1. Approach to the patients with chest pain and their management Prof Dr. S. N. Ojha M.D Ph.D Principal Dr. D. Y. Patil Ayurvedic College Pune http://drojha.wordpress.com/ http://drojha.wordpress.com/

2. ACUTE MYOCARDIAL INFARCTION

3. Defination Defination AMI occurs when the blood supply to the part of hearth is interrupted. The resulting ischemia (restriction in blood supply) and oxygen shortage, If left untreated for a sufficient period, can cause and/or Death (Infarction) of heath muscle tissue (Myocardium) AMI occurs when the blood supply to the part of hearth is interrupted. The resulting ischemia (restriction in blood supply) and oxygen shortage, If left untreated for a sufficient period, can cause and/or Death (Infarction) of heath muscle tissue (Myocardium)

4. Magnitude of the problem Magnitude of the problem 32% Death in India attributed to cardio vascular disease compared to 12% due to respiratory infection, 9% due to diarrhoeal disease and 5% due to tuberculosis. 32% Death in India attributed to cardio vascular disease compared to 12% due to respiratory infection, 9% due to diarrhoeal disease and 5% due to tuberculosis. Prevalence is higher in south India. Prevalence is higher in south India. Urban India(3.45-9.45%) is affected more in comparison to rural India(2-4%) Urban India(3.45-9.45%) is affected more in comparison to rural India(2-4%)

5. Risk factor Risk factor Risk factor for atherosclerosis are generally risk factor for MI Risk factor for atherosclerosis are generally risk factor for MI -Old age -Old age -Male sex -Male sex -Hypercholestrolemia -Hypercholestrolemia -Tobacco smoking -Tobacco smoking -DM with or without insulin resistency) -DM with or without insulin resistency) -High BP -High BP -Obesity -Obesity -Stress -Stress -Hyperhomocysteinemia -Hyperhomocysteinemia -Women using OCP have increased risk of MI -Women using OCP have increased risk of MI -Periodontal disease may be linked to coronary heart disease -Periodontal disease may be linked to coronary heart disease

6. ECG Acute coronary syndrome ST- ElevationNo ST- Elevation CARDIAC MARKERUnstable angina - ve + ve Myocardial infarction STEMINSTEMI Non Q Wave MIQ Wave MI

7. SYMPTOMS SYMPTOMS -Chest Pain -Chest Pain -Levine’s sign ; Chest pain is localized by clenching fist over sternum. -Levine’s sign ; Chest pain is localized by clenching fist over sternum. -Dyspnoea -Dyspnoea -Diaphoresis -Diaphoresis -Weakness -Weakness -Light Headedness -Light Headedness -Nausea -Nausea -Vomiting -Vomiting -Palpitation -Palpitation -Loss of consciousness -Loss of consciousness -Sudden Death -Sudden Death *Most common symptoms of MI in Women include Dyspnoea, Weakness and Fatigue. *In DM, difference in Pain threshold, Autonomic neuropathy and psychological factors have been cited as possible explanation for silent MI. *Probably because the donor heart is not connected to nerves of the host MI in heart transplanted person is silent.

8. PHYSICAL EXAMINATION PHYSICAL EXAMINATION -General appearance may vary; the patient may be comfortable or restless and in severe distress with increased respiratory rate. -General appearance may vary; the patient may be comfortable or restless and in severe distress with increased respiratory rate. -Low grade Fever (38-39 degree celsius ) -Low grade Fever (38-39 degree celsius ) -BP maybe elevated or decreased. -BP maybe elevated or decreased. -Pulse can become irregular -Pulse can become irregular -If Heart failure ensues ; -If Heart failure ensues ; increased JVP hepatojugular reflux, increased JVP hepatojugular reflux, swelling legs due peripheral oedema. swelling legs due peripheral oedema. -Cardiac bulge with a pace different from pulse rhythm can be felt on precordial examination. -Cardiac bulge with a pace different from pulse rhythm can be felt on precordial examination.

9. -On auscultation – -On auscultation – -3 rd and 4 th heart sound. -3 rd and 4 th heart sound. - Systolic murmur - Systolic murmur - Paradoxical splitting of 2 nd heart sound - Paradoxical splitting of 2 nd heart sound - Precordial friction rub - Precordial friction rub - Rales over lung - Rales over lung

10. DIAGNOSIS DIAGNOSIS -History of present illness -History of present illness - Physical Examination - Physical Examination - ECG - ECG - Cardiac Marker CKMB- Troponin - Cardiac Marker CKMB- Troponin -Coronary angiogram -Coronary angiogram - Echo cardiogram - Echo cardiogram - Nuclear medicine (technetium 99m 2- methoxyisobutylisonitrite Or Thallium-201 Chloride) - Nuclear medicine (technetium 99m 2- methoxyisobutylisonitrite Or Thallium-201 Chloride)

11. Some features differentiating cardiac from Non-cardiac chest pain Favoring Ischaemic Origin Against Ischaemic origin 1.Character of Pain Constricting Dull ache Squeezing Knife Like,Sharp Burning stabbing,jabs Heaviness, heavy feeling Aggravated Respiration 2. Location of Pain SubsternalIn the left submamary area Across Mid Thorax,In the Left hemithroax Anteriorly In both arms, shoulders In the Neck, Cheeks, Teeths In the Forearms, Fingers In the interscapular region

12. Some features differentiating cardiac from Non-cardiac chest pain Favoring Ischaemic Origin Against Ischaemic origin 3. Factors Provoking Pain ExercisePain after completion of exercise ExcitementProvoked by a specific body motion Other forms of Stress Cold Weather After Meals

13. IndexDiseaseDurationQualityProvocationReliefLocation 1. Effort angina 5-15 mins Visceral/pressure type During effort or emotion Rest & Nitroglycerine Sternal & radiating 2. Rest Angina Or Unstable Angina 5-15 mins Visceral/pressure type SpontaneousNitroglycerine Substernal & radiating 3. Mitral Valve Prolapse Mins to Hours Superficial Spontaneous(No Pattern) Time Left Anterior 4.OesophagealReflux 10 mins- 1 hour Visceral Recumbency & Lack Of Food Food, Antacid Substernal Epigastric 5. Peptic Ulcer Hrs Visceral, Burning Type Lack Of Food, Acid Food Food Antacid Epigastric & Substernal 6.OesophagealSpasm5-60minsVisceral Spontaneous, Cold Liquids & Exercise Nitroglycerine Substernal & Radiating 7. Biliary Disease Hrs Visceral, Severe Spontaneous, Food- Fatty food Time & Analgesic Epigastric, Radiated To Rt. Scapular Tip 8. Cervical Disc Prolapse Variable (Gradually Subsides) Superficial Head & Neck Movements Time & Analgesic Neck & Arm(Radiculopath y) 9.Hyperventillation2-3minsvisceral Emotions & Tachypneoa Stimulus Removal Substernal 10.MusculoskeletalPainVariableSuperficial Movement & Palpation Time & Analgesic Multiple Sites 11. Pulmonary Causes 30 mins Visceral/Pressuret ype Often Spontaneous Rest,time & bronchodilatation Substernal

17. Wall Affected Leads Showing ST Segment Elevation Leads Showing Reciprocal ST Segment Depression Suspected Culprit Artery Septal V1, V2 None Left Anterior Descending (LAD) Anterior V3, V4 None Left Anterior Descending (LAD) Anteroseptal V1, V2, V3, V4 None Left Anterior Descending (LAD) Anterolateral V3, V4, V5, V6,I, aVL II, III, aVF Left Anterior Descending (LAD), Circumflex (LCX), or Obtuse Marginal Extensive Anterior (Sometimes called Anteroseptal with Lateral extension) V1, V2, V3, V4,V5, V6, I, aVL II, III, aVF Left main coronary artery (LCA)

18. Wall Affected Leads Showing ST Segment Elevation Leads Showing Reciprocal ST Segment Depression Suspected Culprit Artery Inferior II, III, aVF I, aVL Right Coronary Artery (RCA) or Circumflex (LCX) Lateral I, aVL, V5, V6 II, III, aVF Circumflex (LCX), or Obtuse Marginal Posterior (Usually associated with Inferior or Lateral but can be isolated) V7, V8, V9 V1, V2, V3, V4 Posterior Descending (PDA) (branch of the RCA or Circumflex (LCX) Right ventricular (Usually associated with Inferior) II, III, aVF, V1, V4R I, aVL Right Coronary Artery (RCA)

19. TREATMENT TREATMENT First aid First aid Aspirin Aspirin Nitrates Nitrates Automated external defibrillator Automated external defibrillator In case of cardiac arrest, CPR(cardio pulmonary resusitation) can be administered. In case of cardiac arrest, CPR(cardio pulmonary resusitation) can be administered.

20. First line First line Oxygen Oxygen Aspirin Aspirin Nitrates Nitrates Analgesia(morphine) Analgesia(morphine) Beta blocker Beta blocker Anti coagulant like heparin Anti coagulant like heparin Anti platelet agent like clopidogrel Anti platelet agent like clopidogrel

21. Reperfusion Reperfusion Thrombolytic therapy Thrombolytic therapy Percutaneous coronary intervention(PCI) Percutaneous coronary intervention(PCI) Bypass surgery Bypass surgery Monitoring Arrhythmias Monitoring Arrhythmias Anti arrhythmic prophylaxis Anti arrhythmic prophylaxis

22. Secondary prevention Secondary prevention Beta blocker Beta blocker ACE Inhibitor ACE Inhibitor Statin therapy Statin therapy Angiotensin receptor blocker Angiotensin receptor blocker Aldosterone antagonist Aldosterone antagonist Ca channel blocker Ca channel blocker Omega 3 fatty acids Omega 3 fatty acids

23. Rehabilitation Rehabilitation Physical exercise Physical exercise Smoking cessation Smoking cessation Restricted diet Restricted diet Limitations of alcohol intake Limitations of alcohol intake Can resume sexual activity after 3 to 4 weeks. Can resume sexual activity after 3 to 4 weeks.

24. Following drugs are used and found effective in vatika hridroga. Further scientific clinical trial is needful. 01)Drug acting on amasahit meda = Marich, Chitrak, Daruharidra, Rason, Tulasi, Vacha, Pushkarmul, Punarnava, Shuddha shilajeeta 02)Drug acting on rasvaha strotas = Amalaki, Haritaki, Punarnava, Shatavari, Marich & Shilajeet 03)Drug acting on vata dosh = Haritaki, Rason, Guggul, Pushkarmul, Amalaki, Punarnava, Marich, Shilajeet, Chitrak, Tulsi& Shatavari. 04)Medhya drug= Bramhi, Vacha, Shatavari, Haritaki. 05)Drugs dissolute grathit rakta= Kamalkshar, Darbha or Kusha or Paravatshakrut. 06)Hruddya= Arjun, Bramhi, Tulasi, Guggul, Punarnava, Rason & Shatavari. 07)Combination of drugs=Arjun, Vacha, Bramhi, Marich, Chitrak, Tulasi, Haritaki Amalaki, Daruharidra, Punarnava, Shatavari, Rason, Shuddhhashilajit- sambhag(equal part) + puskarmul-2-bhag(2-part) +shuddhha guggul-4-bhag(4-part) Matra= 1GM TDS Anupan= Udak(jal), Madhu.

25. Angina The English word angina refers to a painful constriction tightness somewhere in the body and may refer to : Angina pectoris Abdominal angina Ludwig’s angina Prinzmetal’s angina Vincent’s angina Angina tonsillaris

26. Angina pectoris, commonly known as angina, is severe chest pain due to ischemia (a lack of blood and hence oxygen supply) of heart muscle, generally due to obstruction or spasm of the coronary arteries. Angina pectoris, commonly known as angina, is severe chest pain due to ischemia (a lack of blood and hence oxygen supply) of heart muscle, generally due to obstruction or spasm of the coronary arteries. The term derives from the Greek ankhon (“Strangling”) and the Latin Pectus (“chest”), and can therefore be translated as “a strangling feeling in the chest.” The term derives from the Greek ankhon (“Strangling”) and the Latin Pectus (“chest”), and can therefore be translated as “a strangling feeling in the chest.”

27. Symptoms Symptoms Chest discomfort Chest discomfort the discomfort is usually described as a pressure, heaviness, tightness, squeezing, burning, or choking sensation., the discomfort is usually described as a pressure, heaviness, tightness, squeezing, burning, or choking sensation., anginal pains may also be experienced in the epigastrium,back, neck, jaw, or shoulders, following skin dermatomes. anginal pains may also be experienced in the epigastrium,back, neck, jaw, or shoulders, following skin dermatomes. It is typically precipitated by exertion or emotional stress. It is typically precipitated by exertion or emotional stress. It is exacerbated by having a full stomach and by cold temperatures. It is exacerbated by having a full stomach and by cold temperatures. Pain may be accompanied by breathlessness, sweating and nausea. Pain may be accompanied by breathlessness, sweating and nausea. It lasts for about 3 to 5 minutes, and is relieved by rest or specific anti-angina medication. It lasts for about 3 to 5 minutes, and is relieved by rest or specific anti-angina medication.

28. Risk Factors Risk Factors cigarette smoking, cigarette smoking, diabetes, diabetes, high cholesterol, high cholesterol, high blood pressure, high blood pressure, sedentary lifestyle and sedentary lifestyle and family history family history

29. Coronary Atherosclerosis Thrombosis Narrowing Of coronary Myocardial Ischaemia Chest Pain I.H.D. Pathophysiology Pathophysiology

30. Subtypes Subtypes Stable angina is typically presented as chest discomfort and associated symptoms precipitated by some activity (running, walking etc.) with minimal or non-existent symptoms at rest. Stable angina is typically presented as chest discomfort and associated symptoms precipitated by some activity (running, walking etc.) with minimal or non-existent symptoms at rest. Unstable Angina Unstable Angina It occurs at rest (or with minimal exertion), usually lasting > 10 min; It occurs at rest (or with minimal exertion), usually lasting > 10 min; it is severe and of new onset (i.e., within the prior 4-6 weeks); it is severe and of new onset (i.e., within the prior 4-6 weeks); it occurs with a crescendo pattern (i.e., distinctly more severe, prolonged, or frequent than previously ). it occurs with a crescendo pattern (i.e., distinctly more severe, prolonged, or frequent than previously ).

31. Diagnosis Diagnosis Electrocardiogram (ECG) Electrocardiogram (ECG) Exercise ECG Test (“Treadmill Test”) Exercise ECG Test (“Treadmill Test”) Thallium Scintigram Thallium Scintigram Stress Echocardiography Stress Echocardiography Coronary Angiogram Coronary Angiogram

33. Treatment Treatment Aspirin (75 mg. to 100 mg.) Aspirin (75 mg. to 100 mg.) Beta blockers (eg. Carvedilol, propranolol, atenolol etc.) Beta blockers (eg. Carvedilol, propranolol, atenolol etc.) Short-Acting nitroglycerin Short-Acting nitroglycerin Calcium Channel Blockers (Nifedipine & amlodipine) Calcium Channel Blockers (Nifedipine & amlodipine) Isosorbide mononitrate & Isosorbide mononitrate & Nicorandil Nicorandil If inhibitor- Ivabradine provides pure hear rate reduction If inhibitor- Ivabradine provides pure hear rate reduction ACE inhibitors are also vasodilators. ACE inhibitors are also vasodilators. Statins are the most frequently used lipid / cholesterol modifiers Statins are the most frequently used lipid / cholesterol modifiers Exercise is also a very good long term treatment. Exercise is also a very good long term treatment.

34. Ludwig’s angina (angina ludovici) is a serious potentially life-threatening cellulitis infection of the tissues of the floor of the mouth, usually occurring in adults with concomitant dental infections. Ludwig’s angina (angina ludovici) is a serious potentially life-threatening cellulitis infection of the tissues of the floor of the mouth, usually occurring in adults with concomitant dental infections. Cause Cause is usually a bacterial infection.

35. Symptoms Symptoms swelling, swelling, pain on raising of the tongue, pain on raising of the tongue, swelling of the neck and the tissues of the submandibular and sublingual spaces, swelling of the neck and the tissues of the submandibular and sublingual spaces, malaise, malaise, fever, fever, dysphagia dysphagia in severe cases, stridor in severe cases, stridor Signs Signs patient not being able to swallow his / her own saliva patient not being able to swallow his / her own saliva audible stridor as these strongly suggest that airway compromise is imminent. audible stridor as these strongly suggest that airway compromise is imminent.

36. Treatment Treatment Antibiotic medications, Antibiotic medications, Monitoring and protection of the airway in severe cases, Monitoring and protection of the airway in severe cases, and where appropriate, urgent maxillo-facial surgery and where appropriate, urgent maxillo-facial surgery dental consultation to incise and drain the collections. dental consultation to incise and drain the collections.

37. Abdominal angina (a.k.a. bowelgina) Abdominal angina (a.k.a. bowelgina) is postprandial abdominal pain that occurs in individuals with insufficient blood flow to meet mesenteric visceral demands. is postprandial abdominal pain that occurs in individuals with insufficient blood flow to meet mesenteric visceral demands. Pathophysiology Pathophysiology The most common cause of bowelgina is atherosclerotic vascular disease. The most common cause of bowelgina is atherosclerotic vascular disease. It can be associated with : It can be associated with : Carcinoid Carcinoid Aortic coarctation Aortic coarctation Antiphospholipid syndrome Antiphospholipid syndrome

38. Clinical Clinical Disabling midepigastric or central abdominal pain within 10-15 minutes after eating. Disabling midepigastric or central abdominal pain within 10-15 minutes after eating. Physical examination : Physical examination : The abdomen typically is scaphoid and soft, The abdomen typically is scaphoid and soft,. weight loss signs of peripheral vascular disease, signs of peripheral vascular disease, Causes: Causes: Smoking is an associated risk factor. Smoking is an associated risk factor. Treatment Treatment Stents have been used in the treatment of abdominal angina. Stents have been used in the treatment of abdominal angina.

39. Prinzemtal’s angina( variant angina or angina inversa,) is a syndrome typically consisting of angina (cardiac chest pain) at rest that occurs in cycles. Prinzemtal’s angina( variant angina or angina inversa,) is a syndrome typically consisting of angina (cardiac chest pain) at rest that occurs in cycles. Cause by vasospasm, a narrowing of the coronary arteries caused by contraction of the smooth muscle tissue in the vessel walls rather than directly by atherosclerosis Cause by vasospasm, a narrowing of the coronary arteries caused by contraction of the smooth muscle tissue in the vessel walls rather than directly by atherosclerosis Features Features Symptoms typically occur at rest, rather than on exertion (attacks usually occur at night). Symptoms typically occur at rest, rather than on exertion (attacks usually occur at night).

40. Diagnosis Diagnosis Patients who develop cardiac chest pain are generally treated empirically as an “acute coronary syndrome”, and are generally tested for cardiac enzymes such as creatine kinase isoenzymes or troponin l or T. These may show a degree of positivity, as coronary spasm too can cause myocardial damage. Echocardiography or thallium scintigraphy is often performed. Patients who develop cardiac chest pain are generally treated empirically as an “acute coronary syndrome”, and are generally tested for cardiac enzymes such as creatine kinase isoenzymes or troponin l or T. These may show a degree of positivity, as coronary spasm too can cause myocardial damage. Echocardiography or thallium scintigraphy is often performed. The gold standard is coronary angiography. The gold standard is coronary angiography. ECG finding will more often show ST segment elevation than ST depression. ECG finding will more often show ST segment elevation than ST depression.

42. Treatment Prinzmetal angina typically responds to nitrates and dihydrophyridine calcium channel blockers. Prinzmetal angina typically responds to nitrates and dihydrophyridine calcium channel blockers.

43. Acute necrotizing ulcerative gingivitis Acute necrotizing ulcerative gingivitis Polymicrobial infection of the gums leading to inflammation, bleeding, deep ulceration and necrotic gum tissue. Polymicrobial infection of the gums leading to inflammation, bleeding, deep ulceration and necrotic gum tissue. Symptoms – Symptoms – fever and halitosis. fever and halitosis. Causes Causes Anaerobes such as Bacteroides and Fusobacterium a Anaerobes such as Bacteroides and Fusobacterium a Treatment Treatment Oral cleaning and salt water or hydrogen peroxide-based rinses. Oral cleaning and salt water or hydrogen peroxide-based rinses. Chlorhexidine or metronidazole Chlorhexidine or metronidazole Penicillin is also indicated at 250 mg. every 6 to 8 hours. Penicillin is also indicated at 250 mg. every 6 to 8 hours. Dental care. Dental care.

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