Medicine and Cardiology related lot

2. An Approach to
CHEST PAIN at ER….?
SHAHID ABBAS
MBBS, FCPS (MED), FCPS (CARD)
Interventional Cardiologist & Medical Specialist

3. The Road Map!
Atherosclerosis
IHD
Encountering Chest Pain
Investigations involved
Red flags and Loop holes
Summary
Conclusion

4. A Patient walks in to your
ER with
chest Pain

5. Brain Storming !
• 60 % of chest pain diagnoses were not "organic
• Musculoskeletal 36 % of all diagnoses
• Costochondritis -13 %
• Reflux esophagitis -13%
• Stable angina pectoris -11 %
• Unstable angina or myocardial infarction -1.5 %

6. Better Safe Then Sorry
Life-threatening conditions
• Acute coronary syndrome
• Aortic dissection
• Pulmonary embolism
• Tension pneumothorax
• Pericardial tamponade
• Mediastinitis

8. Initial Assessment Check list
• Resuscitation equipment brought to the bedside
• Airway, breathing, and circulation assessed
• Preliminary history and examination obtained
• 12-lead ECG done and interpreted
• Cardiac monitor attached to patient
• Oxygen given
• IV access and blood work obtained
• Aspirin 150 to 300 mg given (DDT)
• Nitrates and morphine given (unless contraindicated)
ALL IN 10 MINS

9. History of chest pain
General approach about Chest Pain
• Onset of pain
• Provocation/Palliation
• Quality of pain
• Radiation
• Site of pain
• Timing
• Chest Pain equivalents
( breathlessness, Nausea, Vomiting )

10. Important points on history…
 Worsening in the frequency, intensity, duration, and timing of prior
anginal or anginal equivalent symptoms
 New onset symptoms of shortness of breath, nausea, sweating,
extreme fatigue in a patient with a known history of cardiovascular
disease
 Onset of typical anginal symptoms in a previously asymptomatic Pt
 Age greater than 70 years
 Diabetes mellitus
 Women
 Extracardiac vascular disease (PVD, PAD, CVA)

11. Atypical Chest pain
• Pleuritic pain, sharp or knife-like pain related to
respiratory movements or cough
• Primary or sole location in the mid or lower abdominal
region
• Any discomfort localized with one finger
• Any discomfort reproduced by movement or palpation
• Constant pain lasting for days
• Fleeting pains lasting for a few seconds or less
• Pain radiating into the lower extremities or above the
mandible

12. Targeted History…..
• Diagnostic studies in the Past
• Comorbidities: hypertension, diabetes mellitus,
peripheral vascular disease, malignancy
• Recent events: trauma, major surgery or
medical procedures (eg, endoscopy), periods of
immobilization (eg, long plane ride)
• Other factors: cocaine use, cigarette use, family
history
• Contraindications to SK

13. Physical Examination
• Most often the physical examination is not helpful
• Anxious and distressed and may be diaphoretic and
dyspneic
• Differential Diagnosis
• Evidence of systemic hypoperfusion Cardiogenic shock
• Evidence of heart failure
• A screening neurologic examination Subtle/ ongoing
CVA (contraindication to SK)

14. ECG
• A standard 12-lead electrocardiogram (ECG) within
10 minutes
• A single ECG detects < 50 percent of AMIs
• Patients with normal or nonspecific ECGs have a 1
to 5 percent incidence of AMI and a 4 to 23 percent
incidence of unstable angina
• ECG should be repeated as frequently as every 10
minutes if the initial ECG is not diagnostic but
high clinical suspicion for AMI is there
• Prior ECGs are important
Normal ECG DOES NOT RULE OUT ACS

15. Components of the ECG

16. QRS
 Q wave

17. J-Point

18. ST Segment

19. ST Segment Elevation
 Presumptive evidence of AMI
 Indication for acute
reperfusion therapy

20. ST Segment
 Compare to TP segment
ST TP

21. Investigations
 Chest x-ray
 Usually non-diagnostic in ACS
 Helps to identify other important
conditions
 Congestive heart failure
 Pnuemonia
 Pnuemothorax
 Pleural effusion
 Widened mediastinum (aortic dissection)

22. Normal CXR!

23. Left lower lobe pneumonia

24. 1. Interstitial pulmonary edema 2. Bilateral perihilar alveolar edema
3. Bilateral pleural effusions.

27. Thoracic Aortic Dissection
 Classic – Ripping pain to back
 Unequal BP’s > 20mmHg
 Consequence of Thrombolytic Therapy
 DEATH

28. Acute Pericarditis
 Classic – Sharp or pleuritic chest pain.
 Pain is worse when placed in supine
position
 Pain better when sitting
 EKG: PR depression with ST elevation in
diffuse leads
 Consequence of Anticoagulation:
 DEATH

29. Ventricular Aneurysm
 Classic – History of old Myocardial
Infarction.
 Diagnostic Q – Waves on EKG with raised
ST
 Consequence of Anticoagulation:
 NONE

30. Cardiac Enzymes
 Cardiac Troponins
 Blood levels rise after 3-6 hours (can be negative at initial
assessment!)
 Peak at 12-20 hours
 Creatine Kinase (CK)
 May rise earlier than troponin, but less specific for cardiac
muscle
 ALWAYS repeat in 6-8 hours if suspicious for acute
cardiac event (ie, non-STEMI)
 Loop Holes

32. Enzymes Elevation
-- TROP

33. Comparison
Acute Coronary Syndromes – Cardiac Markers
Marker Initial
Rise
Peak Return to
normal
Benefits
Troponin 2-4 hr 10 -24 hr 5 -10 days Sensitive and specific
CK-MB 3-4 hr 10-24 hr 2 – 4 days Unaffected by renal failure
LDH 10 hr 24 -72 hr 14 days
Myoglobin 1-2 hr 4 -8 hr 24 hours Very sensitive, powerful
negative predictive value

34. Predictors of high risk for ACS
History
 Age > 65 years
 Class III or IV angina
 Accelerating tempo CP/ pain similar to MI in the Past
 Women
 Diabetes
 Previous MI/ PCI
 Patient on Disprin
Examination
 Tachycardia /Bradycardia /Hypotension
 Clinical LVF ( S3, transient MR, new or worsening Crepts)

35. Predictors of high risk for ACS
ECG
 Dynamic ST changes
 ST deviation > 0.5 mm
 Multiple leads involvement
 LBBB
 SVT
 Positive cardiac biomarker
CAD Equivalents
( DM, Carotid AD, Abd Aortic aneurysm, Symptomatic PVD)

36. CHEST PAIN
ECG Suggestive of MI Yes
ECG suggestive of ischemia
No
Yes
No None or 1 Risk Factor 2 or more Risk Factor
Intermediate Risk (8 %)
High risk (MACE > 17 %)
Very Low Risk < 1%
Low Risk Risk ( 4%)
No Risk Factors
1 Risk Factor
2 or More Risk Factor

37. High Risk (MACE > 17%)
Treat as ACS
Intermediate Risk (MACE 8%)
Observe for 6-12 hours investigate indoors
Low Risk (MACE 4%)
Observe for 4- 6 Hours investigate indoor/outdoors
Low Risk (MACE 1%)
Investigate Out doors (ETT, MScT angio)

38. Role of ETT in ACS
Asymptomatic low risk Patients
Adequate ETT
• Atleast 8 minutes
• > 85 % THR achieved
Negative ETT in males mean 85% probability that:-
• LMS
• Significant TVCAD are NOT present
Females 65%
Positive ETT has to be investigated further !

39. Role of MScT Angio
Low to intermediate risk
Triple rule out
• LMS
• TVCAD
• PE
Prerequisites
• Tolerant to B blockers
• Closed space
• Sinus rhythm (regular)

40. ACS Emergent Care
 M orphine
 O xygen
 N itro
 A ntiplatelets ( Disprin &
Clopidogril)
 G P IIb IIIA Inhibitors
 B eta Blockers

41. Post discharge Care
 ABCDE
A – Antiplatelets & Antianginals
B – Beta blocker, Blood pressure control
C – Cholesterol lowering, Cigarettes cessation
D – Diabetes control, Diet
E – Education & Exercise ( Life style modifications)