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ACUTE CHEST PAIN

ACUTE CORONARY
SYNDROMES

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

APPROAC
H

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

Suspect Cardiac
Pain in
>40yrs,male
Post menopausal
C/C smoker
DM/HTN
Obese
Sedentary

TYPICAL CARDIAC PAIN


ANGINA EQUIVALENTS

PHYSICAL
FINDINGS
Apprehensive look, Angor
amini
Sweating, cold
skin,Hypotension,
Tachy/Bradycardia,Arrythmi
as
Wide/Narrow pulse pressure
Dyskinetic Apex
S3,S4,Apical sys murmur
Pericardial rub
Basal creps

IHD

c/c stable angina

ACS

UA

NSTEMI STEMI

ACS

60% UA

40%MI

2/3NSTEMI

1/3STEMI

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

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

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

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-MB4. LDH 1
NOT elevated in Pts with UA

Rx of UA /
NSTEMI
GOALS

1. Prevention of Thrombus
2. Restoration of coronary
blood flow
3. Reduction in myocardial o2
demand

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

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

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. LMWH1. Dalteparin(Fragmin)
2. Enoxaparin

Heparin induced thrombocytopenia


3. PLT Count Dec after 5 7 days
4. Occurs in 1 3% people
5. LEPIRUDIN & ARGATROBAN used instead

Anti ischemic Rx
Nitrates NTG 0.5 mg s/l,Sorbitrate 5
mg s/l
C/I

Hypotension,

1. RVMI
2. Tachycardia >100bpm

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

1. CCB2. ACEI Enalapril 2.5 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

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

History
1. Typical cardiac pain / Angina equivalent
2. Silent MI- present with confusion,dyspnoea,unexplained
hypotension
1.
2.
3.
4.

Elderly
Diabetics
Hypertensives
Post op Pts

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

ECG
1. Hyperacute T Waves
2. ST Segment changes
1.
2.
3.
4.
5.

2, 3 aVF - IWMI
V1 V2 V3 AWMI
1 aVL V5 V6- Lateral
PWMI- reciprocal changes in anterior leads
RVMI STE in V4R Q Waves

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

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

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

Contd
THROMBOLYTIC THERAPY
IND-

STE 2mm or > in precordial leads


STE 1mm or>in Inf leads
Fresh LBBB
Posterior MI

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

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

Signs of therapeutic Efficacy

Symptomatic improvement

ECG Change
1.
2.
3.

Late diastolic VPCs


AIVR
Fall of STE

Early peaking & Fall in Enzyme levels

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

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

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

ICATIONS
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

MIAS
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

3rd degree AV Block & Asystole - Trans venous pacing


SVT

Sinus Tachycardia
PSVT
AF & AFl
Accelerated junctional rytham

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

VF good prognosis DC version needed


A/C LVF

Avoid IV Fluids
Morphine is helpful
Diuretics , ACEI,Nitrates
in IWMI & PWMI
Cardiogenic shock
Give IVF,support with Dopamine ,
Dobutamine
Intra aortic balloon pump
RVMI

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

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

THANK YOU