Approach to the patients with Approach to the patients with chest pain chest pain

and their managementand their management

Prof Dr. S. N. Ojha Prof Dr. S. N. Ojha M.D Ph.DM.D Ph.DPrincipalPrincipal

Dr. D. Y. Patil Ayurvedic College PuneDr. D. Y. Patil Ayurvedic College Pune http://drojha.wordpress.com/

ACUTE MYOCARDIAL INFARCTIONACUTE MYOCARDIAL INFARCTION

Defination Defination

AMI occurs when the blood supply to the AMI occurs when the blood supply to the part of hearth is interrupted. The resulting part of hearth is interrupted. The resulting ischemia (restriction in blood supply) and ischemia (restriction in blood supply) and oxygen shortage, If left untreated for a oxygen shortage, If left untreated for a sufficient period, can cause and/or Death sufficient period, can cause and/or Death (Infarction) of heath muscle tissue (Infarction) of heath muscle tissue (Myocardium)(Myocardium)

Magnitude of the problemMagnitude of the problem

32% Death in India attributed to cardio 32% Death in India attributed to cardio vascular disease compared to 12% due to vascular disease compared to 12% due to respiratory infection, 9% due to diarrhoeal respiratory infection, 9% due to diarrhoeal disease and 5% due to tuberculosis.disease and 5% due to tuberculosis.

Prevalence is higher in south India .Prevalence is higher in south India . Urban India(3.45-9.45%) is affected more in Urban India(3.45-9.45%) is affected more in

comparison to rural India(2-4%)comparison to rural India(2-4%)

Risk factorRisk factor Risk factor for atherosclerosis are generally risk factor Risk factor for atherosclerosis are generally risk factor

for MIfor MI -Old age-Old age -Male sex-Male sex -Hypercholestrolemia -Hypercholestrolemia -Tobacco smoking-Tobacco smoking -DM with or without insulin resistency)-DM with or without insulin resistency) -High BP-High BP -Obesity-Obesity -Stress-Stress -Hyperhomocysteinemia-Hyperhomocysteinemia -Women using OCP have increased risk of MI-Women using OCP have increased risk of MI -Periodontal disease may be linked to coronary heart -Periodontal disease may be linked to coronary heart

diseasedisease

ECG

Acute coronary syndrome

ST- Elevation

No ST- Elevation

CARDIAC MARKER

Unstable angina

- ve

+ ve

Myocardial infarction

STEMI NSTEMI

Non Q Wave MI

Q Wave MI

SYMPTOMSSYMPTOMS

-Chest Pain-Chest Pain -Levine’s sign ; Chest pain is localized by clenching fist over sternum.-Levine’s sign ; Chest pain is localized by clenching fist over sternum. -Dyspnoea-Dyspnoea -Diaphoresis-Diaphoresis -Weakness-Weakness -Light Headedness-Light Headedness -Nausea-Nausea -Vomiting-Vomiting -Palpitation-Palpitation -Loss of consciousness-Loss of consciousness -Sudden Death-Sudden Death*Most common symptoms of MI in Women include Dyspnoea, Weakness and *Most common symptoms of MI in Women include Dyspnoea, Weakness and

Fatigue.Fatigue.*In DM, difference in Pain threshold, Autonomic neuropathy and *In DM, difference in Pain threshold, Autonomic neuropathy and

psychological factors have been cited as possible explanation for silent MI.psychological factors have been cited as possible explanation for silent MI.*Probably because the donor heart is not connected to nerves of the host MI in *Probably because the donor heart is not connected to nerves of the host MI in

heart transplanted person is silent.heart transplanted person is silent.

PHYSICAL EXAMINATIONPHYSICAL EXAMINATION

-General appearance may vary; the patient may be -General appearance may vary; the patient may be comfortable or restless and in severe distress with comfortable or restless and in severe distress with increased respiratory rate.increased respiratory rate.

-Low grade Fever (38-39 degree celsius )-Low grade Fever (38-39 degree celsius )

-BP maybe elevated or decreased.-BP maybe elevated or decreased.

-Pulse can become irregular-Pulse can become irregular

-If Heart failure ensues ; -If Heart failure ensues ;

increased JVP increased JVP hepatojugular reflux, hepatojugular reflux,

swelling legs due peripheral oedema. swelling legs due peripheral oedema.

-Cardiac bulge with a pace different from pulse -Cardiac bulge with a pace different from pulse rhythm can be felt on precordial examination.rhythm can be felt on precordial examination.

-On auscultation-On auscultation – –

-3-3rdrd and 4 and 4thth heart sound. heart sound.

- Systolic murmur - Systolic murmur

- Paradoxical splitting of 2- Paradoxical splitting of 2ndnd heart sound heart sound

- Precordial friction rub- Precordial friction rub

- Rales over lung- Rales over lung

DIAGNOSISDIAGNOSIS

-History of present illness-History of present illness

- Physical Examination- Physical Examination

- ECG- ECG

- Cardiac Marker CKMB- Troponin- Cardiac Marker CKMB- Troponin

-Coronary angiogram-Coronary angiogram

- Echo cardiogram- Echo cardiogram

- Nuclear medicine (technetium 99m 2-- Nuclear medicine (technetium 99m 2-methoxyisobutylisonitrite Or Thallium-201 Chloride)methoxyisobutylisonitrite Or Thallium-201 Chloride)

Some features differentiating cardiac from Non-cardiac chest pain

Favoring Ischaemic Origin Against Ischaemic origin

1.Character of Pain

Constricting Dull acheSqueezing Knife Like,SharpBurning stabbing,jabsHeaviness, heavy feeling Aggravated Respiration

2. Location of Pain

Substernal In the left submamary area Across Mid Thorax, In the Left hemithroaxAnteriorlyIn both arms, shouldersIn the Neck, Cheeks, Teeths In the Forearms, Fingers In the interscapular region

Some features differentiating cardiac from Non-cardiac chest pain

Favoring Ischaemic Origin Against Ischaemic origin

3. Factors Provoking Pain

Exercise Pain after completion of exerciseExcitement Provoked by a specific body motionOther forms of StressCold WeatherAfter Meals

IndexIndex DiseaseDisease DurationDuration QualityQuality ProvocationProvocation ReliefRelief LocationLocation

1.1. Effort anginaEffort angina 5-15 mins5-15 mins Visceral/pressure Visceral/pressure typetype

During effort or During effort or emotionemotion

Rest & Rest & NitroglycerineNitroglycerine

Sternal & Sternal & radiatingradiating

2.2. Rest Angina OrRest Angina Or

Unstable AnginaUnstable Angina

5-15 mins5-15 mins Visceral/pressure Visceral/pressure typetype

SpontaneousSpontaneous NitroglycerineNitroglycerine Substernal & Substernal & radiatingradiating

3.3. Mitral Valve Mitral Valve ProlapseProlapse

Mins to HoursMins to Hours SuperficialSuperficial Spontaneous(No Spontaneous(No Pattern)Pattern)

TimeTime Left AnteriorLeft Anterior

4.4. Oesophageal Oesophageal

RefluxReflux

10 mins- 1 hour10 mins- 1 hour VisceralVisceral Recumbency & Recumbency & Lack Of FoodLack Of Food

Food, AntacidFood, Antacid Substernal Substernal EpigastricEpigastric

5.5. Peptic UlcerPeptic Ulcer HrsHrs Visceral, Burning Visceral, Burning TypeType

Lack Of Food, Lack Of Food, Acid FoodAcid Food

Food AntacidFood Antacid Epigastric & Epigastric & SubsternalSubsternal

6.6. Oesophageal Oesophageal

SpasmSpasm

5-60mins5-60mins VisceralVisceral Spontaneous, Cold Spontaneous, Cold Liquids & Liquids & ExerciseExercise

NitroglycerineNitroglycerine Substernal & Substernal & RadiatingRadiating

7.7. Biliary DiseaseBiliary Disease HrsHrs Visceral, SevereVisceral, Severe Spontaneous, Spontaneous, Food- Fatty foodFood- Fatty food

Time & AnalgesicTime & Analgesic Epigastric, Epigastric, Radiated To Rt. Radiated To Rt. Scapular TipScapular Tip

8.8. Cervical Disc Cervical Disc

ProlapseProlapse

Variable Variable (Gradually (Gradually Subsides)Subsides)

SuperficialSuperficial Head & NeckHead & Neck

MovementsMovements

Time & AnalgesicTime & Analgesic Neck & Neck & Arm(RadiculopathArm(Radiculopathy)y)

9.9. HyperventillationHyperventillation 2-3mins2-3mins visceralvisceral Emotions & Emotions & TachypneoaTachypneoa

Stimulus RemovalStimulus Removal SubsternalSubsternal

10.10. Musculoskeletal Musculoskeletal

PainPain

VariableVariable SuperficialSuperficial Movement & Movement & PalpationPalpation

Time & AnalgesicTime & Analgesic Multiple SitesMultiple Sites

11.11. Pulmonary CausesPulmonary Causes 30 mins30 mins Visceral/Visceral/PressuretypePressuretype

Often Often SpontaneousSpontaneous

Rest,time & Rest,time & bronchodilatationbronchodilatation

SubsternalSubsternal

Wall AffectedWall Affected Leads Showing ST Leads Showing ST Segment ElevationSegment Elevation

Leads Showing Leads Showing Reciprocal ST Reciprocal ST Segment DepressionSegment Depression

Suspected Culprit Suspected Culprit ArteryArtery

SeptalSeptal V1, V2V1, V2 NoneNone Left Anterior Left Anterior Descending (LAD)Descending (LAD)

AnteriorAnterior V3, V4V3, V4 NoneNone Left Anterior Left Anterior Descending (LAD)Descending (LAD)

AnteroseptalAnteroseptal V1, V2, V3, V4V1, V2, V3, V4 NoneNone Left Anterior Left Anterior Descending (LAD)Descending (LAD)

AnterolateralAnterolateral V3, V4, V5, V6,I, V3, V4, V5, V6,I, aVLaVL

II, III, aVFII, III, aVF Left Anterior Left Anterior Descending (LAD), Descending (LAD), Circumflex (LCX), Circumflex (LCX), or or Obtuse MarginalObtuse Marginal

Extensive Anterior Extensive Anterior (Sometimes called (Sometimes called Anteroseptal with Anteroseptal with Lateral extension)Lateral extension)

V1, V2, V3, V4,V5, V1, V2, V3, V4,V5, V6, I, aVLV6, I, aVL

II, III, aVFII, III, aVF Left main coronary Left main coronary artery (LCA)artery (LCA)

Wall AffectedWall Affected Leads Showing ST Leads Showing ST Segment ElevationSegment Elevation

Leads Showing Leads Showing Reciprocal ST Reciprocal ST Segment DepressionSegment Depression

Suspected Culprit Suspected Culprit ArteryArtery

InferiorInferior II, III, aVFII, III, aVF I, aVLI, aVL Right Coronary Right Coronary Artery (RCA) or Artery (RCA) or Circumflex (LCX)Circumflex (LCX)

LateralLateral I, aVL, V5, V6I, aVL, V5, V6 II, III, aVFII, III, aVF Circumflex (LCX), Circumflex (LCX), or or Obtuse MarginalObtuse Marginal

Posterior Posterior (Usually (Usually associated with associated with Inferior or Lateral Inferior or Lateral but can be isolated) but can be isolated)

V7, V8, V9V7, V8, V9 V1, V2, V3, V4V1, V2, V3, V4 Posterior Posterior Descending (PDA)Descending (PDA) (branch of the (branch of the RCA RCA or or Circumflex (LCXCircumflex (LCX))

Right ventricular Right ventricular (Usually associated (Usually associated with Inferior)with Inferior)

II, III, aVF, V1, II, III, aVF, V1, V4RV4R

I, aVLI, aVL Right Coronary Right Coronary Artery (RCA)Artery (RCA)

TREATMENTTREATMENT

First aidFirst aid

Aspirin Aspirin NitratesNitrates Automated external defibrillatorAutomated external defibrillator In case of cardiac arrest, CPR(cardio In case of cardiac arrest, CPR(cardio

pulmonary resusitation) can be administered.pulmonary resusitation) can be administered.

First lineFirst line

OxygenOxygen AspirinAspirin NitratesNitrates Analgesia(morphine)Analgesia(morphine) Beta blockerBeta blocker Anti coagulant like heparinAnti coagulant like heparin Anti platelet agent like clopidogrelAnti platelet agent like clopidogrel

ReperfusionReperfusion

Thrombolytic therapyThrombolytic therapy Percutaneous coronary intervention(PCI)Percutaneous coronary intervention(PCI) Bypass surgeryBypass surgery

Monitoring ArrhythmiasMonitoring Arrhythmias Anti arrhythmic prophylaxisAnti arrhythmic prophylaxis

Secondary preventionSecondary prevention

Beta blockerBeta blocker ACE InhibitorACE Inhibitor Statin therapyStatin therapy Angiotensin receptor blockerAngiotensin receptor blocker Aldosterone antagonistAldosterone antagonist Ca channel blockerCa channel blocker Omega 3 fatty acidsOmega 3 fatty acids

RehabilitationRehabilitation Physical exercisePhysical exercise Smoking cessationSmoking cessation Restricted dietRestricted diet Limitations of alcohol intakeLimitations of alcohol intake Can resume sexual activity after 3 to 4 weeks.Can resume sexual activity after 3 to 4 weeks.

Following drugs are used and found effective in vatika hridroga. Further scientific clinical trial is needful.

01) Drug acting on amasahit meda = Marich, Chitrak, Daruharidra, Rason, Tulasi, Vacha, Pushkarmul, Punarnava, Shuddha shilajeeta

02) Drug acting on rasvaha strotas = Amalaki, Haritaki, Punarnava, Shatavari, Marich & Shilajeet

03) Drug acting on vata dosh = Haritaki, Rason, Guggul, Pushkarmul , Amalaki , Punarnava , Marich , Shilajeet, Chitrak, Tulsi& Shatavari.

04) Medhya drug= Bramhi, Vacha, Shatavari, Haritaki.05) Drugs dissolute grathit rakta= Kamalkshar , Darbha or Kusha or

Paravatshakrut.06) Hruddya= Arjun, Bramhi, Tulasi, Guggul, Punarnava, Rason & Shatavari .07) Combination of drugs=Arjun, Vacha, Bramhi, Marich,

Chitrak, Tulasi, Haritaki Amalaki, Daruharidra, Punarnava, Shatavari, Rason, Shuddhhashilajit- sambhag(equal part) + puskarmul-2-bhag(2-part) +shuddhha guggul-4-bhag(4-part)

Matra= 1GM TDS Anupan= Udak(jal), Madhu.

AnginaAngina

The English word The English word angina angina refers to a painful refers to a painful constriction tightness somewhere in the constriction tightness somewhere in the

bodybody

and may refer to : Angina pectorisand may refer to : Angina pectoris Abdominal angina Abdominal angina

Ludwig’s angina Ludwig’s angina Prinzmetal’s angina Prinzmetal’s angina

Vincent’s angina Vincent’s angina Angina tonsillaris Angina tonsillaris

Angina pectoris, Angina pectoris, commonly known as commonly known as angina, angina, is is severe chest pain due to ischemia (a lack of blood and severe chest pain due to ischemia (a lack of blood and hence oxygen supply) of heart muscle, generally due hence oxygen supply) of heart muscle, generally due to obstruction or spasm of the coronary arteries. to obstruction or spasm of the coronary arteries.

The term derives from the Greek The term derives from the Greek ankhon ankhon (“Strangling”) and the Latin (“Strangling”) and the Latin PectusPectus (“chest”), and can (“chest”), and can therefore be translated as “a strangling feeling in the therefore be translated as “a strangling feeling in the chest.”chest.”

SymptomsSymptoms Chest discomfort Chest discomfort the discomfort is usually described as a pressure, heaviness, the discomfort is usually described as a pressure, heaviness,

tightness, squeezing, burning, or choking sensation.,tightness, squeezing, burning, or choking sensation., anginal pains may also be experienced in the anginal pains may also be experienced in the

epigastriumepigastrium ,back, neck, jaw, or shoulders, following skin ,back, neck, jaw, or shoulders, following skin dermatomes. dermatomes.

It is typically precipitated by exertion or emotional stress. It is typically precipitated by exertion or emotional stress. It is exacerbated by having a full stomach and by cold It is exacerbated by having a full stomach and by cold

temperatures. temperatures. Pain may be accompanied by breathlessness, sweating and Pain may be accompanied by breathlessness, sweating and

nausea. nausea. It lasts for about 3 to 5 minutes, and is relieved by rest or It lasts for about 3 to 5 minutes, and is relieved by rest or

specific anti-angina medication. specific anti-angina medication.

Risk FactorsRisk Factors

cigarette smoking, cigarette smoking,

diabetes, diabetes,

high cholesterol, high cholesterol,

high blood pressure, high blood pressure,

sedentary lifestyle and sedentary lifestyle and

family historyfamily history

Coronary Atherosclerosis

Thrombosis

Narrowing Of coronary

Myocardial Ischaemia

Chest Pain

I.H.D.

PathophysiologyPathophysiology

SubtypesSubtypes

Stable anginaStable angina is typically presented as chest is typically presented as chest discomfort and associated symptoms precipitated by discomfort and associated symptoms precipitated by some activity (running, walking etc.) with minimal or some activity (running, walking etc.) with minimal or non-existent symptoms at rest.non-existent symptoms at rest.

Unstable AnginaUnstable Angina It occurs at rest (or with minimal exertion), usually It occurs at rest (or with minimal exertion), usually

lasting > 10 min; lasting > 10 min; it is severe and of new onset (i.e., within the prior 4-6 it is severe and of new onset (i.e., within the prior 4-6

weeks); weeks); it occurs with a crescendo pattern (i.e., distinctly it occurs with a crescendo pattern (i.e., distinctly

more severe, prolonged, or frequent than previouslymore severe, prolonged, or frequent than previously).).

DiagnosisDiagnosis

Electrocardiogram (ECG)Electrocardiogram (ECG)

Exercise ECG Test (“Treadmill Test”)Exercise ECG Test (“Treadmill Test”)

Thallium ScintigramThallium Scintigram

Stress EchocardiographyStress Echocardiography

Coronary AngiogramCoronary Angiogram

TreatmentTreatment

Aspirin (75 mg. to 100 mg.)Aspirin (75 mg. to 100 mg.) Beta blockers (eg. Carvedilol, propranolol, atenolol etc.)Beta blockers (eg. Carvedilol, propranolol, atenolol etc.) Short-Acting nitroglycerinShort-Acting nitroglycerin Calcium Channel Blockers (Nifedipine & amlodipine)Calcium Channel Blockers (Nifedipine & amlodipine) Isosorbide mononitrate & Isosorbide mononitrate & NicorandilNicorandil If inhibitor- Ivabradine provides pure hear rate reductionIf inhibitor- Ivabradine provides pure hear rate reduction ACE inhibitors are also vasodilators.ACE inhibitors are also vasodilators. Statins are the most frequently used lipid / cholesterol Statins are the most frequently used lipid / cholesterol

modifiersmodifiers Exercise is also a very good long term treatment.Exercise is also a very good long term treatment.

Ludwig’s anginaLudwig’s angina ( (angina ludovici)angina ludovici) is a serious is a serious potentially life-threatening cellulitis infection of the potentially life-threatening cellulitis infection of the tissues of the floor of the mouth, usually occurring in tissues of the floor of the mouth, usually occurring in adults with concomitant dental infections. adults with concomitant dental infections.

CauseCause

is usually a bacterial infectionis usually a bacterial infection. .

SymptomsSymptoms swelling,swelling, pain on raising of the tongue,pain on raising of the tongue, swelling of the neck and the tissues of the swelling of the neck and the tissues of the

submandibular and sublingual spaces,submandibular and sublingual spaces, malaise,malaise, fever, fever, dysphagia dysphagia in severe cases, stridor in severe cases, stridor

SignsSigns patient not being able to swallow his / her own saliva patient not being able to swallow his / her own saliva audible stridor as these strongly suggest that airway audible stridor as these strongly suggest that airway

compromise is imminent.compromise is imminent.

TreatmentTreatment

Antibiotic medications,Antibiotic medications,

Monitoring and protection of the airway in Monitoring and protection of the airway in severe cases, severe cases,

and where appropriate, urgent maxillo-facial and where appropriate, urgent maxillo-facial surgery surgery

dental consultation to incise and drain the dental consultation to incise and drain the collections.collections.

Abdominal anginaAbdominal angina (a.k.a. (a.k.a. bowelginabowelgina) ) is postprandial abdominal pain that occurs in is postprandial abdominal pain that occurs in

individuals with insufficient blood flow to individuals with insufficient blood flow to meet mesenteric visceral demands .meet mesenteric visceral demands .

PathophysiologyPathophysiology The most common cause of bowelgina is The most common cause of bowelgina is

atherosclerotic vascular disease.atherosclerotic vascular disease. It can be associated with :It can be associated with : CarcinoidCarcinoid Aortic coarctationAortic coarctation Antiphospholipid syndromeAntiphospholipid syndrome

ClinicalClinical Disabling midepigastric or central abdominal pain Disabling midepigastric or central abdominal pain

within 10-15 minutes after eating.within 10-15 minutes after eating. Physical examinationPhysical examination : : The abdomen typically is scaphoid and soft,The abdomen typically is scaphoid and soft,. weight loss . weight loss signs of peripheral vascular disease, signs of peripheral vascular disease, CausesCauses:: Smoking is an associated risk factor. Smoking is an associated risk factor.

TreatmentTreatment Stents have been used in the treatment of abdominal Stents have been used in the treatment of abdominal

angina. angina.

Prinzemtal’s angina( variant angina Prinzemtal’s angina( variant angina oror angina angina inversainversa,) is a syndrome typically consisting of angina ,) is a syndrome typically consisting of angina (cardiac chest pain) at rest that occurs in cycles. (cardiac chest pain) at rest that occurs in cycles.

CauseCause by vasospasm, a narrowing of the by vasospasm, a narrowing of the coronary coronary arteriesarteries caused by contraction of the smooth muscle caused by contraction of the smooth muscle tissue in the vessel walls rather than directly by tissue in the vessel walls rather than directly by atherosclerosisatherosclerosis

FeaturesFeatures Symptoms typically occur at rest, rather than on Symptoms typically occur at rest, rather than on

exertion (attacks usually occur at night). exertion (attacks usually occur at night).

DiagnosisDiagnosis Patients who develop cardiac chest pain are generally Patients who develop cardiac chest pain are generally

treated empirically as an “treated empirically as an “acute coronary syndrome”acute coronary syndrome”, , and are generally tested for cardiac enzymes such as and are generally tested for cardiac enzymes such as creatine kinasecreatine kinase isoenzymes or isoenzymes or troponintroponin l or T. These l or T. These may show a degree of positivity, as coronary spasm may show a degree of positivity, as coronary spasm too can cause myocardial damage. too can cause myocardial damage. EchocardiographyEchocardiography or thallium scintigraphy is often performed.or thallium scintigraphy is often performed.

The The gold standardgold standard is is coronary angiographycoronary angiography.. ECG finding will more often show ECG finding will more often show ST segment ST segment

elevation than ST depressionelevation than ST depression..

TreatmentTreatment Prinzmetal angina typically responds toPrinzmetal angina typically responds to

nitratesnitrates and dihydrophyridine and dihydrophyridine calcium channel calcium channel blockers.blockers.

Acute necrotizing ulcerative gingivitisAcute necrotizing ulcerative gingivitis Polymicrobial infection of the Polymicrobial infection of the gumsgums leading to inflammation, leading to inflammation,

bleeding, deep ulceration and bleeding, deep ulceration and necroticnecrotic gum tissue. gum tissue.

SymptomsSymptoms – –

fever and fever and halitosishalitosis..

CausesCauses Anaerobes such as Anaerobes such as BacteroidesBacteroides and and FusobacteriumFusobacterium aa

TreatmentTreatment Oral cleaning and salt water or Oral cleaning and salt water or hydrogen peroxidehydrogen peroxide-based -based

rinses. rinses. ChlorhexidineChlorhexidine or or metronidazolemetronidazole PenicillinPenicillin is also indicated at 250 mg. every 6 to 8 hours. is also indicated at 250 mg. every 6 to 8 hours. Dental care.Dental care.

THANK YOUTHANK YOU

For lastest updates visitFor lastest updates visit

http://drojha.wordpress.com/

http://www.facebook.com/Drsnojha