This document discusses the evaluation and management of acute chest pain, which can be caused by conditions like angina, myocardial infarction (MI), or other musculoskeletal and gastrointestinal issues. Key points include: - Taking a history, examining vital signs, performing an ECG and cardiac biomarkers to determine if the pain is cardiac or non-cardiac in nature. - For suspected acute coronary syndromes like unstable angina or NSTEMI, treatment involves antiplatelet therapy, anticoagulation, nitrates, beta blockers and revascularization if needed. - For STEMI, prompt treatment involves aspirin, clopidogrel, thrombolytics if eligible, and managing any arrhythmias or mechanical complications

1. ACUTE CHEST PAIN
ACUTE CORONARY SYNDROMES

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

3. 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

4. Suspect Cardiac Pain in
• >40yrs,male
• Post menopausal
• C/C smoker
• DM/HTN
• Obese
• Sedentary
•TYPICAL CARDIAC PAIN
• ANGINA EQUIVALENTS

5. 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

6. IHD
c/c stable angina
ACS
UA NSTEMI STEMI

7. ACS
60% UA
40%MI
2/3NSTEMI 1/3STEMI

8. PATHOPHYSIOLOGY
1. A/C plaque change
2. Dynamic obstruction (vasospastic)
3. Progressive mechanical obstruction
4. INCREASED myocardial O2 demand
5. Decreased supply of O2

10. UA & NSTEMI
UA Presents as
•Rest angina >10 minutes
•Severe & new onset angina
•Crescendo angina
NSTEMI
•Above features + evidence of
myocardial necrosis

11. ECG
1. Labile ST Segment depression
2. T Inversion
3. Transient ST Elevation

12. Cardiac Specific markers
1. Myoglobin- first to rise (with in 2 hrs) less value
2. Troponin I- has got prognostic
value,PREFFERED MARKER
3. CPK-MB-
4. LDH 1
NOT elevated in Pts with UA

14. Rx of UA / NSTEMI
GOALS
1. Prevention of Thrombus
2. Restoration of coronary blood flow
3. Reduction in myocardial o2 demand

15. • Supplemental o2
• Morphine SO4
1. Reduces pain
2. Causes venodialatation
3. Arteriolar dialatation
4. Vagotonic effect
5. Useful in pul edema
Dosage – 2 -4 mg Iv Rpted every 5 mts or until S/E ensue
S/E – Hypotension,Nausea, vomitting,Apnea,Urinary retention

16. Antiplatelet therapy
1. Aspirin-325 mg non enteric chew stat if no c/I . Later
150 mg /day
2. Clopidogrel- 300mg stat & 75 mg / d
3. Combination – ecospirin + clopidogrel
4. Gp 2 b 3a antagonists
1. Absciximab
2. Epifibatide
3. tirofiban

17. 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 thrombocytopenia
1. PLT Count Dec after 5 – 7 days
2. Occurs in 1 – 3% people
3. LEPIRUDIN & ARGATROBAN used instead

18. Anti ischemic Rx
• Nitrates – NTG 0.5 mg s/l,Sorbitrate 5 mg s/l
C/I – Hypotension,
1. RVMI
2. Tachycardia >100bpm

19. • 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 bpm
Marked 1 AV Block
BR Asthma
Complete HB

20. 1. CCB-
2. ACEI – Enalapril 2.5 ½ OD / BD
1. Inhibits cardiac remodelling
3. Thrombolytic Therapy – not indicated
4. Coronary Revascularisation (PCI,CABG)
5. RISK FACTOR MODIFICATION
1. Stop smoking
2. Lose weight (BMI<25 Desirable,WC < 40in M & <35in F)
3. Exercise
4. BP Controll
5. DM & Hyperlipidemia management

21. STEMI
• MC Cause of death is VF
DIAGNOSIS ( 2 or > of the following)
1. H/o Prolonged chest discomfort / Angina equivalent >30 mts
2. 2mm or < STE in precordial leads OR 1mm or > STE in Inferior leads
3. Elevated biomarkers

22. History
1. Typical cardiac pain / Angina equivalent
2. Silent MI- present with confusion,dyspnoea,unexplained hypotension
1. Elderly
2. Diabetics
3. Hypertensives
4. Post op Pts

23. O/E
1. PSM Mitral area
2. RVMI – Cardiogenic shock,hypotension,^JVP No features of pul
edema

24. ECG
1. Hyperacute T Waves
2. ST Segment changes
1. 2, 3 aVF - IWMI
2. V1 V2 V3 – AWMI
3. 1 aVL V5 V6- Lateral
4. PWMI- reciprocal changes in anterior leads
5. RVMI – STE in V4R Q Waves

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

26. Rx
1. General measures
1. Continuous ECG, BP, SpO2 measurement
2. O2
3. Two IV Lines
4. RVMI – Start IV Fluids. C/I in Pul Edema
5. CCU

27. 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

28. Contd
• THROMBOLYTIC THERAPY
IND- STE 2mm or > in precordial leads
STE 1mm or>in Inf leads
Fresh LBBB
Posterior MI

29. THROMBOLYTIC THERAPY
• C/I
1. H/O ICH
2. AVM, Aneurysms
3. Intracranial tumours
4. Ischemic stroke <3 months
5. Aortic dissection
6. Major Trauma with in 3 months
7. High BP , SBP>180 mm DBP >110mm
8. Bleeding diathesis
9. Previous STK use > 5days & <2 yr
10. >12 hrs after onset of pain

30. Administration
• 1.5 million IU STK in 100 ml NS over 1HR
• Inj Avil + Efcorlin given prior
• ECG & BP monitoring
Adverse reactions
• Life threatening ICH
• Hypotension
• Bleeding from puncture sites
• allergy

31. Signs of therapeutic Efficacy
• Symptomatic improvement
• ECG Change
1. Late diastolic VPCs
2. AIVR
3. Fall of STE
• Early peaking & Fall in Enzyme levels

32. •Heparin is used If infarct is large or if pain continues
Periinfarct management
• Bed Rest
Absolute bed rest for 12 hrs
Sit upright in 24hrs
Ambulated by 2nd & 3rd day
After 3rd day -> gradually ^ ambulation
• Low residue liquid Diet
• Bowels Avoid dstraining at stools . Give laxatives
• Sedation – Alprax 0.25mg 1 HS, Lorazepam 1mg

33. Contd
•Statins - HMG Co A Reductase inhibitors
ATORVASTATIN 10-80 mg/day
Started in those with Dyslipidemias
Target LDL <100 in all Pts with CAD
<70 in those with very high risk
S/E
Hepatotoxicity
Myopathy
Rhabdomyolysis

34. 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

35. ATIONS
• 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

36. S
•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

37. • 3rd degree AV Block & Asystole - Trans venous pacing
• SVT
• Sinus Tachycardia
• PSVT
• AF & AFl
• Accelerated junctional rytham

38. 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

39. •VF – good prognosis – DC version needed
A/C LVF
Avoid IV Fluids
Morphine is helpful
Diuretics , ACEI,Nitrates
RVMI – in IWMI & PWMI
Cardiogenic shock
Give IVF,support with Dopamine , Dobutamine
Intra aortic balloon pump

40. 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

41. • 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