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

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

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

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

6. Emergency Care Unit Pronto Soccorso Pisa Fast Effective Available
Experienced
Updtated
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8. Cardiovascular diseases causing chest pain
Angina and mycordial infarction
Aortic dissection
Pulmonary embolism
Acute pericarditis
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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”
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12. Which was the onset of pain ?
It starts slowly, increasing its
intensity, then slowly fades away.
It lasts about minutes.
In AMI can last even few hours.
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13. What were you doing when it started? Effort Cold Sexual activity
Emotional stress
At rest
Sleeping
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14. used the nitroglycerin pill ?
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
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15. Related symptoms in cardiac chest pain
Short heavy breath
weakness
Cold sweating
“funny heart beat”
fainting
Vomiting
(Sudden death)
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16. Exams performed at the “triage”
ECG + monitoring
Blood samples (troponin, CPK-mB, myoglobin, SGOT)
Emogasanalysis
Chest X-Ray
Monitoring BP
ECHO
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17. Sequence…
ECHO ECG ECG ECHO
chest pain
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18. …although the ECG… …can be abnormal in a chronic heart disease…
A patient with heart problems should always have the last ECG in his wallet.
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19. ..watch out…! A normal ECG does NOT exclude a severe heart problem
Always think :
- Acute aortic dissection
- Pulmonary Embolism
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20. In most cases the pain is difficult to explain….
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
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21. In massive pulmonary embolism
EGA: low oxigen, low CO2,
alcalosis
ECG: S1…Q3
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22. Although in the pulmonary embolism
..very often the thrombosis is NOT
Massive..
…most of survived cases show
multiple little embolisms…
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23. Blood gases analysis Anxiety : pO2 , pCo2 Pulmonary
Nell
Anxiety : pO2 , pCo2
Pulmonary
Embolism : pO2 , pC02
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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….
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25. .. Femoral and radial artery pulses can be different
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
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26. …the pain depends on the position.. ...fever …young patients
Pericarditis
…the pain depends on the position..
...fever
…young patients
…”leather rubbing” noises
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27. When the clinical exam and the clinical history of the patient
do not match
with the instrumental findings ,
ALWAYS THINK that
maybe these could be inadequate
in THAT patient, in THAT moment..
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28. Heart attack…what to do ?
Calm down the patient, sedatives are …welcome
Alert the 118 immediately , explaining
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
Supply oxigen if possible
Talk to the patient , making him sure that
Italians Emergency Doctors are great…!!
(you can say it loud…)
Be ready to start a CPR, find someone around ready to help you…
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
a correct diagnosis and therapy
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33. …thanks for your attention !
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