An introduction to Chest pain

‘how to mend a broken heart’

Case 1

• 55 year old accountant

• Stressed in a meeting at work

• Sudden onset chest pain

Crushing chest pain…

ECG

Coronary artery thrombus

Immediate treatment

• Oxygen

• Analgesia

• Aspirin

• Thrombolysis ‘clot busting drugs’

• Primary angioplasty ‘hot wiring’

Another Case

• Reg G 61 year old retired suffolk farmer

• Osteoarthritis hip• Undergoes total hip

replace (THR)

4 days post-op

• Initially making good recovery

• Sudden onset SOB and sharp ‘stabbing’ chest pain on commode in the evening

• O2 sats 89% on air

• Pulse 130 bpm irregularly irregular

What may have happened?

Immediate investigations

ECG

Immediate management

D-Dimer

• Specific degradation product released into circulation when cross-linked fibrin undergoes endogenous fibrinolysis

• Low D-dimer has high negative predictive value

• Non-specific elevation in sepsis, pregnancy, MI and post surgery

CXR

Imaging

• CXR – to exclude other causes• CTPA

– CT chest– Give iv iodine and time to fill pulmonary

arteries– Arm vein -> RA -> RV -> PA

• Contrast can– Cause allergic reaction– Damage kidneys

What are we looking for?

Ab

Ab

Imaging – Pulmonary angiogram

Treatment

Treatment

• Oxygen to correct hypoxia

• LMWH – dose according to weight

• Commence warfarin loading

• 6 months treatment with warfarin

What would you warn Reg about the risks of treatment?

Case 3 – Mr AL

• 21 year old man

• Known Marfan’s disease

• Previous aortic valve replacement

• Acutely SOB

• R-sided chest pain

Examination findings

• In pain and distressed

• RR 30 / min

• Oxygen saturation 85% on air

• Hyper-resonant over R lung field

• Increased SOB

Radiology

Right lung:– Black– No

markings– No

mediastinal shift

Sternal wires

Heart valve

Pleura

Treatment

Further radiology – post chest drain

Pleura

What does the future hold

• Must not scuba dive

• High chance of recurrence if at increased altitude – no flying for at least 1/12

• Chance of recurrent pneumothorax high

Any questions?