CHEST PAIN

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

Typical vs. Atypical Chest Pain- MCQ 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

Initial Approach at Primary care level ST elevation is important type and serious

Initial Approach at PHC level come in scenario Anterior MI or typical chest pain Ur a GP Chest pain suspicious of MI or ACS what to do ? 1- treat it as quickly as possible Monitor BP, Pulse, O2 saturation Give sublingual glyceryl trinitrate and IV morphine (VD)(if required). If BP ic low 90\60 nirtiat or morphine is contra indicated Give 300 mg aspirin Give 300 mg clopidogrel (plavix) if evidence of ischaemia(elevated troponin levels) on ECG or ( could be MCQ : when to use clopidrogel) Clopidogrel and asprirn is anti-plaltet , aspirin c\i due to active peptic culcer , use cloidrogel instead Only administer oxygen if the patient is breathless, oxygen saturation is <93%, has heart failure or is in cardiogenic shock

Case scenario- MCQ e,.g : typical pic of MI , BP 90\60 >> O2:97% Best ? Aspirin ? Cus low blood pressure and good o2 sat

Cardiac Chest Pain Pulmonary Embolism

Myocardial ischemia or infarction For clinical 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 Could be a MCQ

Work-up Cardiac enzymes : Troponin- more sensitive blood test MCQ :

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 RF: immobilization, fracture of a limb , pregnancy with chest pain :directly choose PE Can be associated with hemoptysis, sycope, dyspnea, calf swelling/pain from DVT – all that PE

Unstable Angina / NSTEMI Definition “… ST-segment depression or prominent T-wave inversion – that’s for unstable agina and/or positive biomarkers of necrosis… in the absence of ST-segment elevation and in an appropriate clinical setting..." الفرق

Unstable Angina / NSTEMI

STEMI-data -