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