APPROACH TO PATIENT WITHCHEST PAIN & ACUTECORONARY SYNDROME Presented by: Siti Nur Hamizah
INTRODUCTION Any pain, pressure, squeezing, choking, numbness or any other discomfort in the chest, neck, or upper abdomen, and is often associated with pain in the jaw, head, or arms. Because of common/overlapping neural pathways, many conditions, both cardiac and extra-cardiac can result in chest pain. Cardiac pain is mediated through upper 5 thoracic ganglia and spinal roots, but ramifications from adjoining spinal roots always exist. Therefore pain in the chest may originate from any structure in thorax and upper abdomen innervated through lower cervical to D6/D7 spinal roots
EVALUATION OF CHEST PAIN: Try to find the nature & cause of chest pain through CLINICAL HISTORY. A) Acute/short lived/ongoing B) Recurrent & episodic C) Persistent Details on pain: Site of pain, localized/diffuse, with radiation if any Intensity & character of pain Precipitating & relieving factors Any relationship with meals &posture & Any effect of local pressure, or variation with breathing, coughing & movements of cervical spine &shoulder joints.
IN GENERAL: Chest pain/discomfort is unlikely to be due to coronary artery disease if: Localized to region under left nipple/in skin/soft tissue Localized to small area (<2-3 cm), anginal pain tend to be diffuse. If chronic & persistent/ recurring and momentarychest pain is sharp, pricking, or stabbing Or varies with posture/breathing and coughing Present for several hours but not accompanied by appropriate ECG changes.
ACUTE CORONARY SYNDROME Encompasses all acute phase of Coronary Heart Disease > Unstable angina + NSTEMI + STEMI which usually present with acute chest pain at rest or on minimal exertion Pathogenesis:
CLINICAL FEATURES• Symptoms: prolonged cardiac pain-chest, throat, arms, epigastrium or back. Anxiety, fear of impending death,nausea and vomiting, breathlessness, collapse, syncope.• Signs: pallor, sweating, tachycardia-(sympathetic activation) vomiting, tachycardia-(vagal activation), hypotension, oliguria, cold peripheries, narrow pulse pressure, raised JVP, third heart sound, quiet first heart sound, diffuse apical impulse, lung crepitations, fever, complication signs->mitral regurgitation, pericarditis.
• Unstable angina is characterised by new onset or rapidly worsening angina, angina on minimal exertion, or angina at rest in the absence of myocardial damage.• In contrast, MI occurs when symptoms occur at rest and there is evidence of myocardial necrosis, as demonstrated by an elevation in cardiac troponin or creatinekinase-MB isoenzyme
INVESTIGATIONECGPlasma cardiac markers-> CK-MB, cardiac troponins T and I (4-6 hours, remains elevated for up to 2 weeks).Other blood tests: leucocytosis, elevated ESR and CRPChest x-rayEchocardiography
IMMEDIATE MANAGEMENT: THE FIRST12 HOURS• Analgesia-to lower adrenergic drive-> reduce vascular resistance, BP, infarct size, susceptibility to ventricular arrythmias.• Antiplatelet therapy- 300mg aspirin daily+ clopidogrel(600mg- 150mg-75mg)• Anticoagulants- unfractionated heparin, fractionated heparin or a pentasaccharide.• Antianginal therapy- sublingual glyceryltrinitrate (300-500mcg), IV nitrates, IV beta-blockers.• Reperfusion therapy: primary percutaneous coronary intervention(PCI), thrombolysis.
LATE MANAGEMENT OF MI • Cessation of Lifestyle smoking, regular modification exercise • diet • Antiplatelet Secondary therapy, b-blocker, prevention ACEI/ARB drug therapy • Statin ,aldosterone receptor antagonist Devices and • Implantable rehabilitation cardiac defibrillator
COMPLICATIONS OF ACUTECORONARY SYNDROME• Arrythmias- ventricular fibrillation, atrial fibrillation, bradycardia.• Ischaemia• Acute circulatory failure• Pericarditis• Mechanical complications- rupture of papillary muscle, rupture of interventricular septum, rupture of ventricle.• Embolism