1. CHEST PAIN Belgian Inter disciplinary Working group of Acute Cardiology Claeys MJ Vandekerckhove Y Bossaert L Calle P Martens P Hollanders G Vrints C Van de Werf F Renard M De Raedt H De Meester A De Smedt J...

2. Thoracic pain aneurysm dissecans Acute coronary syndrome AMI / angina pectoris pneumothorax pericarditis, pleuritis gastric ulcer, oesofagitis pulmonary embolism hyperventilation

3. AMI - Prognosis 28 d. Case Fatality MENWOMEN WHO- MONICA 1985-1990 49% (35-60%) 51% (34-70%)

4. Case-Fatality in Ghent during 1983-1999 in men 25-69 years Year Case-Fatality Rate (%) Prof. G. De Backer, Ghent

5. AMI- case fatality PRE - HOSPITALIN - HOSPITAL Sudden death arrhytmia VF cardiac failure no/late reperfusion !!!!! T I M E = L I F E !!!!!!

7. Prevention - AMI Case Fatality PRE - HOSPITALIN - HOSPITAL Sudden death cardiac failure NO DELAY VF recognition VF treatment Reperfusion Therapy

8. HOME TEL 100 GP AMBULANCE HOSPITAL COMPLETE DIAGNOSIS EMERGENCY DEPT. FAST TRACK DIAGNOSTIC STAIRCASE

9. Chest pain and the patient When should I seek medical help ? Who should I contact?

10. Early recognition of Alarming symptoms !!! Duration > 20 min and/or recurrent attack >1x/u

11. !!!! MEDICAL URGENCY !!!! Call General Physician Call “100” OR

12. Risk stratification (by call): History of cardiac disease and/or Associated symptoms : dyspnoe, fainting, nausea, diaphoresis and / or age (>40 y) High risk Call Medical transport emergency system (MUG - SMUR) No-High risk Call standard transport emergency system Unless overruled by GP

13. Management high risk patient 1. Check vital signs 2. Establish ECG monitoring + defibrillator 3. Give oxygen (3-5 lit/min) 4. Establish IV access 5*. Take 12-lead ECG * only in the presence of authorized medical doctor 6*. Give short acting nitrate sublingual 7*. Give acetylsalicylic acid 150-300 mg po / IV 8*. Give Opioid analgesic (e.g. morfine 1-4mg IV) 9*. Consider pre-hospital thrombolysis if ST elevation AMI and time to hospital > 30 min

14. MUG/SMUR Where to transport ??? Majority of patients hospital with coronary care unit/ intensive cardiac care unit Cardiogenic shock hospital with 24-hour facilities coronary intervention

15. Early-in-hospital Management 1. Check vital signs 2. Establish ECG monitoring + defibrillator 3. Give oxygen (3-5 lit/min) 4. Establish IV access 5. Take 12-lead ECG 6. Obtain serum cardiac markers 7. Cardiological assessment: ST elevation AMI ACS without ST elevation ACS doubtful or non cardiac pathology < 3‘ < 10‘ < 20‘

16. ST- Elevation AMI 1. Check intake ASA / nitrates SL 2. Give Beta blockers 3. Initiate Reperfusion therapy ThrombolysePTCA

17. Primaire PTCA and hospital time N =104 n = 109 n = 76 n = 14O % mort. Berger et al, Circulation, 1999 (Gusto II substudy)

18. ST-elevation AMI: reperfusion therapy Thrombolytic therapy !! door to drug time < 30’!! Direct PTCA !! door to ballon time < 90  30’!! OR Depending on hospital facilities BUT: refer for primary PTCA if - cardiogenic shock or - contra-indication for thrombolysis.

19. Acute coronary syndrome without ST elevation 1. Check intake ASA 2. Check intake nitrates SL 3. Start heparin (LMWH sc or unfractionated IV) 4. Start nitrate IV (if bloodpressure > 100 mmHg) 5. Start Beta-Blockers Consider II b/ III a blockers and invasive evaluation in patients at high risk for thrombotic events (recurrent or ongoing ischemia, troponin +)

20. Chest pain without immediate diagnosis Cardiac pathology Angina, pericarditis, infarction serial cardiac markers ST segment monitoring echocardiography stress stest Non-Cardiac pathology Pulmonary embolism pneumothorax aneruysmam dissecans gastric ulcer. Oesofagitis hyperventilation. CHEST PAIN CLINIC