1. APPROACH TO PATIENT WITH
CHEST PAIN & ACUTE
CORONARY SYNDROME
Presented by: Siti Nur Hamizah

2. INTRODUCTION
 Any pain, pressure, squeezing, choking, numbness or
any other discomfort in the chest, neck, or upper
abdomen, and is often associated with pain in the jaw,
head, or arms.
 Because of common/overlapping neural pathways,
many conditions, both cardiac and extra-cardiac can
result in chest pain.
 Cardiac pain is mediated through upper 5 thoracic
ganglia and spinal roots, but ramifications from
adjoining spinal roots always exist.
 Therefore pain in the chest may originate from any
structure in thorax and upper abdomen innervated
through lower cervical to D6/D7 spinal roots

3. EVALUATION OF CHEST PAIN:
 Try to find the nature & cause of chest pain through CLINICAL
HISTORY.
 A) Acute/short lived/ongoing
 B) Recurrent & episodic
 C) Persistent
 Details on pain:
 Site of pain, localized/diffuse, with radiation if any
 Intensity & character of pain
 Precipitating & relieving factors
 Any relationship with meals &posture &
 Any effect of local pressure, or variation with breathing, coughing &
movements of cervical spine &shoulder joints.

4. IN GENERAL:
 Chest pain/discomfort is unlikely to be due to coronary
artery disease if:
 Localized to region under left nipple/in skin/soft
tissue
 Localized to small area (<2-3 cm), anginal pain tend
to be diffuse.
 If chronic & persistent/ recurring and
momentarychest pain is sharp, pricking, or
stabbing
 Or varies with posture/breathing and coughing
 Present for several hours but not accompanied by
appropriate ECG changes.

6. DIFFERENTIAL DIAGNOSIS
Cardiac Non-Cardiac
Coronary artery disease GIT disorder:
MI a)Esophageal disorder like esophagitis or
esophageal motility disorders
Pericarditis b) Peptic ulcer
myocarditis c)Biliary disease
Pulmonary embolism d)Pancreatitis
Less common causes: Musculoskeletal disorder:
Costochondritis, rib #,
Aortic dissection Radiculopathy
Aneurysm of thoracic aorta Psychogenic chest pain
Severe aortic stenosis
Lungs/ pleura:
Bronchospasm
pulmonary infarct
Pneumonia
Pneumothorax
pulmonary embolism
tuberculosis.
Neurological:
Prolapse intervertebral disc
Herpes zoster
Thoracic outlet syndrome

7. ACUTE CORONARY SYNDROME
 Encompasses all acute phase of Coronary Heart Disease >
Unstable angina + NSTEMI + STEMI which usually present with
acute chest pain at rest or on minimal exertion
 Pathogenesis:

8. CLINICAL FEATURES
• Symptoms: prolonged cardiac pain-chest, throat, arms,
epigastrium or back. Anxiety, fear of impending
death,nausea and vomiting, breathlessness, collapse,
syncope.
• Signs: pallor, sweating, tachycardia-(sympathetic
activation) vomiting, tachycardia-(vagal activation),
hypotension, oliguria, cold peripheries, narrow pulse
pressure, raised JVP, third heart sound, quiet first
heart sound, diffuse apical impulse, lung crepitations,
fever, complication signs->mitral regurgitation,
pericarditis.

9. • Unstable angina is characterised by new onset or rapidly
worsening angina, angina on minimal exertion, or angina at rest in
the absence of myocardial damage.
• In contrast, MI occurs when symptoms occur at rest and there is
evidence of myocardial necrosis, as demonstrated by an elevation
in cardiac troponin or creatinekinase-MB isoenzyme

10. INVESTIGATION
ECG
Plasma cardiac markers-> CK-MB, cardiac
troponins T and I (4-6 hours, remains elevated
for up to 2 weeks).
Other blood tests: leucocytosis, elevated ESR
and CRP
Chest x-ray
Echocardiography

11. IMMEDIATE MANAGEMENT: THE FIRST
12 HOURS
• Analgesia-to lower adrenergic drive-> reduce vascular resistance,
BP, infarct size, susceptibility to ventricular arrythmias.
• Antiplatelet therapy- 300mg aspirin daily+ clopidogrel(600mg-
150mg-75mg)
• Anticoagulants- unfractionated heparin, fractionated heparin or a
pentasaccharide.
• Antianginal therapy- sublingual glyceryltrinitrate (300-500mcg), IV
nitrates, IV beta-blockers.
• Reperfusion therapy: primary percutaneous coronary
intervention(PCI), thrombolysis.

13. LATE MANAGEMENT OF MI
• Cessation of
Lifestyle smoking, regular
modification exercise
• diet
• Antiplatelet
Secondary therapy, b-blocker,
prevention ACEI/ARB
drug therapy
• Statin ,aldosterone
receptor antagonist
Devices and • Implantable
rehabilitation cardiac defibrillator

14. COMPLICATIONS OF ACUTE
CORONARY SYNDROME
• Arrythmias- ventricular fibrillation, atrial
fibrillation, bradycardia.
• Ischaemia
• Acute circulatory failure
• Pericarditis
• Mechanical complications- rupture of papillary
muscle, rupture of interventricular septum,
rupture of ventricle.
• Embolism

15. THANK YOU.