1. An introduction to Chest pain ‘how to mend a broken heart’

2. Case 1 55 year old accountant Stressed in a meeting at work Sudden onset chest pain

3. Crushing chest pain…

4. ECG

5. Coronary artery thrombus

6. Immediate treatment Oxygen Analgesia Aspirin Thrombolysis ‘clot busting drugs’ Primary angioplasty ‘hot wiring’

7. Another Case Reg G 61 year old retired suffolk farmer Osteoarthritis hip Undergoes total hip replace (THR)

10. 4 days post-op Initially making good recovery Sudden onset SOB and sharp ‘stabbing’ chest pain on commode in the evening O 2 sats 89% on air Pulse 130 bpm irregularly irregular

11. What may have happened?

12. Immediate investigations

13. ECG

14. Immediate management

15. D-Dimer Specific degradation product released into circulation when cross-linked fibrin undergoes endogenous fibrinolysis Low D-dimer has high negative predictive value Non-specific elevation in sepsis, pregnancy, MI and post surgery

16. CXR

17. Imaging CXR – to exclude other causes CTPA –CT chest –Give iv iodine and time to fill pulmonary arteries –Arm vein -> RA -> RV -> PA Contrast can –Cause allergic reaction –Damage kidneys

18. What are we looking for?

19. Imaging – Pulmonary angiogram

21. Treatment

22. Oxygen to correct hypoxia LMWH – dose according to weight Commence warfarin loading 6 months treatment with warfarin

23. What would you warn Reg about the risks of treatment?

24. Case 3 – Mr AL 21 year old man Known Marfan’s disease Previous aortic valve replacement Acutely SOB R-sided chest pain

25. Examination findings In pain and distressed RR 30 / min Oxygen saturation 85% on air Hyper-resonant over R lung field Increased SOB

26. Radiology Right lung: –Black –No markings –No mediastinal shift Sternal wires Heart valve Pleura

27. Treatment

28. Further radiology – post chest drain Pleura

29. What does the future hold Must not scuba dive High chance of recurrence if at increased altitude – no flying for at least 1/12 Chance of recurrent pneumothorax high

30. Any questions?