Case 2-Chest Pain

Alifah & LiyanaFaculty of medicine

UiTM,Malaysia

History• Mdm. Xx, 60 y.o, chinese lady known case of HPT and DM for 10 years.• Complaint of chest pain on the day of admission.

– Site : Central– Nature : Tightness– Radiation : jaw and left arm– Duration : 20 minutes– Aggravating factor : -– Relieving factor : GTN ( KK)– Associated symptom : nausea, sweating, dyspnoea,

• Past Medical History- DM , HT 10 years

• Surgical History- Nil

• Drug History - For HT & DM

• Allergy - Nil

• Family History-+ve hx of HT, DM, heart problem

• Social History-Smoker (5sticks/day)- Occasional drinker

• Diet history- High fat food

PHYSICAL EXAMINATIONVital Signs:

BP:135/95 mmHgHR:92 beats/minute (regular rhythm and volume)RR: 22 breaths/minute

General examination- obese

Cardiovascular system• Inspection: On inspection, there is no deformity, no dilated vein, no surgical

scar, and no visible pulsation.

• Palpation:The apex beat is not palpable. There was no parasternal heave. Thrills were also absent.

• Auscultation:S1 and S2 were heard. There was no radiation, no murmur, no rubs and no additional sounds. S3 and S4 were not heard. There was no carotid bruit present. The 1st and 2nd maneuver (mitral stenosis and aortic regurgitation) reveals no significants findings.

Provisional diagnosis• Non ST elevation myocardial infarction (NSTEMI) / unstable angina

History :

- Central chest tightness :Radiated to jaw & left arm20 minutes Relieved by GTNAssociated with : nausea, sweating, dyspnoea

- Known case of DM & HT ( 10 years )- +ve family hx of heart problem- Smoker ( 20 years)- fat food diet

PE : -obese

Differential Diagnosis

1. Acute myocardial infarctionPoints to support : Points to against :ECG : ST segment depressionRelieved by GTNDuration : 20 minutes

2. Aortic dissectionPoints to support : severe, sudden chest pain History of HT & DMPoints to against : Chest Pain : tightness, not radiate to the back No syncope CXR : no boarding of upper mediasternal & distortion of aortic knuckle, no right

sided pleural effusion & left ventricular hypertrophy

• Pulmonary embolism– Pros :chest pain associated with shortness

of breath– Cons :no hemoptysis and no risk factor of

hyper-coagulability like prolong bedrest.

• Pericarditis – Pros :the patient present with chest pain– Cons :the pain not aggravated by changes in

posture like leaning forward.

investigationGeneral :

FBC, BUSE : no significant findingPT, PTT : normalCXR : normal ( No cardiomegaly, perihilar

haziness and lung fields were clear)

Cardiac enzymes

• elevation of :Troponin T CKMB

Lipid Profile

LIPID VALUE NORMAL RANGE

REMARKS

Total cholesterol

6.6 <5.17 mmol/L

Increase

Triglyceride 1.5 0.45 – 1.5 mmol/L

Normal

HDL 1.2 1.0 – 1.79 Normal

LDL 4.7 < 3.4 mmol/L

Increase

ECG• ST segment

depression• T inversion

Final diagnosis• Non ST elevation myocardial

infarction (NSTEMI)

• Points to support :

- Central chest tightness :Radiated to jaw & left arm20 minutes Relieved by GTNAssociated with : nausea, sweating, dyspnoea

- Known case of DM & HT ( 10 years )- +ve family hx of heart problem- Smoker ( 20 years)- fat food diet

- PE : overweight

- IV

Lipid profile : increase LDL & total cholesterol

Cardiac enzyme :Troponin T & CKMB

ECG :ST segment depression & Tinversion

Management of acute coronary syndrome ( NSTEMI)

Criteria for high & low for death or MI

High risk• ECG abnormalities

- Dynamic ST segment changes > 0.05 mV, particularly ST segment depression

- Transient ST segment elevation- T wave inversion > 0.2 mV- Pathological Q wave- Bundle branch block- Sustain Ventricular tachycardia

• Elevated Troponin level

Low Risk• No recurrence of chest pain

within the observational period• No ST segment depression or

elevation but rather negative T wave, flat T wave or normal ECG

• Without elevation of Troponin or other biomarker of cardiac injury

High Risk Low risk

Management

• Post hospitalization

- Medical therapy ( compliance )- Life-style modification: Diet : highly oily fish, fruit, vegetable, fiber & low fats: Exercise : Regular daily exercise: Avoid air travel for 2 months: Reduce & stop smoking- Follow up ( after 3 & 5 weeks )

references

• Sarawak Handbook of medical emergencies• Oxford Handbook of clinical medicine• Davidson’s, Principle & practice of medicine