ACUTE CHEST PAIN

ACUTE CORONARY SYNDROMES

CAUSES• Angina & MI•Muskuloskeletal pain• Esophagitis & Esophagial spasm• Pleurisy• Pneumothorax• Costochondritis• Aortic dissection• Pancreatititis & Cholecystitis• Root pain• Pericarditis• Fibromyalgia•Mediastinitis

APPROACH

• Asess general condition sick/not sick• Check vitals• Short history• Quick examination• Severe pain give Morphine/Pethidine(C/I Br Asthma)• Get ECG Done• S/L Sorbitrate/Aspirin 325mg

Suspect Cardiac Pain in• >40yrs,male• Post menopausal • C/C smoker• DM/HTN• Obese• Sedentary

• TYPICAL CARDIAC PAIN• ANGINA EQUIVALENTS

PHYSICAL FINDINGS• Apprehensive look, Angor amini• Sweating, cold skin,Hypotension,• Tachy/Bradycardia,Arrythmias• Wide/Narrow pulse pressure• Dyskinetic Apex• S3,S4,Apical sys murmur• Pericardial rub• Basal creps

IHD

c/c stable anginaACS

UA NSTEMI STEMI

ACS

60% UA 40%MI

2/3NSTEMI 1/3STEMI

PATHOPHYSIOLOGY

1. A/C plaque change2. Dynamic obstruction (vasospastic)3. Progressive mechanical obstruction4. INCREASED myocardial O2 demand5. Decreased supply of O2

UA & NSTEMIUA Presents as

•Rest angina >10 minutes•Severe & new onset angina•Crescendo angina

NSTEMI•Above features + evidence of

myocardial necrosis

ECG

1. Labile ST Segment depression2. T Inversion3. Transient ST Elevation

Cardiac Specific markers

1. Myoglobin- first to rise (with in 2 hrs) less value2. Troponin I- has got prognostic

value,PREFFERED MARKER

3. CPK-MB-4. LDH 1NOT elevated in Pts with UA

Rx of UA / NSTEMI

GOALS

1. Prevention of Thrombus2. Restoration of coronary blood flow3. Reduction in myocardial o2 demand

• Supplemental o2• Morphine SO4

1. Reduces pain2. Causes venodialatation3. Arteriolar dialatation4. Vagotonic effect5. Useful in pul edemaDosage – 2 -4 mg Iv Rpted every 5 mts or until S/E ensue S/E – Hypotension,Nausea, vomitting,Apnea,Urinary retention

Antiplatelet therapy

1. Aspirin-325 mg non enteric chew stat if no c/I . Later 150 mg /day

2. Clopidogrel- 300mg stat & 75 mg / d3. Combination – ecospirin + clopidogrel4. Gp 2 b 3a antagonists

1. Absciximab2. Epifibatide3. tirofiban

Anticoagulant therapy

1. UFH – 50 – 60 IU/kg Max (5000IU) IV bolus----->12IU/kg/hr (Max 1000) aPTT Titrated to 1.5 to 2.5

2. LMWH-1. Dalteparin(Fragmin)2. Enoxaparin

Heparin induced thrombocytopenia3. PLT Count Dec after 5 – 7 days4. Occurs in 1 – 3% people5. LEPIRUDIN & ARGATROBAN used instead

Anti ischemic Rx

• Nitrates – NTG 0.5 mg s/l,Sorbitrate 5 mg s/l

C/I – Hypotension,

1. RVMI2. Tachycardia >100bpm

• BETA Blockers• Metoprolol 12.5 1 BD,Atenolol 25 1 OD,Carvedilol 3.125 1 BD,Betaxolol• Decreases myocardial o2 demand• C/I – Hypotension,

HR <60 bpmMarked 1 AV BlockBR Asthma Complete HB

1. CCB- 2. ACEI – Enalapril 2.5 ½ OD / BD

1. Inhibits cardiac remodelling

3. Thrombolytic Therapy – not indicated4. Coronary Revascularisation (PCI,CABG)5. RISK FACTOR MODIFICATION

1. Stop smoking2. Lose weight (BMI<25 Desirable,WC < 40in M & <35in F)3. Exercise4. BP Controll5. DM & Hyperlipidemia management

STEMI• MC Cause of death is VF

DIAGNOSIS ( 2 or > of the following)

1. H/o Prolonged chest discomfort / Angina equivalent >30 mts2. 2mm or < STE in precordial leads OR 1mm or > STE in Inferior leads3. Elevated biomarkers

History1. Typical cardiac pain / Angina equivalent2. Silent MI- present with confusion,dyspnoea,unexplained hypotension

1. Elderly2. Diabetics3. Hypertensives4. Post op Pts

O/E

1. PSM Mitral area2. RVMI – Cardiogenic shock,hypotension,^JVP No features of pul

edema

ECG1. Hyperacute T Waves2. ST Segment changes

1. 2, 3 aVF - IWMI2. V1 V2 V3 – AWMI3. 1 aVL V5 V6- Lateral4. PWMI- reciprocal changes in anterior leads5. RVMI – STE in V4R Q Waves

Investigations

• FLP/ FBS• Trop I,CPK MB• CXR• ECG• PT• ECHO

Rx

1. General measures1. Continuous ECG, BP, SpO2 measurement2. O2

3. Two IV Lines4. RVMI – Start IV Fluids. C/I in Pul Edema5. CCU

Medications•Aspirin-325 mg non enteric chew stat if no c/I . Later

150 mg /day•Clopidogrel- 300mg stat & 75 mg / d•No role for Gp 2 b 3a antagonists•Nitrates•Beta Blockers•Atropine 0.6mg iv (Max 2mg) For bradycardia•Morphine+ Phenergan

Contd• THROMBOLYTIC THERAPY IND- STE 2mm or > in precordial leads

STE 1mm or>in Inf leadsFresh LBBBPosterior MI

THROMBOLYTIC THERAPY• C/I

1. H/O ICH2. AVM, Aneurysms3. Intracranial tumours4. Ischemic stroke <3 months5. Aortic dissection6. Major Trauma with in 3 months7. High BP , SBP>180 mm DBP >110mm8. Bleeding diathesis9. Previous STK use > 5days & <2 yr10. >12 hrs after onset of pain

Administration

• 1.5 million IU STK in 100 ml NS over 1HR• Inj Avil + Efcorlin given prior• ECG & BP monitoringAdverse reactions

• Life threatening ICH• Hypotension• Bleeding from puncture sites• allergy

Signs of therapeutic Efficacy

• Symptomatic improvement• ECG Change

1. Late diastolic VPCs2. AIVR3. Fall of STE

• Early peaking & Fall in Enzyme levels

•Heparin is used If infarct is large or if pain continues

Periinfarct management

• Bed RestAbsolute bed rest for 12 hrsSit upright in 24hrsAmbulated by 2nd & 3rd dayAfter 3rd day -> gradually ^ ambulation

• Low residue liquid Diet• Bowels Avoid dstraining at stools . Give laxatives• Sedation – Alprax 0.25mg 1 HS, Lorazepam 1mg

Contd•Statins - HMG Co A Reductase inhibitors

ATORVASTATIN 10-80 mg/day

Started in those with DyslipidemiasTarget LDL <100 in all Pts with CAD<70 in those with very high risk

S/EHepatotoxicityMyopathyRhabdomyolysis

RISK ASSESMENT AFTER MI

• NON INVASIVE- Stress Test evaluation (TMT)

•Done 3-6 wks after D/D from Hospital• INVASIVE- Cardiac catheterisation• Done in those with R/C angina,ischemia,CCF,Mechanical complication of MI

COMPLICATIONS• A/C pericarditis

• Occurs in 15-20 % pts with large MI• Pleuritic type of chest pain with friction rub• Diffuse STE in ECG• Rx- Analgesics,>Aspirin 650 ,Indop 25-50 qid• Steroids

• Avoided in 1st 4 wks ( risk of ventricular rupture)• Dresslers syndrome

• A I process• ^ ESR,Pericardial effusion,fever

ARRYTHMIAS

•WITH HEMODYNAMIC COMPROMISE REQUIRE PROMPT Rx• Left antr fascicle block•Bradycardia - in MI involving R coro A • Observation• Atropine• pacing

•1st degree HB – no Rx needed•2nd degree HB•Mobitz 1- IWMI > No Rx•Mobitz 2 – AWMI > Temporary pacing

• 3rd degree AV Block & Asystole - Trans venous pacing• SVT

• Sinus Tachycardia• PSVT• AF & AFl• Accelerated junctional rytham

Ventricular arrythmias

• VPCs• AIVR- Ventricular rate>60 – 125 bpm• NSVT• VT

• Stable – Inj xylocard 50 mg IV• Inj Amiodarone75 stat & 500 mg in 500 ml NS Iv infusion

• Not stable - DC Version 200J

•VF – good prognosis – DC version needed A/C LVFAvoid IV FluidsMorphine is helpfulDiuretics , ACEI,Nitrates RVMI – in IWMI & PWMICardiogenic shockGive IVF,support with Dopamine , DobutamineIntra aortic balloon pump

Mechanical complications• Aneurysm – due to wall motion abnormality

• A/W Mural Thrombi• Persistent STE > 1 monthsEmpirical anticoagulation (Warf) INR 2-3

• Pappillary M Rupture • Postr medial lip is mostly affected• Echo, Doppler diagnostic

• Ventricular septal rupture A/W AWMI• Free wall rupture• Catastrophic complication• Occurs in hypertensives with large mural thrombi• Common after 1st week

FOLLOW UP CARE

• Continue drugs & Dose Adjustment• Every 4- 6 months in 1st year• Thereafter yrly & SOS