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