DR.

SHERIF WAGDY AYAD,MD Lecturer of Cardiology Alexandria University

Chest Pain
y 5 Million emergency department visits y 2 million hospitalizations annually with cost of more

than $8 billion y Cardiac etiology found in less than one third y 2% of patients with acute MI are unrecognized and discharged from the ED

Chest Pain
y Rapid Dx &Tx = saved muscle = improved outcome y Largest category of loss from malpractice litigation in

the emergency department

Goals
Rapid recognition of management of true ACS 2. Recognition of other life-threatening causes of chest pain
1.
Aortic dissection Pulmonary embolism Tension pneumothorax

3. Minimize cost and hospitalization in patients

with chest pain of benign etiology.

Classic Angina
y y y y y y

Location: central chest Quality: squeezing, pressure, heaviness Radiation: arm(s), neck, jaw Associated symptoms: dyspnea, diaphoresis, nausea Eliciting factors: exertion Relieving factors: rest, nitroglycerin

Cardiovascular Chest Pain

y Coronary Heart Disease y Stable angina pectoris y Unstable angina y Myocardial infarction y Coronary Vasomotor y Myocarditis y Valvular Heart Disease y Aortic stenosis y Mitral stenosis y Hypertrophic cardiomyopathy y Aortic Dissection y Post-pericardiotomy

Disease
y Variant angina y Microvascular angina

y Pericarditis

Differential Dx ACS
y Unstable Angina (UA): y Change in the pattern of angina
y y y y y

New Onset More frequent, severe, easily provoked More difficult to relieve Occurs at rest, lasting >20 min High risk of AMI

Differential Dx ACS
y Pulmonary Embolism: y Atypical, presenting with any combination of:
y y

Chest Pain, Dyspnea, Syncope, Shock, Hypoxia Fever, cough, hemoptosis Reproducible with breathing, palpation Sharp pain, Dyspnea Tachypnea, tachycardia, hypoxemia

y Pain is often pleural

y

y Classic presentaion:
y y

Differential Dx ACS
y Aortic Dissection: y Risk Factors Atherosclerosis, HTN (uncontrolled), Coarctation of Aorta, Bicuspid Aortic Valve, Aortic Stenosis, Marfan Syn, Ehlers-Danlos Syn, Pregnancy y Pain midline Substernal CP, tearing, ripping, searing, radiating to interscapular area y Pain Above AND Below Diaphragm y Often assoc. with stroke, AMI, limb ischemia

Differential Dx ACS y Spontaneous Pneumothorax:

y Risks:
y y

Sudden Change in barometric pressure Smokers, COPD, Idiopathic Bleb DZ sudden, sharp, pleuritic chest pain, and dyspnea Absence of breath sounds ipsilaterally Hyper resonance to percussion CXR Dx simple pneumo

y Pain:
y

y Dx:
y y y

Differential Dx ACS
y Esophageal Rupture (Boerhaave Syn): y Life-threatening y Substernal, sharp CP y Sudden onset after forceful vomiting y Dyspneic, diaphoretic, and ill-appearing y CXR: Normal, SQ air, Pleural Effusions, Pneumothorax, pneumoperitoneum, pneumomediastinum y Water Soluble Contrast Study

Differential Dx ACS
y Acute Pericarditis: y Acute, sharp, severe, constant, substernal CP y Radiation to back, neck, shoulders y Worse with lying down and inspiration y Relief with leaning forward y FRICTION RUB y EKG: ST segment elev., T wave inversion, or PR depression

Differential Dx ACS
y Pneumonia: y Sharp and Pleuritic y Fever, cough, hypoxia y Rales, decreased breath sounds, etc. y CXR

Differential Dx ACS
y Mitral Valve Prolapse: y Women > Men y Discomfort at rest y Assoc. Sx:
y

Dizziness, Hyperventilation, Anxiety, Depression, Palpitations, Fatigue, SVT, Ventricular Dysrhythmia

y Tx: Beta-Adrenergic Blockers y Dx: Echo

Differential Dx ACS
y Musculoskeletal/Chest Wall Disorders: y LOCALIZED, Sharp, positional CP y Reproducible y Types
y y

Costochondritis, Tietze Syndrome Xiphodynia

Differential Dx ACS
y GI Disorders: GERD/dyspepsia y burning, gnawing low CP y Acidic taste y Recumbent position increases pain y Relief per antacids
y

CAREFUL, can also help in ACS

Differential Dx ACS
y Esophageal Spasm: y Sudden onset, dull, tight, gripping y Hot or cold liquids y Large food bolus y Responds to NTG

Differential Dx ACS
y Peptic Ulcer Disease: y Gastric:
y y

Postprandial, dull, boring pain Midepigastric, may awake pt. Relieved after eating

y Duodenal Ulcer:
y

y Symptomatic Tx: antacids y DDx: Pancreatitis and Biliary tract Dz

Differential Dx ACS
y Panic Disorder: y Recurrent, Unexpected panic y Including at least 4 SX:
y

Palpitations, diaphoresis, tremor, dyspnea, choking, CP, nausea, dizziness, derealization, or depersonalization, fear of losing control or dying, paresthesias, chills, hot flashes

y Rule out substance abuse

Immediate Goals
y Cardiac or not? y If cardiac, how to manage?

Unstable Angina / NSTEMI

Definition
ST-segment depression or prominent T-wave inversion and/or positive biomarkers of necrosis in the absence of STsegment elevation and in an appropriate clinical setting..."

ACC/AHA 2007 Guidelines for the Management of Patients with Unstable Angina/Non-ST Elevation Myocardial Infarction

Unstable Angina / NSTEMI

(Unstable Angina)

ACC/AHA 2007 Guidelines for the Management of Patients with Unstable Angina/Non-ST Elevation Myocardial Infarction

Unstable Angina / NSTEMI

LBBB

Selection of the Optimal Reperfusion Options for the STEMI Patient

Invasive Strategy
y Cardiogenic shock (age < 75) y Bleeding risk y Diagnosis in doubt

Full Dose Fibrinolytic Monotherapy Door to balloon (D-B) > 90 min

y y y y

Lack of access to skilled PCI center (D-B) (D-N) > 1 h < 3 h from symptom onset

(pericarditis/aneurysm)

y Door to balloon < 90 min y Skilled PCI center available, defined

by:

y Operator experience > 75

cases/yr y Team experience > 36 primary PCI/yr

y Age > 75 y Symptoms > 2-3 h

Ideal Categorization of Patients with CP

Group 1 Group 2

Group 3

Group 4

MI with ST elevation New LBBB

MI without ST elevation and no LBBB Unstable angina high risk

Unstable angina low risk

NonNon-cardiac chest pain

Primary PCI or Thrombolytics

Heparin, GP IIbIIIa inhibitor

Heparin, admission

Discharge or Treat as condition warrants

y RECENTLY MSCT used for triple rule out:

1-ACS. 2-Pulmonary embolism. 3-Aortic dissection.