CHEST PAIN

Objectives Describe pathogenesis of IHD & essential elements of history taking & the physical examination for a patient with chest pain. Develop a broad differential diagnosis of chest pain, including cardiac & non-cardiac causes. Describe appropriate diagnostic testing for patient presenting with chest pain .

Objectives Describe the use of laboratory studies in the evaluation of patient with chest pain (e.g. CK- MB, Tropinins etc. ). Interpret an ECG of a patient presenting with chest pain & suspicious of acute MI, and its location as anterior, lateral and posterior. Describe current guidelines for the initial management of a patient presenting with chest pain .

Objectives Discuss modifiable & non- modifiable risk factors for cardiac disease . Utilize point of care resources to determine the risk of cardiac disease for an individual patient as defined by the Framingham Heart Study data. Demonstrate therapeutic communication while working with patients and families during a time of crisis.

Case Scenario : After seeing your first booked patient in the consultation room the nurse rushed in saying there is a patient who needs urgent care . A 58-year-old gentle man presents with crushing chest pain, shortness of breath & sweating started one hour ago . He describes it ‘as someone is standing on my chest ’. His chest pain radiates to his neck & jaw . He denied any abdominal or back pain , his breathing has improved with oxygen & he has mild nausea . He has never history of similar pain & no history of heart problems.

Case Scenario : PMH: HTN, DM & Dyslipidemia on Fosinopril , Hydrochlorothiazide, Metformin and Atorvastatin. FH: Father died of heart attack at age of 53 years. His elder brother had CABG at age of 48 . Social history: smoker 2 ppd for 20 years . On Physical Examination : BP 95/65 Pulse: 110/min. Temp. 37.8°C RR 26/min. O2 sat 97% on 15 L O2

Case Scenario : Immediately ECG done, the strip was as follow :

Case Scenario (ECG Findings): There is progressive ST elevation &Q wave in V2-5. ST elevation is now also present in I and aVL . There is some reciprocal ST depression in lead III. This is an acute anterior STEMI . The patient was transferred by ambulance to the hospital immediately .

Case Scenario : Other investigations were carried out , the findings were: RBS: 14mmol/L T.Cholesterol: 6.6mmol/L LDL.C: 3.57 HDL.C: 1.09 Trig. : 1.94mmol/

Facilitative Questions : What are the possible hypotheses for this case presentation in terms of most likely & less likely ? What are the points to be included in the history taking, in this patient ? What initial focused physical examination would you like to do ? What are the risk factors in your patient ?

Facilitative Questions : 5. What is the essential management you need to do in this patient ? 6. Which laboratory test you need to do in this case ? 7. What ECG changes you may expect in this patient ? 8. Elaborate on the changes & significance of cardiac enzymes?

As a general rule any chest pain is ischemic in origin until proven otherwise!

Etiologies Myocardial ischemia or infarction Pulmonary embolus Pneumothorax Pericarditis Tamponade Pneumonia Aortic dissection Gastritis, peptic ulcer disease Musculo-skeletal Shingles

CHEST PAIN

Typical vs. Atypical Chest Pain Characterized as discomfort/pressure rather than pain Time duration >2 mins Provoked by activity/exercise Radiation (i.e. arms, jaw) Does not change with respiration/position Associated with diaphoresis/nausea Relieved by rest/nitroglycerin Pain that can be localized with one finger Constant pain lasting for days Fleeting pains lasting for a few seconds Pain reproduced by movement/palpation

Chest Pain Definitions Acute Chest Pain: Acute - sudden or recent onset (usually within minutes to hours), presenting typically <24 hrs Chest - thorax midaxillary to midaxillary line, xiphoid to suprasternum notch Pain – noxious uncomfortable sensation Ache or discomfort

Initial Approach at Primary care level Evaluation: Airway Breathing Circulation Vital Signs Focused exam Cardiac, pulmonary, vascular, character of pain Perform ECG, if ST elivated or suspecious, immidiatly referral to hospital.

Initial Approach at PHC level Management while awaiting trasfer: Monitor BP, Pulse, O2 saturation Give sublingual glyceryl trinitrate and IV morphine (if required). Give 300 mg aspirin Give 300 mg clopidogrel if evidence of ischaemia on ECG or elevated troponin levels Only administer oxygen if the patient is breathless, oxygen saturation is <93%, has heart failure or is in cardiogenic shock

Non Cardiac Chest Pain Pulmonary Gastrointestinal Musculoskeletal Pneumonia Pleuritis Pneumothorax Pulmonary Embolism Tumor Gastrointestinal GERD Esophageal spasm Mallory-Weiss Tear Peptic Ulcer disease Biliary/Gallbladder Disease Pancreatitis Musculoskeletal Costochondritis Cervical Disk Disease Rib Fracture Intercostal Muscle Cramp Other Herpes Zoster Disorders of the Breast Splenic Infarct Panic Attacks/Anxiety Disorder Fibromyalgia DKA

Cardiac Chest Pain Aortic Dissection Pulmonary Embolism Pulmonary Hypertension Pericardial Diseases Aortic Stenosis Heart Failure Cocaine Abuse Acute Coronary Syndromes Stable Angina Unstable Angina Myocardial Infarction Cardiogenic Shock

Myocardial ischemia or infarction Pressure-type of chest pain Generally involves central to left-sided pain with radiation to jaw or arms Exacerbated by activity, relieved with rest Relieved with nitro spray Associated with nausea, diaphoresis, syncope, shortness of breath Enquire about cardiac risk factors: age, sex, smoking history, diabetes, hypertension, hyperlipidemia, previous myocardial infarction and family history

Myocardial ischemia or infarction ↓BP indicates cardiogenic shock ↑JVP, pulsatile liver and peripheral edema seen in right-sided heart failure Oxygen desaturation, crackles, S3 seen in left-sided heart failure New murmurs: mitral regurgitation murmur in papillary muscle dysfunction

Work-up CXR to look for signs of congestive heart failure Cardiac enzymes: CK (will begin to rise 6 hours after infarct and remain elevated for 24-48 hours), troponin (will begin to rise 12 hours after infarct and remain elevated for 2 weeks). Need to follow serially if first set negative.

Management Strategy for NSTEMI Initial therapy Morphine for pain Oxygen if hypoxic Nitro spray/drip for pain Aspirin

Management Strategy for NSTEMI/NST Chest Pain Establish risk level using the TIMI scoring system: Low risk: May be discharged after symptom control Moderate risk: Admit for further evaluation; add beta blockers , Ace inhibitors . Follow cardiac enzyme levels. If Mi ruled out, Exercise or Adenosine stress test before discharge High Risk: Admit for cardiac catheterization

Management Strategy for STEMI Morphine, oxygen, nitro, aspirin Beta blockers, Ace inhibitors Early invasive strategy with either thrombolytic therapy or percutaneous coronary intervention (preferred)

Pulmonary Embolism Sudden-onset sharp plueretic chest pain, dyspnea Exacerbated by inspiratory effort Can be associated with hemoptysis, sycope, dyspnea, calf swelling/pain from DVT Risk factors: immobilization, fracture of a limb, post-operative complications, hypercoagulable states, inherited deficiencies of antithrombin III, pregnancy. EKG: sinus tachycardia most common, S1Q3invertedT3 with large embolus (classic, but rare!), look for right-axis deviation V/Q scan very sensitive but not specific

Acute Coronary Syndrome Definition “… any constellation of clinical symptoms that are compatible with acute myocardial ischemia..."

Unstable Angina / NSTEMI Definition “… ST-segment depression or prominent T-wave inversion and/or positive biomarkers of necrosis… in the absence of ST-segment elevation and in an appropriate clinical setting..."

Unstable Angina / NSTEMI

Unstable Angina / NSTEMI

STEMI

Key Points Not every chest pain is MI, however every chest pain should be considered as ischemic until proven otherwise A good history and physical exam may help with the diagnosis EKG is the best single diagnostic test to help rule out MI Use the TIMI scoring system to help for the diagnosis and prognosis of MI

Summary Chest pain is a very common complaint but has a broad differential Always try to rule out the life-threatening causes of chest pain It is important to remember that troponin elevation DOES NOT always mean ACS Use the history, physical exam, labs, EKG and imaging to commit to a diagnosis Whenever you are stuck, ask for help. Your seniors are here to help you!

Thank You