1. APPROACH TO THE PATIENT WITH CHEST PAIN YEDITEPE UNIVERSITY FACULTY OF MEDICINE PHASE 4 CARDIOLOGY COURSE 2014-2015 PROF. MUZAFFER DEGERTEKIN, M.D., PhD. MUSTAFA AYTEK SIMSEK, M.D., Attending Physician

2. A PPROACH TO THE P ATIENT WITH C HEST P AIN CAUSES OF ACUTE CHEST PAIN DIAGNOSTIC CONSIDERATIONS IMMEDIATE MANAGEMENT

4. ACUTE CHEST PAIN Acute chest pain is one of the most common reasons for presentation to the emergency department 15% to 25% of patients with acute chest pain actually have ACS The diagnosis of ACS is missed in approximately 2% of patients Mortality for patients with acute myocardial infarction (MI) who are mistakenly discharged from the ED increases twofold

5. CAUSES OF ACUTE CHEST PAIN Myocardial Ischemia or Infarction, Pericardial Disease, Vascular Disease, Pulmonary Conditions, Gastrointestinal Conditions, Musculoskeletal and Other Causes,

7. M YOCARDIAL I SCHEMIA OR I NFARCTION The most common serious cause of acute chest discomfort Supply of myocardial oxygen is inadequate compared with the demand Usually occurs in the setting of coronary atherosclerosis

8. M YOCARDIAL I SCHEMIA OR I NFARCTION O THER LESS COMMON CAUSES Coronary spasm Coronary arteritis, Proximal aortitis, Spontaneous coronary dissection, Proximal aortic dissection, Coronary emboli from infectious or noninfectious endocarditis,thrombus in the left atrium or left ventricle, Myocardial bridge, Congenital abnormality of the coronary arteries

9. M YOCARDIAL I SCHEMIA OR I NFARCTION Classic manifestation of ischemia is angina, which is usually described as a heavy chest pressure or squeezing, a burning feeling, or difficulty breathing The discomfort often radiates to the left shoulder, neck, or arm. It typically builds in intensity over a period of a few minutes. The pain may begin with exercise or psychological stress, but ACS most commonly occurs without obvious precipitating factors

10. N OT CHARACTERISTIC OF MYOCARDIAL ISCHEMIA Pleuritic pain (i.e., sharp or knifelike pain brought on by respiratory movements or cough) Primary or sole location of discomfort in the middle or lower abdominal region Pain that may be localized at the tip of one finger, particularly over the left ventricular apex Pain reproduced with movement or palpation of the chest wall or arms Constant pain that persists for many hours Very brief episodes of pain that last a few seconds or less Pain that radiates into the lower extremities

11. P ERICARDIAL D ISEASE The visceral surface of the pericardium is insensitive to pain, as is most of the parietal surface (Therefore, noninfectious causes of pericarditis usually cause little or no pain. In contrast, infectious pericarditis almost always involves surrounding pleura ) Pleuritic pain with breathing, coughing, and changes in position (Because the central diaphragm receives its sensory supply from the phrenic nerve, and the phrenic nerve arises from the third to fifth cervical segments of the spinal cord, pain from infectious pericarditis is frequently felt in the shoulders and neck) Involvement of the more lateral diaphragm can lead to symptoms in the upper abdomen and back (confusion with pancreatitis or cholecystitis)

12. V ASCULAR D ISEASE A CUTE AORTIC DISSECTION The sudden onset of excruciating ripping pain The location of which reflects the site and progression of the dissection (Ascending aortic dissections tend to manifest with pain in the midline of the anterior chest, and posterior descending aortic dissections tend to manifest with pain in the back of the chest).

13. P ULMONARY C ONDITIONS Dyspnea and pleuritic symptoms The location of which reflects the site of pulmonary disease Pneumothorax. sudden in onset and is usually accompanied by dyspnea Tracheobronchitis…burning midline pain Pneumonia..pain over the involved lung

14. G ASTROINTESTINAL C ONDITIONS Irritation of the esophagus by acid reflux can produce a burning discomfort that is exacerbated by alcohol, aspirin, and some foods Mallory-Weiss tears of the esophagus prolonged vomiting episodes Cholecystitis right upper quadrant abdominal pain Pancreatitis aching epigastric pain

15. M USCULOSKELETAL AND O THER C AUSES Costochondritis Cervical disc disease, Herpes zoster Heavy exercise affecting the nerves of the chest wall

16. P ANIC SYNDROME Major cause of chest discomfort in ED Chest tightness Shortness of breath a sense of anxiety

17. I NITIAL A SSESSMENT Evaluation of the patient with acute chest pain Hemodynamic instability A 12-lead electrocardiogram (ECG)

18. I NITIAL A SSESSMENT History Physical Examination Electrocardiography Chest Radiography Biomarkers

20. I NITIAL A PPROACH : H ISTORY Are you having discomfort? How would you describe the discomfort? Where is the discomfort? Does it radiate anywhere? Any aggravating/alleviating factors? Any associated discomfort? Diaphoresis, nausea, vomiting, cough, fevers 20

21. I NITIAL A PPROACH : H ISTORY Frequency of the discomfort? Time of onset or acute worsening? Has there been any progression? History of Cardiopulmonary disease? Risk factors for cardiopulmonary disease? Family history of cardiopulmonary disease? 21

22. P HYSICAL E XAMINATION Vital signs, Examination of the peripheral vessels Bruits or absent pulses Identify potential precipitating causes Uncontrolled hypertension, anemia, hyperthriodism Important comorbid conditions Chronic obstructive pulmonary disease Evidence of hemodynamic complications Congestive heart failure, New mitral regurgitation, hypotension

23. E LECTROCARDIOGRAPHY 10 minutes after presentation New persistent or transient ST-segment abnormalities (≥0.1 mV) and T inversion (≥0.2 mV) During a symptomatic episode at rest and resolve

24. C HEST R ADIOGRAPHY Usually non-diagnostic Pulmonary edema (ischemia-induced diastolic or systolic dysfunction) Pneumothorax, Pneumonia

25. B IOMARKERS A cardiac troponins (T or I; cTnT or cTnI) Creatine kinase MB isoenzyme (CK-MB, less sensitive)

27. T ROPONINS Blood should be obtained for testing at hospital presentation, and at 6 to 9 hours A normal reference values 0.01 to 0.07 ng/ml Ultrasensitive assays <0.001 ng/ml or <1 pg/ml Serial sampling up to 12 hours after presentation %90 to %95 3 hours of the onset of chest pain 80% to 85%

28. C REATINE K INASE MB I SOENZYME LACK OF SPECIFICITY Found in Skeletal muscle, Tongue, Diaphragm, Small intestine, uterus, and prostate Eleveted Muscular dystrophy High-performance athletics Rhabdomyolysis Alcohol abuse or trauma vs Shorter half-life Useful for gauging the timing of an MI Diagnosing reinfarction

29. O THER M ARKERS Serum myoglobin heart-type fatty acid binding protein C-reactive protein serum amyloid A, myeloperoxidase interleukin-6 D-dimer B-type natriuretic peptides

30. O THER M ARKERS  hs-C-reactive protein (prognostic)  D-dimer (PE)  B-type natriuretic peptide (HF, prognostic)

31. A CUTE C ORONARY S YNDROME L IKELIHOOD T HAT S IGNS AND S YMPTOMS

32. NSTEMI Presentation Working Dx ECG Cardiac Biomarker Final Dx NQMIQw MI UA Unstable Angina Ischemic Discomfort Acute Coronary Syndrome Myocardial Infarction ST Elevation No ST Elevation Non-ST ACS Libby P. Circulation 2001;104:365, Hamm CW, Bertrand M, Braunwald E, Lancet 2001; 358:1533-1538; Davies MJ. Heart 2000; 83:361- 366. Anderson JL, et al. J Am Coll Cardiol. 2007;50:e1-e157, Figure 1. Reprinted with permission.