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