Cardiac technology

1. -Dr. D. Kathirvel, MD (Gen.Med), DM (Cardiology).
-Assistant Professor of Cardiology, GVMCH.

2. AIM of this CME
 To know the importance of recognizing Life
Threatening cause of Chest Pain, especially Acute
Coronary Syndrome,
 and treating it as early as possible.
 there by saving a life…
 By the end of the CME
Every one should be able to assess chest pain of cardiac
origin. And patient should be properly managed.

3. Overview of Chest Pain
 Why it is important?
In General OPD/Casualty…
1/3 pts of Chest Pain are due to Acute Coronary
syndrome.
 We have To Recognize other life threatening causes
 Like Pulm Embolism, Aortic dissection, Pneumothorax
2 % of ACS patients are missed – 2 fold risk of mortality
Chest pain
ACS
Non ACS

4. Epidemiology of chest pain in India1
 Emergency call….Only 17.2% (n = 41,312) of
patients called within 6 h of symptom onset. (Poor
awareness among public)
3 out of 100 pts died before the ambulance arrived
 It is 10 deaths for Tamil Nadu (Top among 11
states studied) and 9 for Andhra Pradesh.
1. Rao, et al.: Epidemiological study on cardiac emergencies in Indian ,2016

5. Common causes of Chest Pain
 Cardiac:
 ACS: Unstable angina, MI,
 Stable ischemic heart disease.
 Pericarditis,
 Mitral Valve Prolapse Syndrome,
 Aortic Stenosis,
 Rheumatic carditis,
 Infective endocarditis.
 Myocardial ischemia due to secondary cause/demand ischemia:
 Anemia,
 LV hypertrophy (LVH, HCM),
 RV hypertrophy (RVH, Severe Pulm stenosis)

6.  Vascular: Aortic dissection, Pulm
Embolism, Pulm HT
 Pulmonary: Pnemothorax, Pleuritis,
Pneumonia
 GI: Pancreatitis, GERD, Peptic ulcer,
GB diseases.
 Musculoskeletal: Costochondritis,,
Myositis. Trumatic
 Neural : Herpes zoster, Cervical
neuralgia ,Panic disorder.

7. Angina
Chest pain due to decreased blood flow to the heart (Commonly
due to Atherosclerotic Coronary Artery Disease –CAD)
i. Characteristic chest pain
 Retrosternal pain – constricting or crushing or squeezing,
a burning feeling, or difficulty breathing/pressure like.
 often radiates to left shoulder, neck, epigastrium or arm
 Pain builds in intensity over time, severe, intolerable.
ii. Aggravating factors (In acute MI, pain present even at rest)
 Exertion/stress (Effort Angina)
iii. Relieving factors
 Rest/Isosorbide dinitrate
All 3: Typical Angina
Any 2: Atypical Angina
Any 1: Non Anginal Chest Pain (NACP)

8.  Chest pain must be always considered cardiac in
nature until proven otherwise.
 Every patient is different
Assess the chest pain with…Pneumonic PQRST
 Positioning: Changing of posture, movement
 Quality: “constricting” or a “crushing” sensation
 Radiation:(66%) shoulders, arms, neck and jaws,
sometimes epigastrium.
 Severity: Accompanying symptoms (Giddiness, syncope,
nausea, vomiting and diaphoresis)
 Time: How long, intermittent, continuous. (> 20min -
Cardiac)
<2 min are non cardiac pain

9. 80%
Angina – Distribution of Pain

11. (Sweating)

12.  Sometimes pain is atypical (Angina equivalents) or
even absent in
 Diabetes Mellitus
 Women
 Elderly
 Angina Equivalents…
 Jaw , Shoulder or left arm pain
 Nausea/vomiting
 Sweating
 Angina may subside after reaching the hospital..
 Due to infarcted myocardium or recanalised artery

13. Non anginal chest pain
 Localised, pointing pain
 More with chest/body movements
 Tender on palpation
 Constant pain
 Brief episodes of pain
 Pain radiating to lower extremities

14. Chest pain due to other causes:
Distinguishing features

15. Pericarditis: Sharp, pleuritic pain
↑ postural change/friction rub.
Lying posture will aggravate the pain

16. Aortic dissection:
Excruciating ripping pain/sudden
onset/anterior chest or back/SHT, Marfans

17. Pulmonary Embolism:
Sudden onset dyspnea and
pain/hypoxia/RV failure.

18. Chest pain due to other causes:
Distinguishing features
Pulmonary HT: Exertional chest pain/ dyspnea/ Signs
of PHT.
Pleuritic pain: Localised/dyspnea.
GERD/Peptic ulcer: Burning substernal pain/epigastric
can radiates to shoulders.
↑meals, recumbent position.
↓antacid

19. Chest pain due to other causes:
Distinguishing features
 GB: Rt upper quadrant pain/ following a meal.
 Pancreatitis: Prolonged severe epigastric pain
radiates to back,
not relieved by antacid.
 Musculoskeletal:
fleeting pain/constant pain,
local tenderness.
reproduced by movements.

20. Chest pain due to other causes:
Distinguishing features
 Herpes zoster: Vesicular rash/ Prolonged burning
pain in dermatomal distribution.
 Panic disorder: Chest tightness not related to
exertion/movement

21. Evaluation of a pt with chest pain
 Very difficult to convince our patient…
 Usually patient will attribute to
 Indigestion
 Food
 Gastric Ulcer pain
 Manual work

23. While evaluation of a Chest pain
patient…
 If the pain suggestive of Angina
 Ask the patient to lie down
 Check Pulse, BP, SpO2
 Take ECG.
 Get an IV line, Blood sample for Troponin T or I
RBS, CBC and start NS slowly.
 Again Take Proper History of Chest pain..
 CXR, ECHO

24. Ask for Risk factors of CAD
 Hypertension.
 Diabetes Mellitus
 Previous h/o CAD
 Dyslipidaemia
 Advanced age/Male
 Family h/o CAD.
 Peripheral vascular disease/CKD
 Smoking/tobacco/Hans use.
 Alcohol /Cocaine use.

25. Physical Examination
 JVP: RV infarction, associated CCF
 Pulse: absent/disparity of pulse in aortic dissection
 BP: Hypotension/Hypertension/Disparity
 SPo2: Hypoxia in PE or pulm edema
 Auscultation:
 CVS: S1, S2 (P2 loudness), murmur, friction rub
 RS: dull note, air entry, crepts, pleural rub/bronchial
breath sound

26. Clinical evaluation

27. ECG:
 Should be obtained in 10 min.
 0.5 mm Changes in ST segment during pain is more
significant
 A complete normal ECG does not rule out ACS
 Take Serial ECGs…
 Take RV leads…V3R, V4R
 Take Posterior leads V7, V8, V9
 Compare with
previous ECG

28. RV lead/Posterior leads

29. RV MI

30. Patient presented with normal ECG
59 yrs, chest
pain with Bowel
symptoms,
ECHO - RWMA
present.
Trop T negative

33. ST – T changes during Ischemia

36. Compare with previous ECG

38. When ECG/Biomarkers are not
diagnostic/suggestive of ACS….Rule out other
causes

39. Role of ECHO in chest pain
 ACS – Wall motion abnormality/thinning
 Pericarditis.
 Endocarditis
 Carditis – Rheumatic
 Hypertrophic cardiomyopathy
 MVPS
 Aortic/Pulmonary stenosis.
 Aortic dissection.
 Pulmonary hypertension.
 Pulmonary embolism

41. Angio of pt with LAD lesion

42. IWMI

43. Angio of pt with RCA lesion

44. Cardiac biomarkers
 Should be measured at presentation (0 hr)
and after 3 - 6 hrs of symptom onset.
 Preferred biomarker is cardiac troponin T or I.
 CK-MB is less sensitive
 only one elevated troponin level above the established
cutoff is required to establish the diagnosis of acute MI,
 Up to 80% of patients with acute MI will have an elevated
troponin level within 2-3 hours of Chest pain.
 Each Lab has their own 99th percentile upper reference
limits and 10% Coefficient of Variation levels.

45.  CK-MB used to diagnose reinfarction
 The 99th percentile cutoff point for cardiac troponin T
(cTnT) is well-known at 0.01 ng/mL
 The following are 99th percentile cutoff values for
acute MI for some of the commonly used troponin I
assays:
 Bayer ACS: Centaur: 0.15
 Bayer ACS:180: 0.07
 Dade Dimension RxL, second generation: 0.07
 Beckman Access, second generation: 0.04
 Roche Elecsys, third generation: 0.01

46. What we use..
 Troponin T Card test
 Gives Positive or Negative result - Not reliable
 Troponin I test (Quantitative)
 Most reliable test of MI

47. T
TMT
Non invasive tests
Stress ECHO,
Radionuclide scan,
CT angio
STEMI
NSTEMI
UA
ECG

48. Management of ACS
 Initial therapy focuses on the following:
 Stabilizing the patient’s condition
 Relieving ischemic pain
 Providing antiplatelets/statins/antithrombotic
 Fibrinolytic therapy/PCI - (percutaneous Coronary
Intervention)
 Time is Muscle.. With in 4 hrs .
 Time window: Duration of
Onset of Chest pain
 TW for thrombolytic therapy
is 12 hrs

49. TIME is muscle…
But people will think differently…

50.  Relieving ischemic pain
after Inj. Ondensetron
 Inj. Morphine 2 -3 mg slow i.v upto 10mg (or)
 Inj. Pethidine 25mg or 50 mg i.v (or)
 Inj. Tramadol 50mg or 100 mg i.v
 Tab. Sorbitrate (ISDN) 5mg sublingual
 if BP > 100mmHg
 Tab. Trimetazidine 35mg MR
 Tab. Nicorandil 5mg, 10 mg
 Tab. Ivabradine 5mg.

51. Loading dose:
1. Give Tab. Aspirin 300mg Chewable
2. Tab. Clopidogrel 300mg
(75 x 4 tab), or
Ticagrelor 90 (2 tab).
3. Tab. Atorvastatin 10mg (8)

53. Loading dose precautions…
 Clopidogrel 300 mg (75 mg when age > 75 yrs)
 Prasugrel 60 mg or Ticagrelor 180 mg may be used in
place of Clopidogrel in NSTEMI/UA
 but not to patients of STEMI going to receive
thrombolytic therapy.
 Prasugrel is contraindicated in
 >75 yrs, <60 Kgs, H/o CVA.

54.  Pharmacologic anti-ischemic therapy includes the
following:
 Inj. Heparin 5000 Units (1cc) iv or
Inj. LMWH 1mg/Kg s.c
 Nitrates (for symptomatic relief) if BP is normal.
 Beta blockers (eg, metoprolol): unless contraindicated
 Calcium channel Blockers: (UA/NSTEMI)
 DILTIAZEM

55. Stabilize the pt
 Brady < 40/min : Inj. Atropine 0.6mg or 1.2mg iv
 Pulm edema: Inj. Lasix 20mg to 200mg iv stat
 Nasal O2,
 Back rest
 Hypotension and Chest clear:
 RVMI
IVF NS 1.5 L rush..
 Hypotension still persist:
 Inotropes:
Inj. Dopamine, or
Inj. Nor adrenaline

56. STEMI
 Time window for Fibrinolytic therapy is
12 hrs of onset of chest pain.
 Pt presented after 12 hrs and < 24 hrs, if there is on going
ischemia/Hypotension with ST Elevation – Late lysis
 Primary PCI -now preferred treatment for STEMI
 Ischemic symptoms < 12 hrs ,
 When fibrinolysis are contraindicated.
 Cardiogenic shock/Acute severe heart failure.
 Ongoing ischemia 12-24 hrs – Class II a.
 upto 36 hrs of onset of MI (Late presentation)

57. STEMI
FMC – First Medical Contact

58. To simplify
 1. Nature of Chest pain - Typical Angina
 2. ECG – ACS findings
 3. ECHO - RWMA
 4. Troponins – Positive
Any one is present, then it is ACS
 we have to admit for Angiogram and manage ACS.
 If Chest pain is atypical...then do TMT.
 Loading dose should be given on the spot.
 LMWH or Heparin can be given at First Med Contact.
 Immediate referral to cardiac intervention centers.

60. Take home message:
 Chest pain – cardiac origin unless proven otherwise
 ACS may have normal ECG.
 Troponin is a must
 ECHO aids in diagnosis, does not rule out ACS.
 ACS : loading dose of Aspirin 300mg /Clopidogrel
300mg/Atorvastatin 8omg given on the spot.
 ACS: Sorbitrate only after measuring BP.
 STE ACS/Non ST ACS – guide the management.
 If a Chest pain patient is coming at night time – Pl
Admit!

62. Example 1
 Hyperacute
MI

63. 45 yrs old man, 3 hrs Time window

64. After thrombolysis

65. Case 2, 32 yrs male, NSTEMI

66. After 4 hours

67. PCI

71. CASE 3: Primary PCI with stent
done for IW STEMI: RCA cut off

74. Take home message:
 Chest pain – cardiac origin unless proven otherwise
 ACS may have normal ECG.
 Troponin is a must
 ECHO aids in diagnosis, does not rule out ACS.
 ACS : loading dose of Aspirin 300mg /Clopidogrel
300mg/Atorvastatin 8omg given on the spot.
 ACS: Sorbitrate only after measuring BP.
 STE ACS/Non ST ACS – guide the management.
 If a Chest pain patient is coming at night time – Pl
Admit!