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Chest Pain

Chest Pain. Dr. Shamim Nassrally BSc (Hons) MB ChB MRCP(UK) Clinical Teaching Fellow. Objectives. By the end of this session you should be able to: Recognise Acute Coronary Syndrome (ACS) Initiate appropriate investigation and management of ACS

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Chest Pain

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  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

  6. Pathophysiology

  7. Terminology Angina UA NSTEMI STEMI ACS

  8. 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 Angina Unstable Angina

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

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

  11. 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

  12. Common risk factors • ?

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

  14. Examination

  15. 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

  16. Investigations • ?

  17. Investigations • Electrocardiogram!! • Blood tests • Full Blood Count • Urea and Electrolytes • Lipid Profile • Clotting screen • Blood sugar • Troponin* • Chest radiograph

  18. Investigations (2) • Transthoracic echocardiography (Handheld/Portable/Departmental) • Exercise tolerance test • Stress echocardiography • Coronary angiography • Further cardiac imaging – Cardiac CT/MR

  19. Troponins

  20. Troponin

  21. 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

  22. Troponin

  23. Management : ACS • STEMI • NSTEMI / UA • Angina

  24. 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

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

  26. 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

  27. Management : NSTEMI • ?

  28. 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

  29. TIMI risk score

  30. TIMI risk score

  31. Post Event management • Lifestyle modification • 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

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

  33. 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

  34. Questions?

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