1. Chest Pain On The Acute Medical Take Acute Block UHCW September 25 th 2014 Dr. Adam Iqbal Clinical Teaching Fellow UHCW NHS Trust

2. Objectives By the end of this session you should be able to: List the common and serious causes of chest pain presenting to the acute medical take Recognise the clinical features of (interactive discussion): –Acute coronary syndrome, aortic dissection, pericarditis –Pulmonary embolism, pneumothorax –Exacerbation of COPD & acute asthma Recognise radiological features of: –Pericardial effusion –Pneumothorax –Pulmonary embolism Discuss management of acute coronary syndromes (didactic teaching)

3. Clinical Assessment A B C D E 1. IDENTIFY problem 2. CORRECT abnormalities …then PROCEED History: –SQITAS –Problem solving –PMHx –DA –SHx, FHx Which system? Cardiac Respiratory Musculoskeletal Gastrointestinal Neurological

4. Clinical Features of ACS … HISTORY CLINICAL EXAMINATION

5. Clinical Features of ACS … HISTORY Sudden onset central chest pain “Squeezing, tight, crushing, pressure, dull ache” Radiation – neck, jaw, arms Typically severe (subjective!) Precipitated by exertion, relieved by rest (but beware unstable disease) Sweaty, nauseous, collapse DM, smoker, IHD, male, age, FHx, alcohol, HTN, PVD, renal failure (Beware atypical presentation in women, DM, elderly) CLINICAL EXAMINATION Usually normal unless complications May be some evidence of risk factors: PVD (i.e. bypasses, tissue loss), DM (fingerprick), tar staining, hypertensive changes (retinal, bruits), arcus

6. Clinical Features of Aortic Dissection HISTORY CLINICAL EXAMINATION

7. Clinical Features of Aortic Dissection HISTORY Sudden onset severe central chest pain “Tearing” Radiation – arms, back May ‘migrate’ Neurological symptoms Autoimmune rheumatic disorders, Ehlers-Danlos, Marfan’s, HTN, trauma, recent instrumentation of aorta CLINICAL EXAMINATION Tachycardic, raised BP Brachial pulse discrepancy Proximal extension: murmur (AR), cardiac tamponade/ischaemia Distal extension: renal failure, visceral, limb, or spinal ischaemia

8. Clinical Features of Pericarditis HISTORY CLINICAL EXAMINATION

9. Clinical Features of Pericarditis HISTORY Sharp central chest pain Worsened by movement, breathing, and lying down (relieved by sitting forwards) Hx of recent cardiothoracic insult (surgery, radiotx, trauma) or MI (AMI, Dressler’s) Recent viral, bacterial, tuberculous illness CLINICAL EXAMINATION Pericardial rub Features of pericardial effusion Haemodynamic compromise Features of acute heart failure (myocarditis or constrictive pericarditis)

14. Clinical Features of Pulmonary Embolism HISTORY CLINICAL EXAMINATION PEs can be small, massive, or multiple

15. Clinical Features of Pulmonary Embolism HISTORY Dyspnoea (chronic or sudden onset) Chest pain (+/- pleuritic) Cough (+/- haemoptysis) Risk factors: prev VTE, smoker, pregnancy, immobility, recent surgery, dehydrated, FHx VTE, drugs, OCP CLINICAL EXAMINATION Tachypnoea, tachycardia Raised JVP, hypotension Features of pulm HTN Minimal chest signs Peripheral DVT PEs can be small, massive, or multiple

20. Clinical Features of Pneumothorax HISTORY CLINICAL EXAMINATION

21. Clinical Features of Pneumothorax HISTORY Sudden onset unilateral pleuritic chest pain or progressively increasing breathlessness Cough Young male (M:F ratio 6:1), tall, COPD, asthma, ca lung, suppurative lung disease, instrumentation (!!) CLINICAL EXAMINATION Tachypnoea, desaturation Haemodynamic compromise if tension Reduced expansion, tympanic PN Mediastinal shift

26. Clinical Features of COPD Exacerbation HISTORY CLINICAL EXAMINATION

27. Clinical Features of COPD Exacerbation HISTORY Cough, Phlegm, Fever Chest pain (tightness, sharp/pleuritic) SOB, wheeze Smoker, known obstructive spirometry, under resp physician, frequent exacerbations CLINICAL EXAMINATION Tar staining, CO2 flap, tachypnoea, tachycardia, cyanosis, hyperexpanded chest, accessory muscle use, resonant PN, crackles, bronchial sounds, wheeze, prolonged expiratory phase

28. Clinical Features of Acute Asthma HISTORYCLINICAL EXAMINATION

29. Clinical Features of Acute Asthma HISTORY SOB Cough Wheeze Phlegm (Diurnal variation, triggers) Hx of atopy DA: beta-blockers, NSAIDs CLINICAL EXAMINATION Tachypnoea, tachycardia Widespread wheeze Accessory muscle use Desaturation, cyanosis, see-sawing

30. Acute Coronary Syndrome Make the diagnosis ! Manage cause / condition / complications ACS Angina UANSTEMI STEMI

31. Pathophysiology

34. 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

35. NSTEMISTEMI Troponin +ve ± ECG changes (ST depression/ T wave inversion) Troponin +ve ST elevation –2mm in 2 consecutive chest leads –1mm in 2 limb leads New onset LBBB

39. Acute Management of ACS A-E assessment (ECG vital) Identify Problem > Correct > Reassess > Proceed Monitoring (!!) UA / NSTEMI –Aspirin 300mg, Clopidogrel 300mg, Clexane 1mg/kg SC BD STEMI –2222 (!!) –Aspirin 300mg, Ticagrelor 180mg Manage symptoms / complications –Beta-blockers prevent arrhythmias (!!) –GTN (SL or infusion) –Analgesia (diamorphine 2.5-10mg IV) & Antiemetic (metoclopramide 10mg IV) –Careful clinical assessment (arrhythmias, heart failure, RVF etc) –Oxygen ONLY IF HYPOXIC

40. ABSOLUTE CONTRAINDICATIONS Active bleeding or GI bleed < 4/52 Suspected aortic dissection Surgery/Trauma/Head injury < 2/52 Recent non-embolic stroke <6/12 RELATIVE CONTRAINDICATIONS HTN Prolonged CPR (>5min) Pregnancy Therapeutic anticoagulation Retinopathy

41. Investigations Electrocardiogram – serial Blood tests –Full Blood Count / U&E –Lipid Profile / BMs –Clotting screen –Troponin (in this trust 3hrs & 6hrs) Chest radiograph Echocardiogram (LV function) Coronary angiogram > PCI Myocardial perfusion scan

42. Post Event management Lifestyle & risk factor modification –Smoking cessation –Dietary changes –Exercise –Diabetes & dyslipidaemia –HTN Secondary prevention –ACE-I –Beta-Blocker –Statins –Dual anti-platelet therapy for 1yr, aspirin for life Cardiac rehabilitation Clinic follow up & repeat echocardiography

43. Summary Chest pain is the single most common presenting complaint on the acute take Know how to recognise the serious (& rare!) Reassure the patient Bear in mind causes not discussed here i.e. GI Apply your clinical reasoning (as opposed to questioning by rote) & you will recognise what you have never seen Be thorough, systematic, logical and … keep an open mind!