• ACS
• Angina
• Chostochondritis
• GORD
• PE
• Pericarditis
• Usually preceded by a viral illness
• Listen for friction rub
  
• Pneumonia
• Pleural effusion
• Dissection
• May spread to carotids and => focal neurological deficit

Oxygen in ACS

• Pts actually do better without oxygen, as long as sats are 98% -ish
• Free radicals => myocardial damage

Anaemia

• => Rise in cardiac output => Chest pain
• => Give blood for symptomatic anaemia, even if Hb is >8

ECGs

• Grrrr
• Check the Hx at the time the ECG is taken
• Look for EVOLVING CHANGES
• Consider V4R for RV infarcts

Enzymes

• Trop
• Immediately on admission, then 4 hours later
• Make sure you check renal function too!
• CK
• First thing to rise
• Check on admission as part of cardiac enzymes
  

• Don't forget:
• Renal function
• Lipid profile
• Glucose
• TFTs
  

• Limited ultrasound examination directed solely at identifying the presence of free intraperitoneal or pericardial fluid
• Can exclude pericarditis, tamponade
  

• Aspirin
• 300 mg initially, then 75 md OD
• Clopidogrel
• But cf NSTEMI / need for PCI
  
• Morphine
• GTN
• LMW heparin
• Not if renal impairment
• Beta blocker
• Unless in heart failure
• Statin
• Immediate benefit
• Even if lipids "normal" (they're not normal for him)
• BEWARE BLEEDING
• Manage on a monitored bed
  

• LV aneurysm from previous MI
• Stroke / CNS pathology
• Signalling from brain?

• IV antiplatelet agents
• Examples:
• Abciximab 
• Eptifibatide
• Tirofiban
• Useful in ACS if clopidogrel is contraindicated (e.g. need a stent)

• Most common cause of chest pain
• Obesity => Sliding hiatus hernia => Reflux
• Semi-urgent referral
• RACP clinic (2 weeks)
• Make a note of risk factors at the top of your clerking
• No risk factors at all => Manage conservatively
• Maybe an ETT
• cf Angiogram for the old, male smoker
• Heart failure => ASCITES
• RENAL FUNCTION is a key investigation
• Trop
• LMW heparin
• Hypothyroidism => Hypercholesterolaemia
• Umbra + Penumbra
• Penumbra grows with time
• Reperfusion arrhythmias from toxic wash-out
• GLP1 => Reduced appetite
• NSAIDs => Clotting risk
• Avoid for pain relief in ACS
• Cardiac rehab has NO survival benefit
• But good psychological effects
• NSTEMI has a WORSE prognosis than STEMI
• Tends to be from diffuse, small-vessel disease (e.g. from diabetes)
  
• Less treatable by PCI
• Entire pericardium is affected
• Give clopidogrel for 1 year post-MI
• Especially important if stented (90X thrombus risk without)
• Monitor BP if you're giving nitrates