Grand Rounds Presentation

Grand Rounds Presentation By Naz Ahmed, Sohail Nawaz, Vikki Holmes, KavaldeepJabbal, Joseph McFarlane and Ryan Langan

Presenting Complaint • 87 year old man • Chest pain when breathing in • Shortness of breath at rest

History of presenting complaint • Patient woken up with chest pain & associated SOB at 5.30am • No relief with GTN spray • After 1 hour of intermittent GTN spray usage • Dizzy, Sweaty and Clammy • General anxiety • 3/7 Hx of a non-productive cough • No palpitations, pyrexia, nausea or loss of consciousness

Characteristics of pain • Site – Central • Onset – 5.30am, woken from sleep • Character – Chest tightness • Radiation – No radiation • Associations – SOB, felt clammy and dizzy • Timing – Pain ongoing • Exacerbating/alleviating factors – None • Severity – 8/10

Differentials • What do you think?

Differential Diagnosis • Pulmonary Embolism • Acute Coronary Syndrome • Pneumothorax • Costochondritis • Pericarditis • Aortic Dissection • Viral LRTI

Past medical history • Angina Pectoris • Diverticular disease • CVA • Left total hip replacement • Past urinary bladder stones

Drug History – on admission • Paracetamol 500mg PRN • Aspirin 75mg OD • Diltiazem – 60mg BD • Isosorbidemononitrate – 60mg OD • Simvastatin – 40mg ON • Clopidogrel – 75mg OM • NKDA

Family history • No known family history of first degree relatives having a cardiopulmonary event under the age of 65

Social History • Residential home (housebound) • Retired – engineer • Uses a Zimmer frame • No consumption of alcohol • Ex smoker – 16 pack years

Systems review • Incontinence (Catheterised) • No other GI problems • No weight loss • No night sweats • No lumps • No fatigue • Apyrexial • No neurological signs

Examination on Admission • Temperature: 36°C • BP: 96/57 • HR: 53 (regular) • Heart sounds: I + II + o • RR: 20 • SaO2: 95% (room air) • Clear lung sounds • Soft, non tender abdomen

Investigations • What do you think?

Tests on Admission • Urea: 7.2mmol/L (↑) (2.5-6.7) • CRP: 35.8mg/L (↑) (<10) • D-dimer: 895mcg/L (↑) (<250) • Troponin T: 0.03mcg/L (↔) (<0.1) • CXR: Normal • ECG: • Normal Sinus Rhythm • RBBB (Already present) • No ST change

Tests - 12 Hours Later • Troponin T: 0.06mcg/L (<0.1) • General observations: • Temperature 36.4°C • BP: 147/75 • HR: 82 • RR: 17 • O2Sats 97% • ECG: • Not on records

Outcome • Treated as a NSTEMI • Due to elevated troponin and angina • Raised D-dimer • DVT, Elderly, Unwell, Inflammation, Trauma, Underlying hepatic disease, Infection, Pregnancy • Low risk due to Well’s score

PE Wells Score

Example ECG

Initial management of NSTEMI • Morphine • (5-10mg IV) + an Antiemetic • Oxygen • Aim for SaO2 >95% (Caution in COPD) • Nitrates • (GTN) Sublingually first, consider IV if no improvement. • Aspirin • 300mg initially, then 75mg/d • Loop diuretic • IV access • Streptokinase (ONLY IN STEMI) • Antiplatelets • In high risk pt’s. Clopidogrel 300mg (initially)  75mg/d • LMWH: Enoxaparin (1mg/kg/12h)

Initial management of NSTEMI In High risk Patients • High risk patients: Persistent or reccurent ishcaemia, ST-depression, Diabetes, or ↑Troponin. Give: • IV Glycoprotein IIb/IIIa inhibitors • Urgent Angiography • Add clopidogrel (if not given already)

Subsequent management of NSTEMI • Clopidogrel • Omega-3 • Bisoprolol • Or Ca2+ channel Blocker if CI • Ramipril • Aspirin • Atorvastatin

THANK YOU

Grand Rounds Presentation