Acute Chest Pain in Emergency Room

1. Acute Chest Pain in Emergency Room Dr Chaitanya Vemuri Post Graduate Student

2. Introduction Chest Pain Diseases of heart aorta lungs pleura mediastinum oesophagus stomach abdominal viscera musculoskeletal psychological

3. Approach History Clinical Examination Differential Diagnosis Investigations

4. History Onset of pain ( abrupt / gradual ) Provocation / Palliation ( activities that provoke pain or alleviate pain ) Quality of Pain ( sharp, squeezing, pleuritic ) Radiation ( shoulder, jaw, back ) Site of pain (substernal, chest wall, diffuse, localized) Timing ( constant / episodic, duration of episodes )

5. Clinical examination ECG Chest X ray 2D Echocardiography Special Investigations

6. Aim in Emergency Room Immediate recognition and exclusion of life-threatening causes of chest pain

7. Acute Coronary Syndrome Aortic Dissection Pulmonary Embolism Pneumothorax Mediastinitis Pericardial Tamponade

8. Case 1 A 58 year old male Smoker k/c/o Systemic Hypertension Dyslipidemia Diabetes mellitus type 2 c/o left sided chest pain since last 30 minutes squeezing pain gradual onset radiating to jaw and left arm associated with dyspnea, sweating and vomiting On ex : Pul : 90 / min BP : 150 / 90 mm Hg RR : 20 /min CVS : S1+,S2+, No murmurs RS : Clear

9. Acute Coronary Syndrome History Left sided or Substernal chest pressure or tightness Onset is gradual Pain radiating to shoulder, jaw Pain increasing on exertion Atypical symptoms � dyspnea, weakness in elderly and diabetics

10. Acute Coronary Syndrome Clinical Examination Nonspecific Signs of Heart failure Acute LVF Bradycardia / Heart block / Hypotension

11. Acute Coronary Syndrome Investigations ECG Cardiac Enzymes 2D Echocardiogram

12. Acute coronary syndrome refers to any constellation of clinical symptoms that are compatible with acute myocardial ischemia and encompasses acute myocardial infarction. - STEMI, - NSTEMI, - Unstable Angina

13. Anterior wall ischemia

14. Acute anterolateral wall ischemia

15. Acute lateral wall ischemia

16. Acute myocardial infarction

17. Acute anterior wall stemi

18. Acute anteroseptal MI with RBBB

19. Acute inferior wall MI

20. Acute inferior wall MI

21. Posterior wall MI

22. Cardiac Enzymes In patients with negative cardiac enzymes within 6 hrs of onset of pain , another sample should be drawn within 6 � 12 hrs Troponin I & Troponin T : Preferred Biomarker Increase in 3-12 hrs after the onset of MI Peak at 24-48 hrs Return to baseline over 5 -14 days

23. Cardiac Enzymes CK-MB : >95% Sensitivity & Specificity for myocardial injury when measured 24-36 hrs after the onset of chest pain Increase within 3-12 hrs of chest pain Peak at 24 hrs Return to baseline after 48-72 hrs CKMB : CK > 2.5 � Suggests myocardial source but not diagnostic

24. 2D Echocardiogram Look for Regional wall motion abnormality LV function RV function Mitral Regurgitation

25. Management Oxygen Inhalation Morphine � pain relief Antiplatelets Statins Betablockers ACEI /ARB IV/ SC Heparin / Thrombolysis / PCI +/- Diuretics

27. Case 2 70 year old male k/c/o Systemic Hypertension c/o Sudden onset Chest pain tearing in nature along the back

28. Aortic Dissection History Sudden onset of sharp, tearing or ripping pain Maximal severity at onset Often begins in chest / can begin in back

29. Aortic Dissection Clinical Examination Absent upper extremity or carotid pulse Discrepancy in Systolic BP > 20 mm Hg between right and left upper limb Aortic Regurgitation 30 % Neurological findings

30. Aortic Dissection Investigations ECG : 15 % - Ischemic changes 30 % - Non specific ST �T changes CXR : Wide mediastinum / Loss of Normal Aortic Knob Contour � 76 % Normal � 10 %

31. Chest X Ray