1. Chest Pain Dr. Shamim Nassrally BSc (Hons) MB ChB MRCP(London) Clinical Teaching Fellow

2. Objectives By the end of this session you should be able to: Recognise Acute Coronary Syndrome (ACS) Initiate appropriate investigation and management of ACS Be able to calculate and interpret TIMI scores Recognise Acute Myocardial Infarction and use appropriate investigation to confirm the diagnosis

3. Acute Block 8 • Week 4 • Tutorial 1 • Intro Simulation • Experience in ED/AMU • Medical Rotation in Junior Phase • Revision/Putting it all together/Ask the “silly” questions

4. Chest pain SOCRATES Identify most likely system involved Cardiac Pulmonary Gastrointestinal Musculoskeletal Neurological (Psychiatry)

5. Chest pain SOCRATES Identify most likely system involved Cardiac Pulmonary Gastrointestinal Musculoskeletal Neurological (Psychiatry)

6. Cardiac Chest pain Coronary Artery disease (CAD) Ischaemic Heart disease (IHD) Atherosclerotic Heart Disease Essentially plaques made of cholesterol and calcium build up in the coronary arteries reducing cardiac muscle perfusion Synonyms

8. Pathophysiology

9. Terminology Angina UA NSTEMI STEMI ACS

10. Angina Unstable Angina Exertional Relieved by rest ± ECG changes ( ST depression, T wave inversion) Troponin negative Can occur at rest Crescendo ± ECG changes ( ST depression, T wave inversion) Troponin negative

11. NSTEMI STEMI Troponin +ve ± ECG changes (ST depression/ T wave inversion) Troponin +ve ST elevation New onset LBBB

13. Cardiac Chest Pain (typical) Site : Onset: Character: Radiation: Associated Features: Timing: Exacerbating & Relieving Factors: Severity:

14. Cardiac Chest Pain (typical) Site : Retrosternal Onset: Sudden, Crescendo, Exertional Character: Dull, Squeezing, Tightness Radiation: Throat/Jaw, Shoulder Associated Features: Dyspnoea, Autonomic Sx Timing: Exertion, Meals, Rest. Duration Exacerbating & Relieving Factors: Exertion/Rest Severity: Subjective – but usually severe

15. Common risk factors ?

16. Common risk factors Hypertension Hypercholesterolaemia / Dyslipidaemia Diabetes Mellitus Smoking Age Male Family History of early CAD Obesity/ Physical Inactivity

17. Examination

18. Examination Unremarkable physical examination Obesity Cholesterol deposits: arcus, xanthoma, xanthelasma Tar stains, nicotine stains Signs of peripheral vascular disease Acute LVF, New murmur of MR or VSD Cardiogenic shock

19. Investigations ?

20. Investigations Electrocardiogram!! Blood tests Full Blood Count Urea and Electrolytes Lipid Profile Clotting screen Blood sugar Troponin* Chest radiograph

23. Investigations (2) Transthoracic echocardiography (Handheld/Portable/Departmental) Exercise tolerance test Stress echocardiography Coronary angiography Further cardiac imaging – Cardiac CT/MR

24. Troponin Proteins released into the blood stream following muscle injury Different isomers of troponin Troponin T and I are specific for cardiac muscle More specific than CK Levels start to rise after muscle damage but only peak after 12 hours

25. Management : ACS STEMI NSTEMI / UA Angina

26. Management : STEMI ? NB: 2/3 criteria New onset LBBB ST elevation of 2mm in 2 contiguous chest leads or 1mm in 2 limb leads Chest pain

27. Management : STEMI ABC approach Analgesia: opioid based (Morphine 10mg IV) Oxygen: 15L via NRM Nitrate: GTN spray Aspirin 300mg PO stat Clopidogrel 600mg PO stat Primary percutaneous angioplasty

29. Thrombolysis Use of clotbusting agents such as streptokinase or tissue plasminogen activators such as alteplase Now superceded by primary PCI Only for Acute myocardial Infarction within 2 hours Used if not possible to get access to percutaneous angioplasty

30. Management : NSTEMI ?

31. Management : NSTEMI / UA ABC approach Analgesia: opioid based Oxygen: 15L via NRM Nitrate: GTN spray Aspirin 300mg PO stat Clopidogrel 300mg PO stat LMWH e.g. 1mg/kg Enoxaparin BD SC GTN infusion for pain Percutaneous angiography (within 48hours) ± angioplasty/ coronary bypass

32. TIMI risk score

33. Post Event management Lifestyle modification Smoking cessation Dietary changes Secondary prevention ACE-I Beta-Blocker Statins Cardiac rehabilitation Risk of further events and associated morbidity e.g. arrhythmias and heart failure

34. Questions

35. Summary ACS is a spectrum from Unstable Angina to STEMI UA/NSTEMI managed differently to STEMI TIMI risk score predicts outcome Use the ABCDE approach Perform the initial Ix and Rx Ask for help early, inform the Cardiologists early Primary angioplasty has revolutionised the area Don’t forget post MI management