1. A patient presented to the emergency room with chest pain. Initial assessment included ECG, cardiac monitoring, bloodwork, oxygen, aspirin, and morphine if not contraindicated. 2. Further evaluation depended on risk level based on history, exam, ECG findings, and cardiac enzymes. Low risk patients could be evaluated as outpatients, while higher risk patients required inpatient monitoring and treatment for acute coronary syndrome. 3. Ongoing management after discharge focused on lifestyle modifications like smoking cessation, exercise, diet, and medication adherence to control risk factors and prevent future events.

2. An Approach to
CHEST PAIN at ER….?
SHAHID ABBAS
MBBS, FCPS (MED), FCPS (CARD)
Interventional Cardiologist & Medical Specialist

3. The Road Map!
Atherosclerosis
IHD
Encountering Chest Pain
Investigations involved
Red flags and Loop holes
Summary
Conclusion

4. A Patient walks in to your
ER with
chest Pain

5. Brain Storming !
• 60 % of chest pain diagnoses were not "organic
• Musculoskeletal 36 % of all diagnoses
• Costochondritis -13 %
• Reflux esophagitis -13%
• Stable angina pectoris -11 %
• Unstable angina or myocardial infarction -1.5 %

6. Better Safe Then Sorry
Life-threatening conditions
• Acute coronary syndrome
• Aortic dissection
• Pulmonary embolism
• Tension pneumothorax
• Pericardial tamponade
• Mediastinitis

8. Initial Assessment Check list
• Resuscitation equipment brought to the bedside
• Airway, breathing, and circulation assessed
• Preliminary history and examination obtained
• 12-lead ECG done and interpreted
• Cardiac monitor attached to patient
• Oxygen given
• IV access and blood work obtained
• Aspirin 150 to 300 mg given (DDT)
• Nitrates and morphine given (unless contraindicated)
ALL IN 10 MINS

9. History of chest pain
General approach about Chest Pain
• Onset of pain
• Provocation/Palliation
• Quality of pain
• Radiation
• Site of pain
• Timing
• Chest Pain equivalents
( breathlessness, Nausea, Vomiting )

10. Important points on history…
 Worsening in the frequency, intensity, duration, and timing of prior
anginal or anginal equivalent symptoms
 New onset symptoms of shortness of breath, nausea, sweating,
extreme fatigue in a patient with a known history of cardiovascular
disease
 Onset of typical anginal symptoms in a previously asymptomatic Pt
 Age greater than 70 years
 Diabetes mellitus
 Women
 Extracardiac vascular disease (PVD, PAD, CVA)

11. Atypical Chest pain
• Pleuritic pain, sharp or knife-like pain related to
respiratory movements or cough
• Primary or sole location in the mid or lower abdominal
region
• Any discomfort localized with one finger
• Any discomfort reproduced by movement or palpation
• Constant pain lasting for days
• Fleeting pains lasting for a few seconds or less
• Pain radiating into the lower extremities or above the
mandible

12. Targeted History…..
• Diagnostic studies in the Past
• Comorbidities: hypertension, diabetes mellitus,
peripheral vascular disease, malignancy
• Recent events: trauma, major surgery or
medical procedures (eg, endoscopy), periods of
immobilization (eg, long plane ride)
• Other factors: cocaine use, cigarette use, family
history
• Contraindications to SK

13. Physical Examination
• Most often the physical examination is not helpful
• Anxious and distressed and may be diaphoretic and
dyspneic
• Differential Diagnosis
• Evidence of systemic hypoperfusion Cardiogenic shock
• Evidence of heart failure
• A screening neurologic examination Subtle/ ongoing
CVA (contraindication to SK)

14. ECG
• A standard 12-lead electrocardiogram (ECG) within
10 minutes
• A single ECG detects < 50 percent of AMIs
• Patients with normal or nonspecific ECGs have a 1
to 5 percent incidence of AMI and a 4 to 23 percent
incidence of unstable angina
• ECG should be repeated as frequently as every 10
minutes if the initial ECG is not diagnostic but
high clinical suspicion for AMI is there
• Prior ECGs are important
Normal ECG DOES NOT RULE OUT ACS

15. Components of the ECG

16. QRS
 Q wave

17. J-Point

18. ST Segment

19. ST Segment Elevation
 Presumptive evidence of AMI
 Indication for acute
reperfusion therapy

20. ST Segment
 Compare to TP segment
ST TP

21. Investigations
 Chest x-ray
 Usually non-diagnostic in ACS
 Helps to identify other important
conditions
 Congestive heart failure
 Pnuemonia
 Pnuemothorax
 Pleural effusion
 Widened mediastinum (aortic dissection)

22. Normal CXR!

23. Left lower lobe pneumonia

24. 1. Interstitial pulmonary edema 2. Bilateral perihilar alveolar edema
3. Bilateral pleural effusions.

27. Thoracic Aortic Dissection
 Classic – Ripping pain to back
 Unequal BP’s > 20mmHg
 Consequence of Thrombolytic Therapy
 DEATH

28. Acute Pericarditis
 Classic – Sharp or pleuritic chest pain.
 Pain is worse when placed in supine
position
 Pain better when sitting
 EKG: PR depression with ST elevation in
diffuse leads
 Consequence of Anticoagulation:
 DEATH

29. Ventricular Aneurysm
 Classic – History of old Myocardial
Infarction.
 Diagnostic Q – Waves on EKG with raised
ST
 Consequence of Anticoagulation:
 NONE

30. Cardiac Enzymes
 Cardiac Troponins
 Blood levels rise after 3-6 hours (can be negative at initial
assessment!)
 Peak at 12-20 hours
 Creatine Kinase (CK)
 May rise earlier than troponin, but less specific for cardiac
muscle
 ALWAYS repeat in 6-8 hours if suspicious for acute
cardiac event (ie, non-STEMI)
 Loop Holes

32. Enzymes Elevation
-- TROP

33. Comparison
Acute Coronary Syndromes – Cardiac Markers
Marker Initial
Rise
Peak Return to
normal
Benefits
Troponin 2-4 hr 10 -24 hr 5 -10 days Sensitive and specific
CK-MB 3-4 hr 10-24 hr 2 – 4 days Unaffected by renal failure
LDH 10 hr 24 -72 hr 14 days
Myoglobin 1-2 hr 4 -8 hr 24 hours Very sensitive, powerful
negative predictive value

34. Predictors of high risk for ACS
History
 Age > 65 years
 Class III or IV angina
 Accelerating tempo CP/ pain similar to MI in the Past
 Women
 Diabetes
 Previous MI/ PCI
 Patient on Disprin
Examination
 Tachycardia /Bradycardia /Hypotension
 Clinical LVF ( S3, transient MR, new or worsening Crepts)

35. Predictors of high risk for ACS
ECG
 Dynamic ST changes
 ST deviation > 0.5 mm
 Multiple leads involvement
 LBBB
 SVT
 Positive cardiac biomarker
CAD Equivalents
( DM, Carotid AD, Abd Aortic aneurysm, Symptomatic PVD)

36. CHEST PAIN
ECG Suggestive of MI Yes
ECG suggestive of ischemia
No
Yes
No None or 1 Risk Factor 2 or more Risk Factor
Intermediate Risk (8 %)
High risk (MACE > 17 %)
Very Low Risk < 1%
Low Risk Risk ( 4%)
No Risk Factors
1 Risk Factor
2 or More Risk Factor

37. High Risk (MACE > 17%)
Treat as ACS
Intermediate Risk (MACE 8%)
Observe for 6-12 hours investigate indoors
Low Risk (MACE 4%)
Observe for 4- 6 Hours investigate indoor/outdoors
Low Risk (MACE 1%)
Investigate Out doors (ETT, MScT angio)

38. Role of ETT in ACS
Asymptomatic low risk Patients
Adequate ETT
• Atleast 8 minutes
• > 85 % THR achieved
Negative ETT in males mean 85% probability that:-
• LMS
• Significant TVCAD are NOT present
Females 65%
Positive ETT has to be investigated further !

39. Role of MScT Angio
Low to intermediate risk
Triple rule out
• LMS
• TVCAD
• PE
Prerequisites
• Tolerant to B blockers
• Closed space
• Sinus rhythm (regular)

40. ACS Emergent Care
 M orphine
 O xygen
 N itro
 A ntiplatelets ( Disprin &
Clopidogril)
 G P IIb IIIA Inhibitors
 B eta Blockers

41. Post discharge Care
 ABCDE
A – Antiplatelets & Antianginals
B – Beta blocker, Blood pressure control
C – Cholesterol lowering, Cigarettes cessation
D – Diabetes control, Diet
E – Education & Exercise ( Life style modifications)