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13.01.07 Chest pain cPBL

Differentials
  • 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

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


Focused Assessment with Sonography for Trauma (FAST)
  • Limited ultrasound examination directed solely at identifying the presence of free intraperitoneal or pericardial fluid
  • Can exclude pericarditis, tamponade


ACS management
  • 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

Interesting other causes of ST elevation
  • LV aneurysm from previous MI
  • Stroke / CNS pathology
    • Signalling from brain?


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


Notes
  • 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
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