1. ‘Taxi Driver in Pain’ Tiara Gill Carrie Ross Mark Hambly

2. Patient Presentation 1 Mr O, 45 year old Nigerian taxi driver P/C Severe central chest pain HPC Arrived by ambulance to A&E at 0310 On high flow O 2, GTN and aspirin in ambulance

3. Differential Diagnoses 1 Immediately life threatening causes of acute chest pain: Acute Coronary Syndrome (ACS) Tension pneumothorax Pulmonary embolism Aortic dissection Oesophageal rupture

4. Patient Presentation 2 S- Central chest O- Sudden, one hour ago [at rest] C- Stabbing R- None A- Sweating T- Constant E- Eased by GTN S- 10/10 eased to 6/10 Chest pain characteristics

5. Patient Presentation 3 Cardiac risk factors Smoker with 25 pack year history Hypertension since 2001 - untreated No previous MI or Angina No relevant family history No diabetes or hyperlipidaemia BMI < 25 No alcohol or recreational drugs Past Medical History None. No medications

6. Patient Presentation 4 Observations HR 72 bpm- BP 134/73 mmHg RR 12 min -1 - Sats 96% on air GCS 15/15 Examination Physical examination in all systems was normal.

7. Differential Diagnoses 2 History and examination highly suggestive ACS Unstable angina Myocardial infarction

8. 12 Lead ECG - Inferior Leads Inferior leads II, III, AVF - area supplied by right coronary artery - 1mm ST elevation in adjacent limb leads - can affect SA and AV nodes

9. 12 Lead ECG - Lateral Leads Lateral leads - I, aVL, 5, 6 - Area supplied by Circumflex Artery1mm ST - ST depression in aVL - reciprocal changes

10. 12 Lead ECG - Anterior Leads Anterior leads - 2, 3, 4 - Area supplied by anterior descending artery - No abnormalities

11. Diagnosis Inferior ST elevation myocardial infarction Why? Appropriate chest pain history Diagnostic ECG changes Trop T negative on admission

12. Immediate Investigations Haematology - FBC, Clotting Biochemistry - U&E, Trop T, - glucose, lipid profile CXR In this case, all these investigations were normal.

13. Acute Management Thrombolysis - Tenecteplase iv Anticoagulate - Heparin iv Analgesia - Diamorphine iv Anti-emetic - Metaclopramide iv ß blockade - Atenolol ECG - CONTINUE MONITORING

14. Treatment Complications BP: 65/30 HR: 30 ß blocker effect - referred to Cardiology Fluid replacement (gelofusin) Atropine Transfer to CCU BP: 120/66

15. Right Coronary Angiogram Note - there was also 40% occlusion of the circumflex artery (off left main stem)

16. RCA Post Angioplasty and Stent

17. Case summary 45 year old Nigerian man presented with chest pain and ECG changes consistent with acute inferior ST elevation MI He was thrombolysed Troponin T was positive at 12 hours Angiography revealed a 90% stenosis in the RCA which has been stented

18. Rationale for Treatment of MI and Secondary Prevention of Ischaemic Cardiac Events

19. Thrombolysis Primary aims - Save life, save myocardium Only shown to have prognostic benefit in ST elevation MI and acute LBBB Traditionally streptokinase, but recently TPA - no difference in therapeutic benefit Risk of bleeding - screening questions FTT Collaboration, Lancet 1994;343:311-322ISIS-3 Lancet 1992;339:753-770

20. Effects of Thrombolysis on Mortality Source: FTT Collaboration, Lancet 1994;343:311-322

21. Secondary Prevention Reduce risk factors Medical treatment - Treats symptoms not stenosis - 4As and nitrates Surgical - Treats stenosis - CABG - Angioplasty with stent ATC BMJ 1994;308:81-106HOPE NEJM 2000;342:145-53 WOSCOPS NEJM 1995;333:1301-74S, Lancet 1994;334:1383-9 Teo K JAMA 1993;270:1589-94

22. Surgical - CABG CABG gives prognostic benefit and symptomatic relief over stenting in those with: - Left mainstem disease, and - Severe three vessel disease. In less severe disease, the risks of CABG outweigh the benefits it has over stenting. Associated with personality changes. Poyen JCS 2003; 44(3):307-12EAST JACC 2000; 35:1116-21

23. Surgical - Stenting Stenting gives symptomatic relief and similar prognostic benefit to patients with milder disease. Benefits Risks Local anaestheticRestenosis (12%) More minor surgeryAcute ischaemic Shorter hospital stay event (5.5%) NICE 1999 report

24. New developments Drug eluting stents

25. Questions and Comments