Chest Pain and Shortness of Breath

1. Chest Pain and Shortness of Breath Brett Sheridan, M.D., F.A.C.S Assistant Professor Cardiothoracic Surgery Department of Surgery

2. Causes of Chest Pain and SOB • Myocardial Infarction • Pulmonary Embolism • Pneumothorax • Hemopneumothorax • Thoracic Aortic Dissection • Esophageal Rupture • Gastro-esophageal Reflux • Empyema

3. 47 y/o man is jogging with his daughter when he suddenly collapses unconscious……

4. 1) Heart Disease2) Cancer3) Stroke Most common causes of death in the US…

5. How many people in the US died from cardiovascular disease in 2001?

6. Do more men or women die from cardiovascular disease?

7. Acute coronary syndrome (ACS) is defined by EITHER acute myocardial infarction OR unstable angina.These patients are divided into 3 subsets:ST elevation myocardial infarction (STEMI) non-ST elevation MI Unstable angina

8. Describe the initial stabilizing treatment for symptomatic ischemic heart disease presenting in the ER • ECG within 10 minutes • Supplemental O2 • IV access continuous ECG monitoring • Sublingual NTG if SBP > 90 mmHG • Morphine • ASA (chewed) • Labs • If ST elevation > 1mV or LBBB then reperfusion (fibrinolysis or PTCA)

9. What is AMI management in first 24 hours? • Limited activity 12 hrs and monitor 24 hrs • No prophylactic antiarrythmics • IV heparin if: • large anterior MI, • PTCA, LV thrombus or • thrombolytics administered • SQ heparin for all others • ASA indefinitely • IV NTG x 24 hrs • IV beta-blocker if stable • ACE inhibitor if BP permits • Statin therapy

10. Why are patients referred for CABG instead of undergoing a PCI approach to coronary artery disease?

11. Percutaneous coronary angioplasty (PTCA, PCI,…)

12. Percutaneous coronary angioplasty (PTCA, PCI,…)

13. Percutaneous coronary angioplasty (PTCA, PCI,…)

14. Natural history of percutaneous coronary angioplasty…..uh-oh!

15. Cite 2 prospective randomized trials comparing PCI vs CABG for the treatment of multivessel CAD

16. Inclusion Criteria • Symptomatic • Multivessel CAD • LVEF > 30% • Baseline Characteristics • Class III/IV angina - 66% • Previous MI - 42% • 3 vessel CAD - 30% • mean LVEF = 60%

17. Comparison of Coronary-Artery Bypass Surgery and Stenting for the Treatment of Multivessel Disease(Arterial Revascularization Therapies Study Group) CABGPCI Patients (n)                                    605                                      600 Late outcome                              ---------------------1 year-----------------Death                                           2.8%                                  2.5%MI                                                4.0%                                   5.3% CVA 2.0% 1.5% Revascularization *                    4 %                               17%Event-free survival *                  88%                                74%Symptom-free *                          90%                                    79% Cost *                            $13,638                              $10,665

18. Event –free Survival: CABG vs PCIS 14% benefit w/ CABG!

20. Risk of Repeat Revascularization 16 % benefit w/ CABG!

21. Risk of Death 3.7 % SURVIVAL benefit w/ CABG!

22. Conclusions-SoS Trial • Again, repeat revascularization remains more common after PCI (with or without a stent) in multivessel CAD. • In this study, higher rate of all cause mortality with PCI

23. Contrast the difference between “off-pump” CABG versus the typical cardiopulmonary bypass supported CABG.

24. Traditional CABG • General anesthetic • Median sternotomy • Conduit harvest (LITA, radial, vein) • Institution of cardiopulmonary bypass (CPB) • Cardiac arrest • Placement of aorto-coronary grafts • Seperation from CPB • Close

26. Advantages - Traditional CABG • Still Heart • Exposure and access • Visualization • The most intensely scrutinized procedure in US medicine SAFETY

27. Disadvantages - Traditional CABG • Proinflammatory response to CPB • Suggestion of end-organ injury • CNS • Pulmonary • Renal • Increased fluid shifts

28. Off-Pump Stabilizer

29. Off-Pump- Snare

30. Off-Pump Stabilizing Devices

32. Off-Pump Exposure of PDA

33. List 10 complications of CABG and there relative frequency

34. Death 3% • Stroke 1-2% • Bleeding requiring re-op 3-5% • Wound Problems 0.5-5% • Myocardial infarction 2-30% • Arrhythmias 10-60% • Pneumonia 4% • Pneumothorax 1-2% • Cardiac Tamponade 3-6% • Pericardial Inflammation 18% • Renal Insufficiency 15-20%

35. What four medications prevent MI and death following a myocardial infarction.

36. “Class I” Indications • ASA • Beta-blockers • ACE inhibitor • Statins

45. Risk Of Pneumothorax • Pain • SOB ( dyspnea) • Hypoxia • Hypotension (embarrassed CO) • Death

46. Spontaneous Primary Subpleural bleb Secondary Chronic Obstructive lung disease Bullous disease Cystic fibrosis Pneumocystis-related Idiopathic pulmonary fibrosis Pulmonary embolism Catamenial Esophageal perforation Neonatal Acquired Trauma Iatrogenic DDX of Underlying Pulmonary Pathology

47. Treatment options • Observation • Tube thoracostomy • Surgery • Other “dated” options • Needle aspiration • Chemical pleurodesis

48. Observation • Asymptomatic • Pneumothorax less than 20% • ER for 4-6 hours w/ repeat CXR • F/U within 48 hours and CXR • Any doubts --admit

49. Tube Thoracostomy • Primary Method of Management • Prompt re-expansion of lung • Prevents life-threatening sequelae • Allows pleural-pleural apposition –sealing injured lung • Tube removed once air leak resolves for 12 hours

50. Prognosis • Usually resolves within 1-2 days • 30% chance of recurrence • Increases to 60-70% if second pneumothorax