Chest Pain Dr. Shamim Nassrally BSc (Hons) MB ChB MRCP(UK) Clinical Teaching Fellow

Objectives By the end of this session you should be able to: Recognise Acute Coronary Syndrome (ACS) Initiate appropriate investigation and management of ACS Be able to calculate and interpret TIMI scores Recognise Acute Myocardial Infarction and use appropriate investigation to confirm the diagnosis

Chest pain SOCRATES Identify most likely system involved Cardiac Pulmonary Gastrointestinal Musculoskeletal Neurological (Psychiatry)

Chest pain SOCRATES Identify most likely system involved Cardiac Pulmonary Gastrointestinal Musculoskeletal Neurological (Psychiatry)

Cardiac Chest pain Coronary Artery disease (CAD) Ischaemic Heart disease (IHD) Atherosclerotic Heart Disease Essentially plaques made of cholesterol and calcium build up in the coronary arteries reducing cardiac muscle perfusion Synonyms

Pathophysiology

Terminology ACS Angina UA NSTEMI STEMI

Angina Unstable Angina Exertional Relieved by rest ± ECG changes ( ST depression, T wave inversion) Troponin negative Can occur at rest Crescendo ± ECG changes ( ST depression, T wave inversion) Troponin negative

NSTEMI STEMI Troponin +ve ± ECG changes (ST depression/ T wave inversion) Troponin +ve ST elevation New onset LBBB

Cardiac Chest Pain (typical) Site : Onset: Character: Radiation: Associated Features: Timing: Exacerbating & Relieving Factors: Severity:

Cardiac Chest Pain (typical) Site : Retrosternal Onset: Sudden, Crescendo, Exertional Character: Dull, Squeezing, Tightness Radiation: Throat/Jaw, Shoulder Associated Features: Dyspnoea, Autonomic Sx Timing: Exertion, Meals, Rest. Duration Exacerbating & Relieving Factors: Exertion/Rest Severity: Subjective – but usually severe

Common risk factors ?

Common risk factors Hypertension Hypercholesterolaemia / Dyslipidaemia Diabetes Mellitus Smoking Age Male Family History of early CAD Obesity/ Physical Inactivity

Examination

Examination Unremarkable physical examination Obesity Cholesterol deposits: arcus, xanthoma, xanthelasma Tar stains, nicotine stains Signs of peripheral vascular disease Acute LVF, New murmur of MR or VSD Cardiogenic shock

Investigations ?

Investigations Electrocardiogram!! Blood tests Chest radiograph Full Blood Count Urea and Electrolytes Lipid Profile Clotting screen Blood sugar Troponin* Chest radiograph Why a,d what are we looking for on these investigations

Anterior lateral MI (ECG A)

STEMI. (ECG S) 2

Investigations (2) Transthoracic echocardiography (Handheld/Portable/Departmental) Exercise tolerance test Stress echocardiography Coronary angiography Further cardiac imaging – Cardiac CT/MR Dependant on possible diagnoses

Troponins

Troponin

Troponin Proteins released into the blood stream following muscle injury Different isomers of troponin Troponin T and I are specific for cardiac muscle More specific than CK Levels start to rise after muscle damage but only peak after 12 hours

Troponin

Management : ACS STEMI NSTEMI / UA Angina

Management : STEMI ? NB: 2/3 criteria New onset LBBB ST elevation of 2mm in 2 contiguous chest leads or 1mm in 2 limb leads Chest pain

Management : STEMI Primary percutaneous angioplasty ABC approach Analgesia: opioid based (Morphine 10mg IV) Oxygen: 15L via NRM Aspirin 300mg PO stat Clopidogrel 600mg PO stat Primary percutaneous angioplasty

Thrombolysis Use of clotbusting agents such as streptokinase or tissue plasminogen activators such as alteplase Now superceded by primary PCI Only for Acute myocardial Infarction with 1-3 hours of event Used if not possible to get access to percutaneous angioplasty

Management : NSTEMI ?

Management : NSTEMI / UA ABC approach Analgesia: opioid based Oxygen: 15L via NRM Aspirin 300mg PO stat Clopidogrel 300mg PO stat LMWH e.g. 1mg/kg Enoxaparin BD SC GTN infusion for pain Percutaneous angiography (with 48hours) ± angioplasty/ coronary bypass

TIMI risk score

TIMI risk score

Post Event management Lifestyle modification Secondary prevention Smoking cessation Dietary changes Secondary prevention ACE-I Beta-Blocker Statins Cardiac rehabilitation Risk of further events and associated morbidity e.g. arrhythmias and heart failure

Angina Managed as OP, initially medically Anti-platelets, anti-anginals, risk factor/ lifestyle modification May require bypass surgery or angioplasty

Summary ACS is a spectrum from Angina to STEMI UA/NSTEMI managed differently to STEMI TIMI risk score predicts outcome Use the ABCD approach Perform the initial Ix and Rx Ask for help early, inform the Cardiologists early Primary angioplasty has revolutionised the area Don’t forget post MI management

Questions?