chest pain dr. shamim nassrally bsc (hons) mb chb mrcp(london) clinical teaching fellow

Chest Pain

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

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

Acute Block 8

• Week 4– Tutorial 1

– Intro Simulation

– Experience in ED/AMU

– Medical Rotation in Junior Phase

• Revision/Putting it all together/Ask the “silly” questions

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

• ?

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

• ?

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

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

Management : ACS

• STEMI

• NSTEMI / UA

• Angina

Management : STEMI

• ?

• 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

• Nitrate: GTN spray

• 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 within 2 hours

• Used if not possible to get access to percutaneous angioplasty

Management : NSTEMI

• ?

Management : NSTEMI / UA• ABC approach

• Analgesia: opioid based

• Oxygen: 15L via NRM

• Nitrate: GTN spray

• Aspirin 300mg PO stat

• Clopidogrel 300mg PO stat

• LMWH e.g. 1mg/kg Enoxaparin BD SC

• GTN infusion for pain

• Percutaneous angiography (within 48hours) ± angioplasty/ coronary bypass

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

Questions

Summary• ACS is a spectrum from Unstable Angina to STEMI

• UA/NSTEMI managed differently to STEMI

• TIMI risk score predicts outcome

• Use the ABCDE 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