1. Chest Pain Dr. Shamim Nassrally BSc (Hons) MB ChB MRCP(UK)
Clinical Teaching Fellow

2. Objectives By the end of this session you should be able to:
Recognise Acute Coronary Syndrome (ACS)
Initiate appropriate investigation and management of ACS
Be able to calculate and interpret TIMI scores
Recognise Acute Myocardial Infarction and use appropriate investigation to confirm the diagnosis

3. Chest pain SOCRATES Identify most likely system involved Cardiac
Pulmonary
Gastrointestinal
Musculoskeletal
Neurological (Psychiatry)

4. Chest pain SOCRATES Identify most likely system involved Cardiac
Pulmonary
Gastrointestinal
Musculoskeletal
Neurological (Psychiatry)

5. Cardiac Chest pain Coronary Artery disease (CAD)
Ischaemic Heart disease (IHD)
Atherosclerotic Heart Disease
Essentially plaques made of cholesterol and calcium build up in the coronary arteries reducing cardiac muscle perfusion
Synonyms

7. Pathophysiology

8. Terminology
ACS
Angina UA NSTEMI STEMI

9. Angina Unstable Angina
Exertional
Relieved by rest
± ECG changes ( ST depression, T wave inversion)
Troponin negative
Can occur at rest
Crescendo
± ECG changes ( ST depression, T wave inversion)
Troponin negative

11. NSTEMI STEMI Troponin +ve
± ECG changes (ST depression/ T wave inversion)
Troponin +ve
ST elevation
New onset LBBB

12. Cardiac Chest Pain (typical)
Site :
Onset:
Character:
Radiation:
Associated Features:
Timing:
Exacerbating & Relieving Factors:
Severity:

13. Cardiac Chest Pain (typical)
Site : Retrosternal
Onset: Sudden, Crescendo, Exertional
Character: Dull, Squeezing, Tightness
Radiation: Throat/Jaw, Shoulder
Associated Features: Dyspnoea, Autonomic Sx
Timing: Exertion, Meals, Rest. Duration
Exacerbating & Relieving Factors: Exertion/Rest
Severity: Subjective – but usually severe

14. Common risk factors ?

15. Common risk factors Hypertension Hypercholesterolaemia / Dyslipidaemia
Diabetes Mellitus
Smoking
Age
Male
Family History of early CAD
Obesity/ Physical Inactivity

16. Examination

17. Examination Unremarkable physical examination Obesity
Cholesterol deposits: arcus, xanthoma, xanthelasma
Tar stains, nicotine stains
Signs of peripheral vascular disease
Acute LVF, New murmur of MR or VSD
Cardiogenic shock

18. Investigations ?

19. Investigations Electrocardiogram!! Blood tests Chest radiograph
Full Blood Count
Urea and Electrolytes
Lipid Profile
Clotting screen
Blood sugar
Troponin*
Chest radiograph
Why a,d what are we looking for on these investigations

20. Anterior lateral MI (ECG A)

21. STEMI. (ECG S) 2

22. Investigations (2)
Transthoracic echocardiography (Handheld/Portable/Departmental)
Exercise tolerance test
Stress echocardiography
Coronary angiography
Further cardiac imaging – Cardiac CT/MR
Dependant on possible diagnoses

23. Troponins

24. Troponin

25. Troponin
Proteins released into the blood stream following muscle injury
Different isomers of troponin
Troponin T and I are specific for cardiac muscle
More specific than CK
Levels start to rise after muscle damage but only peak after 12 hours

26. Troponin

27. Management : ACS
STEMI
NSTEMI / UA
Angina

28. Management : STEMI ? NB: 2/3 criteria New onset LBBB
ST elevation of 2mm in 2 contiguous chest leads or 1mm in 2 limb leads
Chest pain

29. Management : STEMI Primary percutaneous angioplasty ABC approach
Analgesia: opioid based (Morphine 10mg IV)
Oxygen: 15L via NRM
Aspirin 300mg PO stat
Clopidogrel 600mg PO stat
Primary percutaneous angioplasty

30. Thrombolysis
Use of clotbusting agents such as streptokinase or tissue plasminogen activators such as alteplase
Now superceded by primary PCI
Only for Acute myocardial Infarction with 1-3 hours of event
Used if not possible to get access to percutaneous angioplasty

31. Management : NSTEMI ?

32. Management : NSTEMI / UA
ABC approach
Analgesia: opioid based
Oxygen: 15L via NRM
Aspirin 300mg PO stat
Clopidogrel 300mg PO stat
LMWH e.g. 1mg/kg Enoxaparin BD SC
GTN infusion for pain
Percutaneous angiography (with 48hours) ± angioplasty/ coronary bypass

33. TIMI risk score

34. TIMI risk score

35. Post Event management Lifestyle modification Secondary prevention
Smoking cessation
Dietary changes
Secondary prevention
ACE-I
Beta-Blocker
Statins
Cardiac rehabilitation
Risk of further events and associated morbidity e.g. arrhythmias and heart failure

36. Angina Managed as OP, initially medically
Anti-platelets, anti-anginals, risk factor/ lifestyle modification
May require bypass surgery or angioplasty

37. Summary ACS is a spectrum from Angina to STEMI
UA/NSTEMI managed differently to STEMI
TIMI risk score predicts outcome
Use the ABCD approach
Perform the initial Ix and Rx
Ask for help early, inform the Cardiologists early
Primary angioplasty has revolutionised the area
Don’t forget post MI management

38. Questions?