05 patient with acute thoracic pain

8/7/2019 05 Patient With Acute Thoracic Pain

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ACUTE THORACIC PAIN

2004-2005


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CLASSIFICATION

A. Pain of cardiac origin

1. Coronary artery disease

2. Acute aortic dissection

3. Pulmonary embolism

4. Acute pericarditisB. Mediastinal pain

C. Retrosternal pain of digestive origin

D. Thoracic pain

1. pleuro-pulmonary

2. rheumatic

3. neuromuscular

4. abdominal

5. psychosomatic


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1.

ANGINA

A. ANGINA with NORMAL ECG

anginal pain

positive family history

CV RFother factors: anxiety, spasm, oesophagus

reflux, peptic ulcer, acute pancreatitis


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B. RECENT ANGINA + ECG CHANGES:

ST elev./ depression > 0,5 mm

T wave inverted

ACUTE CORONARY SYNDROME

UNSTABLE ANGINA

MI with ST depression (non Q ?)

MI with ST elevation (transmural ?)


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C. PROLONGED ANGINA > 20 min

D. RESTING ANGINA + ST CHANGES

E. ANGINA + MITRAL REGURGITATION(recent or aggravated)

F. X SYNDROME


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F. X Coronary Syndrome

effort angina

ET +normal coronarography

stress ECHO: contractility alterations


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CLINICTYPICAL ANGINA NON-TYPICAL ANGINA

1. RETROSTERNAL PAIN

2. TRIGGER

effort

emotional stress

3.VANISH

at restNTG

Coronary pain has 2 of 3 features

Non-coronary pain has 1 or none of the 3 features


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ISCHEMIC CASCADE

flow alteration. flow visualising

metabolic alteration PET

diastolic dysfunction ECO Doppler

kinetics ECO de stress

Ions channels changes ECG

sympathetic activation ANGINA (clinic)

MYOCARDIAL NECROSIS


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Clinical caseM.A. 72 years (M)

Symptoms for 3 weeks:

Non-typical angina epigastric pain irradiated in the

right hipocondrium, no fixed timing, no effort angina,

improves slowly at NTGIn the last days 6 tb NTG/day

RF:

smoker

TC = 204, TG = 125,

LDL = 148, HDL = 32 (mg/dl)


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ECG in crises


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Therapeutic approach

kPTCA (stent RCA)

kAntiplatelet

kStatin

kBeta-blocker

k

Smoking cessation


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INVESTIGATIONS

Resting ECG

Stress test

Rhythm Holter

Doppler echo

Stress echo - dobutamine

Isotopic ventriculography

Myocardial scintigraphyPET

Angiocoronarography


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Stress testing (ST)= widespread method withstandardized protocols and low costs to

assess CAD.

S.U.A. 1991,1992 6,2 mil ST

27% CAD


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ACC/AHA guidelines ST indications:

Absolute indications:

1. Dg: men with typical / untypicalsymptoms and cumulated RF

2. Prognosis: assess functional capacity instable angina and after AMI

3. Prognosis: assess functional capacity after

revascularization procedures4. Dg: symptomatic arrhythmias at stress


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ACC/AHA guidelines ST indications:

Relative indications:

1. Dg: women with typical / untypical angina

2. Therapy monitoring in CAD or HF

3. Screening: asymptomatic men > 40 years

with cumulated RF

4. Vasospastic angina evaluation


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ET = generally a safe procedure;- AMI, SCD: rate 1:2500

High risk:- recent AMI

- malignant ventricular arrhythmias


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ET CONTRAINDICATIONS

ABSOLUTE: REL

- Recent AMI (2 days) - left main stenosis

- Unstable angina - moderate aortic stenosis

- Uncontrolled arrhythmias

-

Severe aortic stenosis-

dyselectrolitemias- Decompensated HF - uncontrolled HT

- Pulmonary embolism ( SBP>200mmHg,

- Aortic dissection DBP>110mmHg)

- Acute myopericarditis -pulmonary hypertension- Peripheral thrombosis - CMHO

- Infirmities - high degree AV block

Modificat dupa Fletcher et al si Gibbons et al.


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Criteria for HR in a ST :

- Target stress = Max HR = 220 age (years)

- Submaximal stress = 80 85 % Max HR

- Closely to maximal stress = 90 % Max HR

- Maximal effort symptom - limited


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ST FINISHING CRITERIAABSOLUTE: - decrease of SBP >10 mmHg from normalwith ischemic

changes

- moderate orsevereangina

- ataxia

- low cerebralperfusion signs

- sustainedVT

- technicaldifficulties

-patientsrequest

-STdepression > 2 mm

RELATIVE: - decrease SBP >10 mmHg from normalwithout ischemicchanges

-STdepression > 1 mm

- arrhythmias, otherthan sustainedVT

-progressive pain increase

- hypertensivebehaviour(SBP > 230 mmHg or/andDBP> 115mmHg)

-fatigue,claudicatiuon, wheezing


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ST INTERPRETATION:

1 Symptoms2 Stress capacity (METS)

3 Hemodynamic behavior :

HR max x BP = double product

4 ECG: specific ST changes at stress


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EFFORT ST CHANGES:

Patients with normal ECG:

positive Stress Test: > 1mm ST variations, 60 80 ms

from the J point

ST depression

ST elevation: coronary spasm

- V1: ischemia

- in regions with MI: aneurism / wall dyskinesia;

- no MI: transmural ischemia or critical stenosis.

STvariation in precordialleads = more exact than in

inferior leads


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LIMITATIONS:

Relatively diminished sensitivity:

monovascular disease

women elderly

significant comorbidities

no available data on LV function


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MYOCARDIAL PERFUSION

SCINTIGRAPHY:

With: - Thalium 201

- Technetium 99m

Indications

- monovascular CAD

- teritory assessment in CAD

- assessment of viability of

myocardium


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STRESS ECHOCARDIOGRAPHY:With Dobutamine:

- risks + side effects

INTERPRETATION:

ST DEPRESSION DURING DOBUTAMINE PERFUSION IN PATIENTSWITHNORMAL ECG HAS A MODERATE PREDICTIVE POWER FOR

CAD

Useful in patients with: history of MI or altered wall kinetics,pacemakers, renal impairment, dilated cardiomyopathy, LVH,

LBBB.


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Dobutamine stress test


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PET scan


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Glucose utilization during PET


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ScintigraphyTc-99m


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MRI


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Contrast ultrasound


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Not every thoracic pain is

coronary pain

Thoracic pain + ST variations + positivemarkers =Acutecoronary syndrome

Main goal: Reperfusion

ST elevation =

tthrombolysis orPCI (stent)

ST depression +

positive markers =IIb/IIIa inhibitors

Thoracic pain ECG changes, but nopositive markers = assessacuterisk

Troponin +ECG every 6 hours

Positive = high risk

/reperfusion

Negative = continue

evaluation

ST and other

Positive=

coronarography Negative =dischar e


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Diagnosis of AMI in the emergency room

History of precordial pain/ thoracic pain

ST elevation or a new LBBB

Increased levels of necrosis markers (CK-MB, troponins)

! Dont wait for results to initiate reperfusion

2D Echography and scintigraphy useful in differential

diagnosis of AMI


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Emergency treatment

Opioids I.V. (4-8 mg morphin, then 2 mg every 5 min)

O2

(2-4 l/min)

Beta-blocker i.v. or nitrate when opioids are not effective

Tranquilizers may be useful

B f h it l d l i h it l t t t


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Before hospital and early in hospital treatment

Reperfusion therapy recommendation Class Evidence

level

I IIa IIb IIIreperfusion therapy is indicated in all patients with history

of thoracic pain/ less than < 12 hours and ST elevation or a

new bundle branch block

X A

Primary PCI

-preferably in the first 90 min after diagnosis

-patients in shockand those with contarindications for

fibrynolytics

- GP IIb/IIIa antagonists and PCI

without stenting

with stenting

X

X

X

X

A

C

A

A

Thrombolysis

-alteplase, tenecteplase X A


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Contraindications for thrombolitic therapy

Absolute contraindications:- haemorrhagic stroke

- ischemic stroke in the last 6 months

- CNS disorders

- neoplasias

- traumas/ surgery/ the last 3 weeks

- gastro-intestinal haemorrhage in the last month- known haemorrhagic disease

- aortic dissection

Relative contraindications:- transient ischemic attack in the last 6 months

-oral anticoagulants

-pregnancy or the 1st weekpostpartum

- severe HT (SBP > 180 mmHg)

- severe liver disease

- infective endocarditis

- active ulcer

i i l C bi i h


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Initial Treatment Combination therapy

Streptokinase

(SK)

1,5 mil. U in 100 ml 5% dextrose or

0,9% NaCl for 30-60 min.

With or without

heparin I.V.

For24-48 h

Alteplase

(tPA)

15 mg I.V. in bolus, 0,75 mg/kg for

30 min, then 0,5 mg/kg in 60 min

Do not exceed 100mg

Heparin I.V.

For24-48 h

Reteplase

(r-PA)

10U + 10U I.V.

la 30 min

Heparin I.V.

For24-48 h

Tenecteplase

(TNK-tPA)

Single dose I.V. bolus

30 mg < 60kg

35 mg 60-70kg

40 mg 70-80kg

45 mg 80-90kg50mg > 90kg

Heparin I.V.

For24-48 h

Most frequent regimen

All patients receive Aspirin (if no contraindications)


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Heparin treatment

I.V. in bolus:

60U/kg max. 4000U

I.V. perfusion:

12U/kg for24 to 48 hours max. 1000U/h.aPTT target 50-70 ms

aPTT should be monitored at 3,6,12, 24 hours after treatment

initiation


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Rehabilitation

Lifestyle advice

Active in profession

Also in patients with significant LV

dysfunction

Initiated early in hospital


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D. Thoracic origin

1.PLEURO-PULMONARY

(a) acute pneumonia

(b) pleurisy

(c) pulmonary / pleural neoplasia

(d) pneumotorax

D Thoracic pain


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D. Thoracic pain

2. Rheumatic pain

(a) spondilosis

(b) scapulo-humeral periartrytis

(c) Thoracic wall pain

(d) Tietze syndrome3. Bone pain

leukemia

multiple myeloma

osteosarcoma

metastasis

TBC


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05 patient with acute thoracic pain

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