1. CHEST PAIN

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

3. 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

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

5. 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

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

7. Cardiac Chest Pain
Pulmonary Embolism

8. Myocardial ischemia or infarction
For clinical
Enquire about cardiac risk factors: age, sex, smoking history, diabetes, hypertension, hyperlipidemia, previous myocardial infarction and family history

9. 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

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

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

12. 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

13. 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

14. Unstable Angina / NSTEMI

15. STEMI-data -