The document provides information on evaluating and managing patients presenting with chest pain and acute coronary syndrome. It discusses how to take a clinical history to determine the nature and cause of chest pain. Differential diagnoses are provided for cardiac and non-cardiac causes. Acute coronary syndrome is described as encompassing unstable angina, NSTEMI, and STEMI, which present with chest pain at rest or minimal exertion due to plaque rupture or erosion in coronary arteries. Immediate management in the first 12 hours and long-term management are outlined.

1. APPROACH TO PATIENT WITH
CHEST PAIN & ACUTE
CORONARY SYNDROME
Presented by: Siti Nur Hamizah

2. 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

3. 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.

4. 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.

6. DIFFERENTIAL DIAGNOSIS
Cardiac Non-Cardiac
Coronary artery disease GIT disorder:
MI a)Esophageal disorder like esophagitis or
esophageal motility disorders
Pericarditis b) Peptic ulcer
myocarditis c)Biliary disease
Pulmonary embolism d)Pancreatitis
Less common causes: Musculoskeletal disorder:
Costochondritis, rib #,
Aortic dissection Radiculopathy
Aneurysm of thoracic aorta Psychogenic chest pain
Severe aortic stenosis
Lungs/ pleura:
Bronchospasm
pulmonary infarct
Pneumonia
Pneumothorax
pulmonary embolism
tuberculosis.
Neurological:
Prolapse intervertebral disc
Herpes zoster
Thoracic outlet syndrome

7. 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:

8. 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.

9. • 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

10. INVESTIGATION
ECG
Plasma 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 CRP
Chest x-ray
Echocardiography

11. IMMEDIATE MANAGEMENT: THE FIRST
12 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.

13. 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

14. COMPLICATIONS OF ACUTE
CORONARY 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

15. THANK YOU.