myocardial infarction

PROF: OFCARDIOLOGY

LUMHS

EVALUATION OF CHEST PAIN

Objectives To be able to rapidly and accurately assess a

patient complaining of acute chest pain To be able to formulate an accurate

differential diagnosis for acute chest pain To understand and be able to initiate basic

initial therapy for a patient in acute chest pain

The background: Chest pain is one of the most common chief

complaints of patients presenting to EDs annually.

8-10% of the 119 million annual ED visits are for chest pain and related symptoms

Accurate diagnosis remains a challenge

there are a lot of importment data of the pain: localisation radiation onset of the pain the type (press, smart,cutting) dinamic of the pain (continouosly, ongoing, undulaiting) answer to the medical therapy

CHEST PAIN

The challenges: Patients presenting with chest pain who have

life threatening underlying disease often look well on initial presentation

It is estimated that 8-10% of patients presenting with ACS are discharged mistakenly from the ED

These patients have 30 day mortality of 2%

Challenges cont: Missed MI is the most common cause for

litigation stemming from ED treatment Higher awards are recovered in medical

malpractice lawsuits for missed MI than for any other condition

Internists are second only to family practitioners as the most likely group to be sued for missed MI

Chest Pain Visceral

Often referred Aching, heaviness, discomfort Difficult to localize pain

Somatic Sharp, easily localized

Chest Pain Definitions Acute Chest Pain:

Acute - sudden or recent onset (usually within minutes to hours), presenting typically <24 hrs

Chest - thorax midaxillary to midaxillary line, xiphoid to suprasternum notch

Pain – noxious uncomfortable sensation Ache or discomfort

Initial Approach Triage

Chest pain Significant abnormal pulse Abnormal blood pressure Dyspnoea These pts need IV, O2, Monitor, ECG

Initial Approach Evaluation:

Airway Breathing Circulation Vital Signs Focused exam

Cardiac, pulmonary, vascular

Initial Approach History:

Character of pain Presence of associated symptoms Cardiopulmonary history Pain intensity, 0-10 pain

Initial Approach Secondary exam:

History Quality, radiation/migration, severity, onset, duration,

frequency, progression and provoking or relieving factors of pain

Risk factors Physical exam Review old records/ekg’s

Categorizing Chest Pain1. Chest Wall Pain

• Sharp, Precisely localized• Reproducible: Palpation, movement

2. Pleuritic or Respiratory CP• Somatic pain, Sharp• Worse with breathing/coughing

3. Visceral CP• Poorly localized, aching, heaviness

1. Chest wall Costosternal synd Costochrondritis Precordial catch synd Slipping Rib Synd Xiphodynia Radicular Synd Intercostal Nerve Fibromyalgia

2. Pleuritic Pulmonary Embolism Pneumonia Spontaneous pneumo Pericarditis Pleurisy

3. Visceral Pain: Typical Exertional

Angina Atypical Angina Unstable Angina Acute Myocardial

Infarction (AMI)

Aortic Dissection Pericarditis Esophageal Reflux

or spasm Esophageal Rupture Mitral Valve

Prolapse

Categorizing Chest Pain Assessment of Risk Factors CAD:

Cigarette Smoking Diabetes Hypertension Hypercholesterolemia Family History

Differential Diagnosis ofChest Pain Non Cardiac

Cardiac

Non Cardiac Chest Pain Pulmonary

Pneumonia Pleuritis Pneumothorax Pulmonary Embolism Tumor

Gastrointestinal GERD Esophageal spasm Mallory-Weiss Tear Peptic Ulcer disease Biliary/Gallbladder Disease Pancreatitis

Musculoskeletal Costochondritis Cervical Disk Disease Rib Fracture Intercostal Muscle Cramp

Other Herpes Zoster Disorders of the Breast Splenic Infarct Panic Attacks/Anxiety Disorder Fibromyalgia DKA

Cardiac Chest Pain

Aortic Dissection Pulmonary Embolism Pulmonary

Hypertension Pericardial Diseases Aortic Stenosis Heart Failure Cocaine Abuse

Acute Coronary Syndromes Stable Angina Unstable Angina Myocardial Infarction Cardiogenic Shock

Chest Pain

Non Cardiac

Cardiac

PE

PTX

Oesophageal disaster

Aortic disease

Myo/pericardium

Coronary disease

Coronary spasm

Obstructive CAD

ACS

Stable angina

Pulmonary Embolism:

PE: Presentation Presentation variable Suspect in any patient c/o new or worsening

dyspnoea, chest pain or prolonged hypotension without obvious etiology

Symptoms: dyspnoea (sec. to min) > pleuritic chest pain > cough

Signs: tachypnoea > tachycardia > rales > loud P2

PE: Diagnosis

PE: ECG

PE: Management

PE: Clinical guidelines

PE: Anticoagulation Enoxaparin 1mg/kg Q12H UFH: 80IU/kg then 18IU/hr (5000IU max) Fondaparinux

5mg daily if <50kg 7.5mg daily if 50-100kg 10mg daily if >100kg

If clinical suspicion high, initiate anticoagulation prior to confirming diagnosis

Long term management: V-K antagonists LMWH preferred in

patients with malignancy or pregnancy

Duration: 1st provoked: 3mo 1st unprovoked, malignancy

or recurrent, consider indefinite tx

Chest Pain

Non Cardiac

Cardiac

PE

PTX

Oesophageal disaster

Aortic disease

Myo/pericardium

Coronary disease

Coronary spasm

Obstructive CAD

ACS

Stable angina

Pneumothorax: Presentation Primary Spontaneous PTX:

Seen in patinets without underlying lung disease Smoking, FH and Marfans predispose Usually 20s-40s, present with sudden onset dyspnea and

pleuritic CP at rest Physical findings include decreased chest excursion,

decreased breath sounds, hyperresonance Hypoxeima common, hypercapnea uncommon 2/2

perfusion of PTX but adequate ventilation with contralateral lung

Pneumothorax: Presentation Secondary Spontaneous PTX

Seen in patients with underlying lung disease Any lung disease predisposes however COPD

most common PCP, CF and TB also common causes Similar physical presentation to PSP ABG typically abnormal 2/2 underlying lung

disease

Pneumothorax: Diagnosis CXR: Look for

pleural line Can be difficult in

patients with COPD CT scan can

overestimate size of PTX

Pneumothorax

Pneumothorax

Pneumothorax: Treatment ABCD Assess haemodynamic

stability If < 2cm and stable,

can observe If > 2cm, chest tube If haemodynamically

unstable, chest tube

Chest Pain

Non Cardiac

Cardiac

PE

PTX

Oesophageal disaster

Aortic disease

Myo/pericardium

Coronary disease

Coronary spasm

Obstructive CAD

ACS

Stable angina

Oesophageal rupture: Hospitalized: >50% 2/2 instrumentation of

esophagus Traumatic: MVA, chest wall trauma Spontaneous: (transmural perforation)

Vomiting (Boerhaave’s Syndrome): retching followed by severe chest and epigastric pain, tachypnoea, dyspnoea, fever, cyanosis, shock

Caustic ingestion, pill esophagitis, Barrett’s, oesophageal ulcers in HIV patients

Oesophageal rupture: Diagnosis

CXR: early shows mediastinal or free peritoneal air Hours to days

later: widening of mediastinum, pleural effusion

Oesophageal rupture: CT scan: Oesophageal

oedema, extra oesophageal air, perioesophageal fluid

Oesophagram: Extravasation of contrast

NO role for endoscopy which introduces more air into mediastinum

Oesophageal rupture: Treatment Management variable

and depends on size, location, rapidity of diagnosis and underlying disease

Treatment surgical Complications:

mediastinitis , sepsis, shock, death

Chest Pain

Non Cardiac

Cardiac

PE

PTX

Oesophageal disaster

Aortic disease

Myo/pericardium

Coronary disease

Coronary spasm

Obstructive CAD

ACS

Stable angina

Aortic dissection: Presentation Sharp, “tearing” anterior or posterior chest

and back pain. Typically sudden onset and severe Chest pain more common with type A

dissections Complicated by CVA, syncope, MI (RCA) or

HF

Aortic dissection: Diagnosis Generally suspected by history/physical Variations in pulses or blood pressure (>20

mmHG difference between R and L arm) ECG: variable depending on complications Imaging when stable

CXR: mediastinal widening CT chest, TEE, MRI other options and all

superior to TTE

Aortic Dissection: Predisposing factors:

Aortic aneurysm HTN Vasculitis Marfan’s or other collagen diseases CABG/cardiac catheterizaion Drugs (crack cocaine) Trauma

Aortic dissection: Classification

Aortic dissection

Aortic dissection

Aortic Dissection: Management Type A: Surgical Type B and uncomplicated: Medical Type B and complicated (major branch

involved, continued expansion or aortic rupture

Long term management includes B blocker, serial imaging at 3, 6 and 12 months and reoperation if indicated

Acute Management ICU admission Pain control: Morphine Reduction of SBP to 100-120 or lowest

tolerated, HR <60, intubate if unstable IV B blocker 1st line (labetolol, propranolol, esmolol) If HR <60 and SBP >100 with good mentation and renal

function nitroprusside If hypotensive, look for blood loss, tamponade or HF prior

to giving volume

Chest Pain

Non Cardiac

Cardiac

PE

PTX

Oesophageal disaster

Aortic disease

Myo/pericardium

Coronary disease

Coronary spasm

Obstructive CAD

ACS

Stable angina

Pericarditis Chest pain (anterior chest, sharp, pleuritic,

exacerbated by inspiration, can decrease with leaning forward, radiation to trapezius)

Often first sign of other systemic disease Multiple possible etiologies, viral and

autoimmune most common in US Consider TB outside US

Pericarditis: Diagnosis Typically need 2/4:

Chest pain Friction rub ECG changes (wide spread ST elevation with PR

depression) Pericardial effusion

Consider tamponade (sinus tachycardia, JVD, pulsus paradoxus, Kussmaul’s sign)

Pericarditis: ECG:

Pericarditis: Treatment NSAIDs are mainstay of therapy (IBU or high

dose ASA Can also use colchicine or glucocorticoids Tamponade: conservative management with

monitoring, serial echo, volume expansion and treatment of underlying cause vs. pericardiocentesis

Myocarditis Presentation variable Viral most common etiology in developed

countries Presents with HF, chest pain, sudden cardiac

death or arrhythmias Workup with biomarkers, ECG, CXR, TTE,

cardiac MR and endomyocardial biopsy Consider in young male with new onset HF

Chest Pain

Non Cardiac

Cardiac

PE

PTX

Oesophageal disaster

Aortic disease

Myo/pericardium

Coronary disease

Coronary spasm

Obstructive CAD

ACS

Stable angina

Acute coronary syndrome

Pathogenesis of UA/NSTEMI

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

Definition“… any constellation of clinical

symptoms that are compatible with acute myocardial

ischemia..."

Acute Coronary Syndrome

Pathophysiology:Acute coronary perfusion deficit Mechanism:

coronary plaque rupture (95%) lead to partial or total coronary occlusion

coronary spasm Prinzmetal angina (transient ST elevation) myocardial infarction (if the ischemic period is to long)

coronary embolisation

current complaint: pain

there are a lot of importment data of the pain: localisation radiation onset of the pain the type (press, smart,cutting) dinamic of the pain (continouosly, ongoing, undulaiting) answer to the medical therapy

Acute coronary syndrome: diagnosis

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

Unstable Angina / NSTEMI

Definition“… ST-segment depression or

prominent T-wave inversion and/or positive biomarkers of

necrosis… in the absence of ST-segment 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)

Unstable Angina / NSTEMI

STEMI

LBBB

Physical ExamT 36oC, P 85, BP 140/80, R 15, Pain 2/10

General – no distress

Neuro - A&O

CVS - normal inspection, PMI normal and nondiplaced, no heave, regular rhythm with normal sounds, no murmers or rubs, JVP 7 cm, radial and pedal pulses normal

Pulmonary - clear

Abdomen – nontender without hepatomegaly

Extremities – no edema

Chest X-RayQuality – exposure and rotation

Bony structures

Mediastinum

Heart

Costophrenic angles

Lung fields

TIMI Risk Score

Antman et al JAMA 2000; 284: 835 - 842www.timi.org

Age 65 3 CAD risk factors(FHx, HTN, chol, DM, active smoker)

ST deviation 0.5 mm cardiac markers

Recent (24H) severe angina

HISTORICAL

PRESENTATION

RISK SCORE = Total Points (0 - 7)

Known CAD (stenosis 50%)

ASA use in past 7 days

1

11

1

1

11

POINTS RISK OF CARDIAC EVENTS (%)BY 14 DAYS IN TIMI 11B*

0/12345

6/7

RISKSCORE

3357

1219

DEATH OR MI

DEATH, MI ORURGENT REVASC

5813202641

*Entry criteria:UA or NSTEMII defined as ischemic pain at rest within past 24H, with evidence of CAD (ST segment deviation or +marker)

A Chest Pain Case

A Chest Pain CaseCAD risk factors

- + Family history- HTN- Dyslipidemia

Home meds- ASA 81 mg po daily- HCTZ 25 mg po daily

Biomarkers- CK 413- MB 7 with index of 2- Troponin I 6.8

TIMI Risk Score- 5

Age 65 3 CAD risk factors(FHx, HTN, chol, DM, active smoker)

ST deviation 0.5 mm cardiac markers

Recent (24H) severe angina

HISTORICAL

PRESENTATION

RISK SCORE = Total Points (0 - 7)

Known CAD (stenosis 50%)

ASA use in past 7 days

1

11

1

1

11

POINTS

A Chest Pain CaseCAD risk factors

- + Family history- HTN- Dyslipidemia

Home meds- ASA 81 mg po daily- HCTZ 25 mg po daily

Biomarkers- CK 413- MB 7 with index of 2- Troponin I 6.8

TIMI Risk Score- 5

RISK OF CARDIAC EVENTS (%)BY 14 DAYS IN TIMI 11B*

0/12345

6/7

RISKSCORE

3357

1219

DEATH OR MI

DEATH, MI ORURGENT REVASC

5813202641

*Entry criteria:UA or NSTEMII defined as ischemic pain at rest within past 24H, with evidence of CAD (ST segment deviation or +marker)

Thygensen, et al JACC 50: 2173, 2007

Other reasons for Troponins

Heart failurePulmonary embolus

Renal failure

ACSACS

STEMISTEMI

high riskhigh risk•early high riskearly high risk•late high risklate high risk

STEMI STEMI >>12 h12 hSTEMI STEMI ≤ 12 h≤ 12 h

cardiogenic cardiogenic shock shock ≤ 36 h≤ 36 h

Ope

n ar

tery

theo

ry

Ope

n ar

tery

theo

ry

Primary PCI Primary PCI ((CABG))((CABG))

ThrombolysisThrombolysis rescue PCI rescue PCI ((CABG))((CABG))

PCI ((CABG))PCI ((CABG))

NSTE-ACSNSTE-ACS

risk stratificationrisk stratification

med. th.med. th.non-inv.im. (echo, stress-test etc.non-inv.im. (echo, stress-test etc.

PCI ((CABG))PCI ((CABG))

First primary PCI program in 1999

24-hour organised primary PCI in Budapest since 01.01.2003.

First primary PCI in 1993

In-hospital mortality (STEMI)

30

1510

70

5

10

15

20

25

30

35

60-s 70-s 80-s 90-s

CCU + defibrillatorCCU + defibrillator

thrombolysisthrombolysis

primary primary PCIPCI

In-hospital mortality dramatically decreased under the last 30 years:In-hospital mortality dramatically decreased under the last 30 years:

STEMI Quick diagnosis (Typical chest pain and ECG ) Time window? Prehospital therapy

aspirin 250 mg morphine nitroglycerin

again the pain, hypertensive state, left ventricular failure Attention! Right ventricular infarction can cause sever hypotension!

O2

Send the patient to the hospital

ACSACS

STEMISTEMI

high riskhigh risk•early high riskearly high risk•late high risklate high risk

STEMI STEMI >>12 h12 hSTEMI STEMI ≤ 12 h≤ 12 h

cardiogenic cardiogenic shock shock ≤ 36 h≤ 36 h

Ope

n ar

tery

theo

ry

Ope

n ar

tery

theo

ry

Primary PCI Primary PCI ((CABG))((CABG))

ThrombolysisThrombolysis rescue PCI rescue PCI ((CABG))((CABG))

PCI ((CABG))PCI ((CABG))

UA/NSTEMIUA/NSTEMI

risk stratificationrisk stratification

med. th.med. th.non-inv.im. (echo, stress-test etc.non-inv.im. (echo, stress-test etc.

PCI ((CABG))PCI ((CABG))

Inferior STEMI

RCA PCI

RCA occlusion

After stenting ►

In the CCU a lot of technical devices (IABP,respirator, dialysator) are necessary

IAB Inflation

IAB Deflation

Complication of myocardial infarction Arrhythmias

Life-threating: Ventricular tachycardia / ventricular fibrillation – sudden death (I.

symptom?) II-III degree AV block – asystolie

Ventricular failure (LV mass loss >40%) pulmonal oedem cardiogenic shock right ventricular failure – impared filling pressure (CAVE: NITRO!)

Mechanical complication mitral papillar rupture – acute mitral regurgitation ventricular septal rupture free wall rupture – pericardial Tamponade

Acute mitral flail, chordal rupture

Cardiac rupture syndromes complicating STEMI

Anterior myocardial rupture

Rupture of the ventricular septum

Complete rupture of a necrotic papillary muscle

Pericardial Tamponade

Pericardial Tamponade

Pericardial Tamponade

Pericardial Tamponade

Conclusion The acute coronary syncrome is an acute, life-threating

coronary event Need an urgent hospitalisation Short anamnesis (mostly the pain!!), physical examination rapidly perfom an ECG according to the ECG: NSTE-ACS or STEMI In case of NSTE-ACS: risk stratification In case of STEMI:

If the patient has typical chest pain + typical ECG with acut STEMI – If the patient has typical chest pain + typical ECG with acut STEMI – it is enough to diagnose!it is enough to diagnose!

If the time-window is <12 hours: reperfusion therapy (primary PCI or if pPCI is not feasible thrombolytic therapy)

ACS: General principles Unstable Angina

Rest angina: Usually >20 minutes duration New onset severe angina Increasing angina

NSTEMI STEMI

ACS: Management Initial therapy: Oxygen, nitro, ASA, ECG HR control Antiplatelets: Clopidogrel, Prasugrel Anticoagulation: Pain control: Conservative vs. Invasive management

ACS: Cautions B blockers Morphine Inferior MI (RV infarct) Compare ECGs UH vs. LMWH Repeat ECGs Always consider chief complaint

ACS: A word about troponin Just because there is no troponin, doesn’t

mean it’s not ACS Just because there is troponin, doesn’t mean

it’s ACS Troponin is prognostic more than diagnostic

Practical application: Called by nursing to evaluate patient with

chest pain Ask for vitals over phone, stability of the

patient and brief details ECG Go see the patient

Practical application Focused history and physical exam

Focused history and chart review Vitals: BP in both arms, pulsus paradoxus GEN: Distress Neck: JVD, carotid bruits Lungs: Crackles, wheezing, effusions Precordium: Heaves, reproducible pain CVS: Regular/irregular, new murmurs, rubs or gallops, muffled

heart sounds Abd: Pulsatile masses, renal bruits Ext: LE edema, peripheral pulses

Practical application ECG: compare to old, repeat frequently Other imaging studies as indicated by

presentation: CXR, stat TTE, CT scan Biomarkers if applicable KEY: Commit to a diagnosis Begin initial therapy Call for help at any point you are not

comfortable

Conclusions: Chest pain is one of the most frequently encountered

complaints in both the inpatient and outpatient settings and is a significant financial burden on our health care system

Clinicians must be able to rapidly and accurately assess a patient with chest pain to maximize patient outcomes and minimize unnecessary workup

The evaluation of chest pain requires good history and physical exam skills, ECG, CXR and few other diagnostic tests

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