1. Cardiac Chest Pain Maurizio Cecchini - Cardiologist Emergency Department Pronto Soccorso “S.Chiara” Pisa

2. Who is he? 1980-1982 fellow at the Institute of Cardiology - University of Pisa 1980-1982 fellow at the Institute of Cardiology - University of Pisa 1982 graduated in Medicine and Surgery - U. of Pisa 1982 graduated in Medicine and Surgery - U. of Pisa 1985 specialized in Cardiovascular Medicine - U. of Pisa 1985 specialized in Cardiovascular Medicine - U. of Pisa 1985-1989 Head of the Mobile Coronary Care Unit -Pisa 1985-1989 Head of the Mobile Coronary Care Unit -Pisa 1989 -2001 underchief and then Chief of the Coronary Care Unit of the University Cardiology Department 1989 -2001 underchief and then Chief of the Coronary Care Unit of the University Cardiology Department 2001 -2005 Emergency Doctor at the Emergency Department “Pronto Soccorso” of Pisa 2001 -2005 Emergency Doctor at the Emergency Department “Pronto Soccorso” of Pisa

3. Coronary Care Units in Pisa Hospital Cardiology Unit 8 beds Hospital Cardiology Unit 8 beds University Cardiology Unit 8 beds University Cardiology Unit 8 beds C.N.R. Cardiology Unit 8 beds C.N.R. Cardiology Unit 8 beds Coronary angiography + PTCA 24 h\24 Coronary angiography + PTCA 24 h\24 Heart Surgery team available 24 h\24 Heart Surgery team available 24 h\24

4. Rescue PTCA Average time in Pisa Acute AMI are recovered immediately in CCU. Acute AMI are recovered immediately in CCU. Rescue PTCA in 30 -40 min. time (even Rescue PTCA in 30 -40 min. time (even if not in the main Hospital ) if not in the main Hospital ) (Deaths during assisted transport = 0%) (Deaths during assisted transport = 0%)

6. Emergency Care Unit Pronto Soccorso Pisa FastEffectiveAvailableExperiencedUpdtated maurizio cecchini 2005

8. Cardiovascular diseases causing chest pain - Angina and mycordial infarction - Aortic dissection - Pulmonary embolism - Acute pericarditis maurizio cecchini 2005

9. Chest pain in angina and myocardial infarction

10. Where do you feel pain ?

11. Which kind of pain is it? - pressure - constriction - burning - “disconfort” - “bad digestion” maurizio cecchini 2005

12. Which was the onset of pain ? It starts slowly, increasing its intensity, then slowly fades away. It lasts about 20-30 minutes. In AMI can last even few hours. maurizio cecchini 2005

13. What were you doing when it started? Effort Cold Sexual activity Emotional stress At rest Sleeping maurizio cecchini 2005

14. What happened when you used the nitroglycerin pill ? The pain faded away in 3-5 min (but even in hiatus hernia…) No improvement or transient improvement in AMI maurizio cecchini 2005

15. Related symptoms in cardiac chest pain Short heavy breath weakness Cold sweating “funny heart beat” fainting Vomiting (Sudden death) maurizio cecchini 2005

16. Exams performed at the “triage” Exams performed at the “triage” ECG + monitoring ECG + monitoring Blood samples (troponin, CPK-mB, myoglobin, SGOT) Blood samples (troponin, CPK-mB, myoglobin, SGOT) Emogasanalysis Emogasanalysis Chest X-Ray Chest X-Ray Monitoring BP Monitoring BP ECHO ECHO maurizio cecchini 2005

17. Sequence… Sequence… ECHO ECG ECG ECHO chest pain chest pain maurizio cecchini 2005

18. …although the ECG… …although the ECG… …can be abnormal in a chronic heart disease… …can be abnormal in a chronic heart disease… A patient with heart problems should always have the last ECG in his wallet. A patient with heart problems should always have the last ECG in his wallet. maurizio cecchini 2005

19. ..watch out…!..watch out…! A normal ECG does NOT exclude a severe heart problem problem Always think : Always think : - Acute aortic dissection - Pulmonary Embolism maurizio cecchini 2005

20. PULMONARY EMBOLISM In most cases the pain is difficult to explain…. Generical chest disconfort.. Like a blade.. Like a weight.. Like a belt…a knot maurizio cecchini 2005

21. In massive pulmonary embolism EGA: low oxigen, low CO2, alcalosis ECG: S1…Q3 maurizio cecchini 2005

22. Although in the pulmonary embolism..very often the thrombosis is NOT Massive.. …most of survived cases show multiple little embolisms… maurizio cecchini 2005

23. Blood gases analysis Anxiety : pO2, pCo2 Nell Pulmonary Embolism : pO2, pC02 maurizio cecchini 2005

24. Aortic dissection The pain is severe, can migrate from the front down on the back. Neurological symptoms may occur if the dissection includes the origin of the carotid arteries as well as an AMI can be present if the coronary arteries are involved in the dissection. Diagnosis can be DIFFICULT, if you do not think about it…. maurizio cecchini 2005

25. AORTIC DISSECTION.. Femoral and radial artery pulses can be different...The pain “comes and goes”,often in the back chest…. Aortic incompetence murmur can be present maurizio cecchini 2005

26. Pericarditis …the pain depends on the position.....fever …young patients …”leather rubbing” noises maurizio cecchini 2005

27. When the clinical exam and the clinical history of the patient do not match do not match with the instrumental findings, ALWAYS THINK that ALWAYS THINK that maybe these could be inadequate in THAT patient, in THAT moment.. maurizio cecchini 2005

28. Heart attack…what to do ? Calm down the patient, sedatives are …welcome Calm down the patient, sedatives are …welcome Alert the 118 immediately, explaining Alert the 118 immediately, explaining what is happening, where exactly you are what is happening, where exactly you are Don’t put the phone down, leave your mobile number to the 118 operator

30. Waiting for the ambulance Put the patient in a comfortable position Put the patient in a comfortable position Supply oxigen if possible Supply oxigen if possible Talk to the patient, making him sure that Talk to the patient, making him sure that Italians Emergency Doctors are great…!! Italians Emergency Doctors are great…!! (you can say it loud…) (you can say it loud…) Be ready to start a CPR, find someone around ready to help you… THINK FORWARD THINK FORWARD

32. Having plenty of instrumental exams available can force us to reduce the time of hearing the patient, to let him tell us how he really feels, the reason why he came to be visited,therefore, TO FAIL TO FAIL a correct diagnosis and therapy maurizio cecchini 2005

33. …thanks for your attention ! maurizio cecchini 2005