Chest Pain Angina MI

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Introduction Chest pain is a common symptom seen in:

Cardiovascular Diseases

Respiratory Diseases

Gastrointestinal

Musculoskeletal Disease The cause/DD of chest pain can be identified by knowing

the history of pain:

Trauma (car accident, fall, collision)

site/nature/duration (most painful area, sharp, dull, or burningpain, last for seconds/minutes/hours)

provoking/relieving factors (what brings pain/makesworse/better)

Any medical condition/drug/smoking

Associated symptoms (dyspnea, nausea, dizziness)


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Types of Chest Pain

Angina MI

Dissecting thoracicaneurysm

Pericarditis

Oesophageal pain

Central Chet pain:

Pleuritic pain

Fractured rib

Musculoskeletal pin

Tietzes syndrome Shingles

Non-Central Chet pain:


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Differential Diagnose

CVS RS GI MS Other

Ischemia

(Angina)

Pulmonary

Embolism

Esophageal

spasm

Costochondritis Herpes zoster

Myocardial

Infration

Pleurisy Esophagitis Muscle trauma Bornholms

disease(myalgia)

Pericarditis/myoc

arditis

Pneumothorax Rib fractures Idiopathic chest

pain

Dissecting

thoracic

aneurysm

Trachitis/pneu

monia

osteoarthritis

Mitral valve

prolapse

malignancy


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Examination/Investigation

Examination:-General appearance: sweating, pallor, distress

-BP in both arms ( for aneurysm, will be difference of 15)

-JVP and carotid pulse(bruie in carotid pulse(

-RR/PR

-Apex beat/ heart sounds

-Lung field (crepitating as in HF)

-Localized tenderness/pain over the chest

-Skin rash (HZ)

-Swelling or tenderness of legs (deep vein thrombus)

Investigations:-ECG and Chest X-Ray

-Others depending on DD


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Ischemia (Angina)

Myocardial infraction

Common Cause


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- A strangling sensation in the chest that is a gripping or

crushing discomfort maybe felt around the whole chest or

deep within the chest

- The pain my radiate to the neck, jaw, rarely to the teeth,back or abdomen

- Types:

Angina Pectoris

Stable Angina Unstable Angina (more serious)


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Is predictable chest pain

Any event that increases oxygen demand can cause an angina

attack

Although less serious than unstable angina, it can be extremely

painful.

Relieved by rest and responds well to medical treatment

Some typical triggers include the following:

Exercise.Cold weather.

Emotional tension.

Large meals.

Stable Angina


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No physical signs in examination, but anemia can be seen in sever

attacks

Investigations:

First line investigations:CBC

Fasting lipid profile

Fasting blood glucose

ESR

TFT12-lead resting ECG: Provide info on- rhythm, presence of heart block,

previous MI, Myocardial Hypertrophy and Ischemia (if done between the attack,ECG will be normal. If one during attacks, ECG findings will be S-T depression)

Further investigations: Exercise ECG and Coronary arteriography

To know if patient has sever disease or not

Management


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Treatment:

Non-drug treatment: aims to prevent CHD

Stop smoking

Treat/control BP

Diet: decrease salts+ increase fruits/vegetablesIncrease exercise

Treat/control diabestus

Drug treatment:

As required medication:GTN spry: 1-2 puffs

GTN sublingual tablets

Regular treatment:

First line is Beta-Blockers (atenolol 50-100mg/day)

Management


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Treatment:

For patient with left ventricular dysfunction:

long acting nitrate 1st line and add long acting

dihydrpyrimidine calcium channel blocker if symptom are not

controlled.

K channel activator .(Nicorandil).if all above not working

Prevention:

Aspirin

StatinsACE inhibitors

Aspirin 75mg/ clopidogrel 75mg for secondary prevention

Statins to those with cvd.

Management


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Stable angina and acute coronary syndrome(ACS)

ACS includes:

ST elevation MI: ECG positive for ST elevation and enzymes alsopositive. Do angiography+stant(cathLab)+treat if not available do thrombolytictrapping

Non ST elevation MI:no ECG finding, but positive enzymes

Unstable angina: normal ECG and normal enzymes

Management differ in each one of these types

Intro


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Pain in minimal or no exertion that may occur at night due to

complete blockage to the coronary artery completely

A patient is usually diagnosed with unstable angina under one or

more of the following conditions: Pain awakens a patient or occurs during rest

A patient who has never experienced angina has severe or

moderate pain during mild exertion (walking two level blocks or

climbing one flight of stairs)

Stable angina has progressed in severity and frequency within

a two-month period, and medications are less effective in

relieving its pain

Unstable Angina


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Management:

Treat as MIUrgent referral to cardiology

Admit if attacks are sever, occur at rest, or last> 20min event

with GTN spray

Management


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It is due to the formation ofocclusive thrombusat the

site of rupture or erosion of an atheromatous plaque in a

coronary artery

The thrombus undergoes spontaneous lysis over thecourse of next few days

By the time irreversible myocardialdamage occurred.

Without treatment, the infarct related artery can remain

permanently occluded

Myocardial Infraction


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Presentation:Sustained central chest pain not relived by sublingual

GTN

Other features:Collapsed/ cardiac arrest

Breathlessness

Anxiety/fear of dying

Nausea/vomitting

Sweating

Pain in one or both arms, jaw, back and upper

abdomen



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Investigations:12-Lead ECG: ECG-ST elevation or R waves and ST depression

in lead V1-V2 ( indicates posterior wall infraction)

CXR

Blood test

Echocardiography

Plasma biochemical markers (CK)



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To diagnose a myocardial infarction you need to go

beyond looking at a rhythm strip and obtain a 12-Lead

ECG which sees the heart from 12 different views.

helps you see what is happening in different portionsof the heart.

12 ECG Leads: 3 Limb leads- I,II,III

3 Augmented leads- aVR, aVL, Avf6 Precordial leads- V1 V6

MI-ECG


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Anterior Myocardial Infarction:

If you see changes in leads V1 - V4 that are consistent with a

myocardial infarction, you can conclude that it is an anterior

wall myocardial infarction

MI-ECG


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Lateral Myocardial Infarction:

Leads I, aVL, and V5- V6

Inferior Myocardial Infraction:

Leads II, III and aVF

MI-ECG


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Anterolateral MI

When ECG involves both the anterior wall (V2-V4) and the

lateral wall (V5-V6, I, and aVL)

MI-ECG


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Summary:1. R waves and ST depression in lead (V1, V2 and sometimes

V3)Posterior wall MI

2. If ST segment elevation in V1-V4

Anterior wall MI3. If ST segment elevation in lead I,aVL, V5, and V6Lateral

wall MI

4. If ST segment elevation in lead aVF, lead II,III, V5-V6Inferior

wall MI

MI-ECG


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MI-Laboratory evaluationBiochemical evidence:

blood level of intra cellular macromolecules

that leak out of injured cell is measured:

1. Myoglobin (Not specific for MI)

2. Cardiac Troponin T & I

3. Creatine KinaseMB isoform and LDH(not specific forMI)


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Troponins (best marker) & CK MB are highly specific

Molecule Appear Peak DisappearTnT & TnI 2-4 hrs 48 hrs Remain elevated for7-10 days

CK-MB 2-4 hrs 24-48 hrs Returns to normalwith in 72 hrs

MI-Laboratory evaluation


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Give 300mg aspirin po unless contraindicated

Insert cannula

Give IV analgesia (morphin 2.5-5mg)

Give antiemetics (metoclopramide 10mg)

Give sublingual GTN

Give oxygen if avalible

If bradycardia atropine 3mg IVImmediate transfer to the hospital

Management


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Summary of Acute management of MI:

Memorize OMAN

O: oxygen

M:morphin

A: aspirin

N: nitroglycride (dont give if there is inferior wall MI because it decreasesthe blood pressure right coronary artery involves reducing the blood supply)

Management


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Thank you


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QuestionsWhich one of the following has been shown to decrease mortality

late after a myocardial infarction?

A)Nitrates

B)Beta-Blockers

C)Digoxin

D)Thiazide diuretics

What is the finding of ECG in a patient with Acute Myocardial

infraction?

A. ST elevation

B. R waves

C. ST depression in lead V1-V2

D. Wide QRS


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The ECG shows:

Sinus rhythm

Normal axis

Q waves in leads V2-V4

Raised ST segments in leads V2-V4

Inverted T waves in leads I, VL, V2-V6

Clinical interpretation This is a classic acute anterior myocardial

infarction.

Question-2

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Chest Pain Angina MI

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