CHEST PAIN MANAGEMENT

ACS

• Any condition brought on by sudden, reduced blood flow to the heart

EKG!!!

• Should be done within 10 min of arrival of pt to ED

DIFFERENTIALS

• Aortic dissection • Leaking or ruptured thoracic aneurysm • Pericarditis with tamponade • Pulmonary embolism • Pneumothorax • Peptic ulcer disease

UNSTABLE ANGINA

• ACS in which there is no detectable release of the enzymes and biomarkers of myocardial necrosis.

• Will have CP even at rest • May have ST changes on EKG

CANADIAN CLASSIFICATION SYSTEM

• Grade I – Angina with strenuous, rapid, or prolonged exertion; ordinary physical activity, such as climbing stairs, does not provoke angina

• Grade II – Slight limitation of ordinary activity; angina occurs with postprandial, uphill, or rapid walking; when walking more than 2 blocks of level ground or climbing more than 1 flight of stairs; during emotional stress; or in the early hours after awakening

• Grade III – Marked limitation of ordinary activity; angina occurs with walking 1-2 blocks or climbing a flight of stairs at a normal pace

• Grade IV – Inability to carry on any physical activity without discomfort; rest pain occurs

HIGH LIKELIHOOD OF PROGRESSION

• History of previous MI, sudden death, or other known history of CAD

• Chest, neck, jaw, or left arm pain consistent with prior documented angina

• Transient hemodynamic or ECG changes during pain

• ST-segment elevation or depression of 1 mm or more

• Marked symmetrical T-wave inversion in multiple precordial leads

LOW PROBABILITY OF PROGRESSION

• Chest pain classified as probably not angina • Chest discomfort reproduced by palpation • T-wave flattening or inversion of less than 1 mm in

leads with dominant R waves • Normal ECG findings

WORK UP

• 3 Serial troponins separated by 4-6 hours • EKG • CXR • CBC • CMP • ?echo • ?cardiac angiography

CARDIAC MARKERS/SIGNIFICANCE

EKG CRITERIA

• Remember 1 box of elevation or depression in limb leads

• 2 boxes of change in anterior leads

TREATMENT OF ANGINA-MEDICAL

• Aspirin*** • Beta-adrenergic blocking agents • Thienopyridines (eg, clopidogrel and prasugrel) • GP IIb/IIIa antagonists • Heparin • Direct thrombin inhibitors • Nitrates***

***MONA

TREATMENT

• Admission to either telemetry or CCU • Need cardiology consult-interventionalist (in case

progression)

NSTEMI

• ST depression with +cardiac biomarkers • Similar treatment as unstable angina • Admit to ICU • Cardiology consult • Medical Management

THE DRUGS

• ASA 324mg CHEWABLE PO • Nitro 0.3mg SL x 3 over 15 minutes or usually 1 inch

of paste • Heparin 5000 units bolus then heparin drip of 12-15

units/kg/hr (max: 1000 units/hr) • Beta Blockers PO (ex: metoprolol 50mg) • Plavix 300mg loading dose • Integrelin 180 mcg/kg bolus then 2mcg/kg/min (1

mcg if RF)

STEMI

• Send labs if have time otherwise, no need for biomarkers (we know they will be elevated)

• CXR if possible • Decide whether the patient will be treated with

thrombolysis or primary PCI should be made within 10 minutes

GOALS

• TpA– door to drug time of 30 min • PCI—door to baloon time of 90 min

ED TREATMENT--TPA

• ≤67 kg: 15 mg IVP bolus over 1-2 minutes, THEN 0.75 mg/kg IV infusion over 30 minutes (not to exceed 50 mg), and THEN 0.5 mg/kg IV over next 60 minutes (not to exceed 35 mg over 1 hr)

• >67 kg (100 mg total dose infused over 1.5 hr): 15 mg IVP bolus over 1-2 minutes, THEN 50 mg IV infusion over next 30 minutes, and THEN remaining 35 mg over next 60 minutes

ED TREATMENT-PCI

• CALL CATH LAB IMMEDIATELY (CODE CORE) • Give ASA • Give beta-blocker—NOT in cocaine use though • Some cards will have you start plavix in ED

ED TREATMENT

• Pt should be admitted to the ICU

AORTIC DISSECTION

RISK FACTORS

• HTN • Connective tissue dz (marfans) • Cocaine/amphetamine use • trauma

PRESENTATION

• 96 percent of acute aortic dissections could be identified based upon some combination of the following three clinical features:

-Abrupt onset of thoracic or abdominal pain with a sharp, tearing and/or ripping character -Mediastinal and/or aortic widening on chest radiograph -A variation in pulse (absence of a proximal extremity or carotid pulse) and/or blood pressure (>20 mmHg difference between the right and left arm) • May also have dizziness or Syncope

CLASSIFICATION

WORK UP

• D-dimer, troponins and LDH may be elevated • May see EKG changes • CXR wide mediastinum • CT chest (AAA protocol)/abdomen once pt is

stable enough • Can do TEE if not stable

TREATMENT

• Acute ascending aortic dissection (Stanford type A) is a surgical emergency

• Patients who are hemodynamically stable with uncomplicated aortic dissections confined to the descending thoracic aorta (Stanford type B) are best treated with medical therapy

TREATMENT-SURGICAL

• Need cardiothoracic immediately • Sustain hemodynamic stability • To OR for stenting

TREATMENT-MEDICAL

• morphine to adequately control pain • Intravenous beta blockers are initiated to reduce

the heart rate below 60 beats/min. • Nitroprusside can be added, if needed, to achieve

a systolic blood pressure of 100 to 120 mmHg. • Direct vasodilators, such as hydralazine, should

be avoided.

TIME TIME TIME

• REMEMBER that time is of essence in these conditions