1. Chest Pain in the Emergency Department Junior Teaching C. Brown August 2015

2. Objectives  Overview of the wide differential diagnosis of ‘chest pain’ which presents to the ED  Outline Aberdeen ED assessment and referral pathways for major ‘chest pain’ conditions (suspected or diagnosed):  Acute Coronary Syndromes  Pulmonary Embolism

3. Chest Pain  Outline your differential diagnosis of a patient presenting with chest pain:

4. Chest Pain  Outline your differential diagnosis of a patient presenting with chest pain:  Cardiac  ACS (Unstable angina/NSTEMI/STEMI)  Angina  Pericarditis  Aortic dissection  Other…  Respiratory  PE  Pneumonia  Pneumothorax  Other…  Gastro  Oesophagitis  Oesophageal reflux  Other…  MSK  Costocondriasis  Rib fracture  Soft tissue injuries  Other…

5. Acute coronary syndromes Clinical syndromes caused by the same disease process:  unstable angina (UA)  non-ST-elevation myocardial infarction (NSTEMI)  ST-elevation myocardial infarction (STEMI) This section: Advanced Life Support Course: All rights reserved © Resuscitation Council (UK) 2010 ( revised May 2014)

6. Stable angina Pain or discomfort from myocardial ischaemia:  tightness/ache usually across chest  may radiate to throat/arms/back/epigastrium  consistently provoked by exercise  settles when exercise stops NOT an acute coronary syndrome NB: DIFFICULT ED DIAGNOSIS AS BY TIME PATIENTS ARRIVE SYMPTOMS ARE GENERALLY WORSE THAN ‘NORMAL’

7. Unstable angina 1. Angina on exertion with increasing frequency over a few days, provoked by less exertion 2. Angina occurring recurrently and unpredictably - not specific to exercise 3. Unprovoked and prolonged episode of chest pain  ECG may be normal  ST segment depression suggests high risk  no troponin release  cardiac enzymes usually normal or

8. Acute ST depression

9. Non-ST-elevation myocardial infarction (NSTEMI)  symptoms suggesting acute MI  non-specific ECG abnormalities  ST segment depression  T wave inversion  troponin release NB: A NEGATIVE TROPONIN IN THE ED DOES NOT RULE OUT NSTEMI. FURTHER REFERRAL WARRANTED (SEE LATER SLIDES)

10. NSTEMI

11. ST-elevation myocardial infarction (STEMI)  symptoms suggesting acute MI  acute ST segment elevation  Q waves likely to develop  troponin release  early effective treatment may limit myocardial damage and prevent Q wave development

12. Anterolateral STEMI

13. Immediate treatment for all acute coronary syndromes ABCDE approach  aspirin 300 mg orally (crush/chew)  nitrate (GTN spray or tablet)  oxygen if appropriate  morphine  Current Aberdeen recommendations  STEMI: Activate PCI ‘Cath lab’  NSTEMI (ED +’ve troponin): Ticagrelor & Fondaparinux (balanced against bleeding risk)  Possible NSTEMI (ED –’ve troponin): Depending on ‘risk’ ticagrelor/fondaparinux if suitable for ambulatory emergency care (AEC) refer, otherwise refer SSMU. Overnight refer SSMU.

14. Ambulatory Emergency Care Or SSMU Ambulatory Emergency Care Or SSMU

15. Pulmonary Embolism  Investigation depends on ‘risk’  Well’s score for PE

16. Dichotomised Well’s Score PE

19. Questions/Conclusion  Remember ‘pitfalls’ when assessing the patient presenting with ‘chest pain’ in the ED. The elderly, female and diabetic patient may present with ‘atypical’ pain. Have a high index of suspicion  D-Dimer should only be used in ‘PE unlikely’ patients scored using the dichotomised Well’s score.  Ambulatory Emergency Care (9am-5pm currently) should be considered for a number of ED patients who were previously admitted.