05 patient with acute thoracic pain
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ACUTE THORACIC PAIN
2004-2005
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CLASSIFICATION
A. Pain of cardiac origin
1. Coronary artery disease
2. Acute aortic dissection
3. Pulmonary embolism
4. Acute pericarditisB. Mediastinal pain
C. Retrosternal pain of digestive origin
D. Thoracic pain
1. pleuro-pulmonary
2. rheumatic
3. neuromuscular
4. abdominal
5. psychosomatic
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1.
ANGINA
A. ANGINA with NORMAL ECG
anginal pain
positive family history
CV RFother factors: anxiety, spasm, oesophagus
reflux, peptic ulcer, acute pancreatitis
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B. RECENT ANGINA + ECG CHANGES:
ST elev./ depression > 0,5 mm
T wave inverted
ACUTE CORONARY SYNDROME
UNSTABLE ANGINA
MI with ST depression (non Q ?)
MI with ST elevation (transmural ?)
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C. PROLONGED ANGINA > 20 min
D. RESTING ANGINA + ST CHANGES
E. ANGINA + MITRAL REGURGITATION(recent or aggravated)
F. X SYNDROME
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F. X Coronary Syndrome
effort angina
ET +normal coronarography
stress ECHO: contractility alterations
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CLINICTYPICAL ANGINA NON-TYPICAL ANGINA
1. RETROSTERNAL PAIN
2. TRIGGER
effort
emotional stress
3.VANISH
at restNTG
Coronary pain has 2 of 3 features
Non-coronary pain has 1 or none of the 3 features
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ISCHEMIC CASCADE
flow alteration. flow visualising
metabolic alteration PET
diastolic dysfunction ECO Doppler
kinetics ECO de stress
Ions channels changes ECG
sympathetic activation ANGINA (clinic)
MYOCARDIAL NECROSIS
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Clinical caseM.A. 72 years (M)
Symptoms for 3 weeks:
Non-typical angina epigastric pain irradiated in the
right hipocondrium, no fixed timing, no effort angina,
improves slowly at NTGIn the last days 6 tb NTG/day
RF:
smoker
TC = 204, TG = 125,
LDL = 148, HDL = 32 (mg/dl)
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ECG in crises
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Therapeutic approach
kPTCA (stent RCA)
kAntiplatelet
kStatin
kBeta-blocker
k
Smoking cessation
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INVESTIGATIONS
Resting ECG
Stress test
Rhythm Holter
Doppler echo
Stress echo - dobutamine
Isotopic ventriculography
Myocardial scintigraphyPET
Angiocoronarography
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Stress testing (ST)= widespread method withstandardized protocols and low costs to
assess CAD.
S.U.A. 1991,1992 6,2 mil ST
27% CAD
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ACC/AHA guidelines ST indications:
Absolute indications:
1. Dg: men with typical / untypicalsymptoms and cumulated RF
2. Prognosis: assess functional capacity instable angina and after AMI
3. Prognosis: assess functional capacity after
revascularization procedures4. Dg: symptomatic arrhythmias at stress
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ACC/AHA guidelines ST indications:
Relative indications:
1. Dg: women with typical / untypical angina
2. Therapy monitoring in CAD or HF
3. Screening: asymptomatic men > 40 years
with cumulated RF
4. Vasospastic angina evaluation
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ET = generally a safe procedure;- AMI, SCD: rate 1:2500
High risk:- recent AMI
- malignant ventricular arrhythmias
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ET CONTRAINDICATIONS
ABSOLUTE: REL
- Recent AMI (2 days) - left main stenosis
- Unstable angina - moderate aortic stenosis
- Uncontrolled arrhythmias
-
Severe aortic stenosis-
dyselectrolitemias- Decompensated HF - uncontrolled HT
- Pulmonary embolism ( SBP>200mmHg,
- Aortic dissection DBP>110mmHg)
- Acute myopericarditis -pulmonary hypertension- Peripheral thrombosis - CMHO
- Infirmities - high degree AV block
Modificat dupa Fletcher et al si Gibbons et al.
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Criteria for HR in a ST :
- Target stress = Max HR = 220 age (years)
- Submaximal stress = 80 85 % Max HR
- Closely to maximal stress = 90 % Max HR
- Maximal effort symptom - limited
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ST FINISHING CRITERIAABSOLUTE: - decrease of SBP >10 mmHg from normalwith ischemic
changes
- moderate orsevereangina
- ataxia
- low cerebralperfusion signs
- sustainedVT
- technicaldifficulties
-patientsrequest
-STdepression > 2 mm
RELATIVE: - decrease SBP >10 mmHg from normalwithout ischemicchanges
-STdepression > 1 mm
- arrhythmias, otherthan sustainedVT
-progressive pain increase
- hypertensivebehaviour(SBP > 230 mmHg or/andDBP> 115mmHg)
-fatigue,claudicatiuon, wheezing
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ST INTERPRETATION:
1 Symptoms2 Stress capacity (METS)
3 Hemodynamic behavior :
HR max x BP = double product
4 ECG: specific ST changes at stress
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EFFORT ST CHANGES:
Patients with normal ECG:
positive Stress Test: > 1mm ST variations, 60 80 ms
from the J point
ST depression
ST elevation: coronary spasm
- V1: ischemia
- in regions with MI: aneurism / wall dyskinesia;
- no MI: transmural ischemia or critical stenosis.
STvariation in precordialleads = more exact than in
inferior leads
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LIMITATIONS:
Relatively diminished sensitivity:
monovascular disease
women elderly
significant comorbidities
no available data on LV function
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MYOCARDIAL PERFUSION
SCINTIGRAPHY:
With: - Thalium 201
- Technetium 99m
Indications
- monovascular CAD
- teritory assessment in CAD
- assessment of viability of
myocardium
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STRESS ECHOCARDIOGRAPHY:With Dobutamine:
- risks + side effects
INTERPRETATION:
ST DEPRESSION DURING DOBUTAMINE PERFUSION IN PATIENTSWITHNORMAL ECG HAS A MODERATE PREDICTIVE POWER FOR
CAD
Useful in patients with: history of MI or altered wall kinetics,pacemakers, renal impairment, dilated cardiomyopathy, LVH,
LBBB.
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Dobutamine stress test
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PET scan
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Glucose utilization during PET
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ScintigraphyTc-99m
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MRI
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Contrast ultrasound
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Not every thoracic pain is
coronary pain
Thoracic pain + ST variations + positivemarkers =Acutecoronary syndrome
Main goal: Reperfusion
ST elevation =
tthrombolysis orPCI (stent)
ST depression +
positive markers =IIb/IIIa inhibitors
Thoracic pain ECG changes, but nopositive markers = assessacuterisk
Troponin +ECG every 6 hours
Positive = high risk
/reperfusion
Negative = continue
evaluation
ST and other
Positive=
coronarography Negative =dischar e
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Diagnosis of AMI in the emergency room
History of precordial pain/ thoracic pain
ST elevation or a new LBBB
Increased levels of necrosis markers (CK-MB, troponins)
! Dont wait for results to initiate reperfusion
2D Echography and scintigraphy useful in differential
diagnosis of AMI
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Emergency treatment
Opioids I.V. (4-8 mg morphin, then 2 mg every 5 min)
O2
(2-4 l/min)
Beta-blocker i.v. or nitrate when opioids are not effective
Tranquilizers may be useful
B f h it l d l i h it l t t t
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Before hospital and early in hospital treatment
Reperfusion therapy recommendation Class Evidence
level
I IIa IIb IIIreperfusion therapy is indicated in all patients with history
of thoracic pain/ less than < 12 hours and ST elevation or a
new bundle branch block
X A
Primary PCI
-preferably in the first 90 min after diagnosis
-patients in shockand those with contarindications for
fibrynolytics
- GP IIb/IIIa antagonists and PCI
without stenting
with stenting
X
X
X
X
A
C
A
A
Thrombolysis
-alteplase, tenecteplase X A
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Contraindications for thrombolitic therapy
Absolute contraindications:- haemorrhagic stroke
- ischemic stroke in the last 6 months
- CNS disorders
- neoplasias
- traumas/ surgery/ the last 3 weeks
- gastro-intestinal haemorrhage in the last month- known haemorrhagic disease
- aortic dissection
Relative contraindications:- transient ischemic attack in the last 6 months
-oral anticoagulants
-pregnancy or the 1st weekpostpartum
- severe HT (SBP > 180 mmHg)
- severe liver disease
- infective endocarditis
- active ulcer
i i l C bi i h
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Initial Treatment Combination therapy
Streptokinase
(SK)
1,5 mil. U in 100 ml 5% dextrose or
0,9% NaCl for 30-60 min.
With or without
heparin I.V.
For24-48 h
Alteplase
(tPA)
15 mg I.V. in bolus, 0,75 mg/kg for
30 min, then 0,5 mg/kg in 60 min
Do not exceed 100mg
Heparin I.V.
For24-48 h
Reteplase
(r-PA)
10U + 10U I.V.
la 30 min
Heparin I.V.
For24-48 h
Tenecteplase
(TNK-tPA)
Single dose I.V. bolus
30 mg < 60kg
35 mg 60-70kg
40 mg 70-80kg
45 mg 80-90kg50mg > 90kg
Heparin I.V.
For24-48 h
Most frequent regimen
All patients receive Aspirin (if no contraindications)
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Heparin treatment
I.V. in bolus:
60U/kg max. 4000U
I.V. perfusion:
12U/kg for24 to 48 hours max. 1000U/h.aPTT target 50-70 ms
aPTT should be monitored at 3,6,12, 24 hours after treatment
initiation
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Rehabilitation
Lifestyle advice
Active in profession
Also in patients with significant LV
dysfunction
Initiated early in hospital
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D. Thoracic origin
1.PLEURO-PULMONARY
(a) acute pneumonia
(b) pleurisy
(c) pulmonary / pleural neoplasia
(d) pneumotorax
D Thoracic pain
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D. Thoracic pain
2. Rheumatic pain
(a) spondilosis
(b) scapulo-humeral periartrytis
(c) Thoracic wall pain
(d) Tietze syndrome3. Bone pain
leukemia
multiple myeloma
osteosarcoma
metastasis
TBC
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