 AV BlockBR Asthma Complete HB
1. CCB- 2. ACEI – Enalapril 2.5 ½ OD / BD
1. Inhibits cardiac remodelling
3. Thrombolytic Therapy – not indicated4. Coronary Revascularisation (PCI,CABG)5. RISK FACTOR MODIFICATION
1. Stop smoking2. Lose weight (BMI<25 Desirable,WC < 40in M & <35in F)3. Exercise4. BP Controll5. DM & Hyperlipidemia management
STEMI• MC Cause of death is VF
DIAGNOSIS ( 2 or > of the following)
1. H/o Prolonged chest discomfort / Angina equivalent >30 mts2. 2mm or < STE in precordial leads OR 1mm or > STE in Inferior leads3. Elevated biomarkers
History1. Typical cardiac pain / Angina equivalent2. Silent MI- present with confusion,dyspnoea,unexplained hypotension
1. Elderly2. Diabetics3. Hypertensives4. Post op Pts
O/E
1. PSM Mitral area2. RVMI – Cardiogenic shock,hypotension,^JVP No features of pul
edema
ECG1. Hyperacute T Waves2. ST Segment changes
1. 2, 3 aVF - IWMI2. V1 V2 V3 – AWMI3. 1 aVL V5 V6- Lateral4. PWMI- reciprocal changes in anterior leads5. RVMI – STE in V4R Q Waves
Investigations
• FLP/ FBS• Trop I,CPK MB• CXR• ECG• PT• ECHO
Rx
1. General measures1. Continuous ECG, BP, SpO2 measurement2. O2
3. Two IV Lines4. RVMI – Start IV Fluids. C/I in Pul Edema5. CCU
Medications•Aspirin-325 mg non enteric chew stat if no c/I . Later
150 mg /day•Clopidogrel- 300mg stat & 75 mg / d•No role for Gp 2 b 3a antagonists•Nitrates•Beta Blockers•Atropine 0.6mg iv (Max 2mg) For bradycardia•Morphine+ Phenergan
Contd• THROMBOLYTIC THERAPY IND- STE 2mm or > in precordial leads
STE 1mm or>in Inf leadsFresh LBBBPosterior MI
THROMBOLYTIC THERAPY• C/I
1. H/O ICH2. AVM, Aneurysms3. Intracranial tumours4. Ischemic stroke <3 months5. Aortic dissection6. Major Trauma with in 3 months7. High BP , SBP>180 mm DBP >110mm8. Bleeding diathesis9. Previous STK use > 5days & <2 yr10. >12 hrs after onset of pain
Administration
• 1.5 million IU STK in 100 ml NS over 1HR• Inj Avil + Efcorlin given prior• ECG & BP monitoringAdverse reactions
• Life threatening ICH• Hypotension• Bleeding from puncture sites• allergy
Signs of therapeutic Efficacy
• Symptomatic improvement• ECG Change
1. Late diastolic VPCs2. AIVR3. Fall of STE
• Early peaking & Fall in Enzyme levels
•Heparin is used If infarct is large or if pain continues
Periinfarct management
• Bed RestAbsolute bed rest for 12 hrsSit upright in 24hrsAmbulated by 2nd & 3rd dayAfter 3rd day -> gradually ^ ambulation
• Low residue liquid Diet• Bowels Avoid dstraining at stools . Give laxatives• Sedation – Alprax 0.25mg 1 HS, Lorazepam 1mg
Contd•Statins - HMG Co A Reductase inhibitors
ATORVASTATIN 10-80 mg/day
Started in those with DyslipidemiasTarget LDL <100 in all Pts with CAD<70 in those with very high risk
S/EHepatotoxicityMyopathyRhabdomyolysis
RISK ASSESMENT AFTER MI
• NON INVASIVE- Stress Test evaluation (TMT)
•Done 3-6 wks after D/D from Hospital• INVASIVE- Cardiac catheterisation• Done in those with R/C angina,ischemia,CCF,Mechanical complication of MI
COMPLICATIONS• A/C pericarditis
• Occurs in 15-20 % pts with large MI• Pleuritic type of chest pain with friction rub• Diffuse STE in ECG• Rx- Analgesics,>Aspirin 650 ,Indop 25-50 qid• Steroids
• Avoided in 1st 4 wks ( risk of ventricular rupture)• Dresslers syndrome
• A I process• ^ ESR,Pericardial effusion,fever
ARRYTHMIAS
•WITH HEMODYNAMIC COMPROMISE REQUIRE PROMPT Rx• Left antr fascicle block•Bradycardia - in MI involving R coro A • Observation• Atropine• pacing
•1st degree HB – no Rx needed•2nd degree HB•Mobitz 1- IWMI > No Rx•Mobitz 2 – AWMI > Temporary pacing
• 3rd degree AV Block & Asystole - Trans venous pacing• SVT
• Sinus Tachycardia• PSVT• AF & AFl• Accelerated junctional rytham
Ventricular arrythmias
• VPCs• AIVR- Ventricular rate>60 – 125 bpm• NSVT• VT
• Stable – Inj xylocard 50 mg IV• Inj Amiodarone75 stat & 500 mg in 500 ml NS Iv infusion
• Not stable - DC Version 200J
•VF – good prognosis – DC version needed A/C LVFAvoid IV FluidsMorphine is helpfulDiuretics , ACEI,Nitrates RVMI – in IWMI & PWMICardiogenic shockGive IVF,support with Dopamine , DobutamineIntra aortic balloon pump
Mechanical complications• Aneurysm – due to wall motion abnormality
• A/W Mural Thrombi• Persistent STE > 1 monthsEmpirical anticoagulation (Warf) INR 2-3
• Pappillary M Rupture • Postr medial lip is mostly affected• Echo, Doppler diagnostic
• Ventricular septal rupture A/W AWMI• Free wall rupture• Catastrophic complication• Occurs in hypertensives with large mural thrombi• Common after 1st week
FOLLOW UP CARE
• Continue drugs & Dose Adjustment• Every 4- 6 months in 1st year• Thereafter yrly & SOS