acd – 12.11 chest pain
TRANSCRIPT
ACD – 12/11/2014
Chest pain occuring in the hospital
Bayan Mesmar – PGY3
Case:
• A 60 yo pt admitted for chemotherapy for multiple myeloma. Pt has failed
multiple therapies including autlogus bone marrow transplant and started to
follow up here for second opinion regarding alternative treatment options.
• Past medical hx: • ESRD on regular HD TTS.
• HTN
Case
• Labs on admission:
CBC: 9/ 9/30/ 80
Renal chem: Na 144, K 5.0, Cl 93, CO2 32, BUN/Cr 80/9.
Trop 1.4.
LFTs: AST 36, ALT 36, LD 450.
ESR : > 140
CRP 130.
• Some one got a CXR and an ECG on admission for
whatever reason:
ECG:
Case:
• Day 2- D10
Pt was receiving HD, did well.
Started on prophylactic Abx (levaquin+acyclovir) in
preparation for chemo + diflucan for oral thrush.
Underwent staging for Myeloma >> aggressive disease.
Started on (PACMED) on day 10.
Case
• Day 13 pager goes off in the early evening just when you
are having your third cup of coffee and heading toward
the door to the parking lot:
Chest pain!
• Retrosternal chest pains, that pt describes as heaviness
in nature, increased by taking deep breaths. Not radiating.
No associated N/V, no diaphoresis.
• No other symptoms.
Labs drawn by the nurses before you
arrive during the chest painLabs:
CBC: Hb 8.2 , WCC 3.7 , Plts 28
Renal chem : Na 139, K 5.1, Cl 108 ,Co2 28, BUN/CR
65/8.2.
Trop 3.59 ( up from ~1.50) , CK 159 (WNL) , CK- MB 5.2.
ABG: 7.36/33/113 2L nc (baseline).
What now?
Orders??
That’s a big troponin isn’t it?
Straight to cath lab?
Or straight to someone else’s care so you don’t have to
think about it?
So maybe you ordered some of these
things. If so, here you go…CXR: unchanged.
V/Q scan: low probability.
Lower/upper extremity Doppler : negative.
Did you order an ECG? I’m sure you did…
Can you make a diagnosis from this
ECG? Maybe in the PR segment in II?
Maybe from this ECG taken a little later?
Pericarditis:
• Acute Pericarditis:
- Acute inflammation of the pericardial sac, with our without myocarditis.
- Recorded in about 0.1 to 0.2 percent of hospitalized patients and 5 percent of patients admitted to the Emergency Department for non-ischemic chest pain.
- Presentation: varies depending on the cause.
- The vast majority of patients with acute pericarditis present with chest pain (>95% of cases). Maybe minimal or absent in uremic patients.
- Chest pain that results from acute pericarditis is typically fairly sudden in onset and occurs over the anterior chest. Although dull, oppressive pain or radiation of the pain to the shoulders (particularly the trapezius ridges) may occur.
Etiologies:
ECG
ECG changes:
Diffuse ST elevation
(typically concave up)
with reciprocal ST
depression in leads
aVR and V1 There is
also an atrial current
of injury, reflected by
elevation of the PR
segment in lead aVR
and depression of the
PR segment in other
limb leads and in the
left chest leads,
primarily V5 and V6
• Stage 2, typically seen in the first week, is characterized by normalization of
the ST and PR segments.
• Stage 3 is characterized by the development of diffuse T wave inversions,
generally after the ST segments have become isoelectric. However, this
stage is not seen in some patients.
• Stage 4 is represented by normalization of the ECG or indefinite persistence
of T wave inversions ("chronic" pericarditis).
Troponins?
• Acute pericarditis may be associated with increases in serum biomarkers of
myocardial injury such as cardiac troponin I or T secondary to epicardial inflammation
or involvement of adjacent myocardium. Elevation of creatine kinase or its MB fraction
(CK-MB) is very uncommon. On one study series percentage was found to be 32%.
• Inflammatory markers: elevated CRP and ESR.
Pericarditis Vs STEMI: When to wake cath lab
people up from sleep:
• If any of the following is present consider STEMI:• Reciprocal ST depressions in any leads other than V1 or aVR. Pay
particular attention to aVL which, in patients with inferior wall STEMI, may show T- wave inversion or extremely subtle reciprocal ST depression.
• ST segment more elevated in Lead III than in Lead II.
• worsening or new Q-waves.
• Prolonged QTc is often seen with STEMI.
• QR-T complexes (“checkmark sign”)
• Fragmented QRS complexes.
Pericarditis:
- PR-segment dépressions in multiple leads
- Friction rub (60% to 85% of cases)
Treatment:
Admit? Most patients can be treated conservatively in out patient setting. Hospital
admission should be reserved for patients with high fever,, cardiac tamponade,
Immunosuppressed state, severe effusion, myocardial involvement (elevated troponins),
patients who are on anticoagulation.
- NSAIDS
- Aspirin
- Colchicine+ NSAID > ICAP trial (colchicine added to standard anti-inflammatory
therapy significantly reduced the risk of recurrence (17 percent versus 38 percent with
anti-inflammatory therapy alone)
Steroids?
The 2004 European Society of Cardiology (ESC) guidelines recommended that systemic
steroids to be used when:
●Patients with symptoms refractory to standard therapy
●Acute pericarditis due to connective tissue disease
●Autoreactive (immune-mediated) pericarditis
●Uremic pericarditis
• Thank you. –Bayan Mesmar