myocardial infarction

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  • ObjectivesTo be able to rapidly and accurately assess a patient complaining of acute chest painTo be able to formulate an accurate differential diagnosis for acute chest painTo 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:localisationradiationonset of the painthe 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 presentationIt 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 treatmentHigher awards are recovered in medical malpractice lawsuits for missed MI than for any other conditionInternists are second only to family practitioners as the most likely group to be sued for missed MI

  • Chest PainVisceralOften referred Aching, heaviness, discomfortDifficult to localize painSomaticSharp, easily localized

  • Chest Pain DefinitionsAcute Chest Pain:Acute - sudden or recent onset (usually within minutes to hours), presenting typically
  • Initial ApproachTriageChest painSignificant abnormal pulseAbnormal blood pressureDyspnoeaThese pts need IV, O2, Monitor, ECG

  • Initial ApproachEvaluation: AirwayBreathingCirculationVital SignsFocused examCardiac, pulmonary, vascular

  • Initial ApproachHistory:Character of painPresence of associated symptomsCardiopulmonary historyPain intensity, 0-10 pain

  • Initial ApproachSecondary exam:HistoryQuality, radiation/migration, severity, onset, duration, frequency, progression and provoking or relieving factors of painRisk factorsPhysical examReview old records/ekgs

  • Categorizing Chest PainChest Wall PainSharp, Precisely localizedReproducible: Palpation, movementPleuritic or Respiratory CPSomatic pain, SharpWorse with breathing/coughingVisceral CPPoorly localized, aching, heaviness

  • Chest wallCostosternal syndCostochrondritisPrecordial catch syndSlipping Rib SyndXiphodyniaRadicular SyndIntercostal NerveFibromyalgiaPleuriticPulmonary EmbolismPneumoniaSpontaneous pneumoPericarditisPleurisy

  • 3.Visceral Pain:Typical Exertional AnginaAtypical AnginaUnstable AnginaAcute Myocardial Infarction (AMI)

    Aortic DissectionPericarditisEsophageal Reflux or spasmEsophageal RuptureMitral Valve Prolapse

  • Categorizing Chest Pain Assessment of Risk FactorsCAD:Cigarette SmokingDiabetesHypertensionHypercholesterolemiaFamily History

  • Differential Diagnosis ofChest PainNon Cardiac


  • Non Cardiac Chest PainPulmonaryPneumoniaPleuritisPneumothoraxPulmonary EmbolismTumorGastrointestinalGERDEsophageal spasmMallory-Weiss TearPeptic Ulcer diseaseBiliary/Gallbladder DiseasePancreatitisMusculoskeletalCostochondritisCervical Disk DiseaseRib FractureIntercostal Muscle CrampOtherHerpes ZosterDisorders of the BreastSplenic InfarctPanic Attacks/Anxiety DisorderFibromyalgiaDKA

  • Cardiac Chest PainAortic DissectionPulmonary EmbolismPulmonary HypertensionPericardial DiseasesAortic StenosisHeart FailureCocaine AbuseAcute Coronary SyndromesStable AnginaUnstable AnginaMyocardial InfarctionCardiogenic Shock

  • Chest PainNon CardiacCardiacPEPTXOesophageal disasterAortic diseaseMyo/pericardiumCoronary diseaseCoronary spasmObstructive CADACSStable angina

  • Pulmonary Embolism:

  • PE: PresentationPresentation variableSuspect 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 > coughSigns: tachypnoea > tachycardia > rales > loud P2

  • PE: Diagnosis

  • PE: ECG

  • PE: Management

  • PE: Clinical guidelines

  • PE: AnticoagulationEnoxaparin 1mg/kg Q12HUFH: 80IU/kg then 18IU/hr (5000IU max)Fondaparinux5mg daily if 100kgIf clinical suspicion high, initiate anticoagulation prior to confirming diagnosis

  • Long term management:V-K antagonistsLMWH preferred in patients with malignancy or pregnancyDuration:1st provoked: 3mo1st unprovoked, malignancy or recurrent, consider indefinite tx

  • Chest PainNon CardiacCardiacPEPTXOesophageal disasterAortic diseaseMyo/pericardiumCoronary diseaseCoronary spasmObstructive CADACSStable angina

  • Pneumothorax: PresentationPrimary Spontaneous PTX: Seen in patinets without underlying lung diseaseSmoking, FH and Marfans predisposeUsually 20s-40s, present with sudden onset dyspnea and pleuritic CP at restPhysical 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: PresentationSecondary Spontaneous PTXSeen in patients with underlying lung diseaseAny lung disease predisposes however COPD most commonPCP, CF and TB also common causesSimilar physical presentation to PSPABG typically abnormal 2/2 underlying lung disease

  • Pneumothorax: DiagnosisCXR: Look for pleural lineCan be difficult in patients with COPDCT scan can overestimate size of PTX

  • Pneumothorax

  • Pneumothorax

  • Pneumothorax: TreatmentABCDAssess haemodynamic stabilityIf < 2cm and stable, can observeIf > 2cm, chest tube If haemodynamically unstable, chest tube

  • Chest PainNon CardiacCardiacPEPTXOesophageal disasterAortic diseaseMyo/pericardiumCoronary diseaseCoronary spasmObstructive CADACSStable angina

  • Oesophageal rupture: Hospitalized: >50% 2/2 instrumentation of esophagusTraumatic: MVA, chest wall traumaSpontaneous: (transmural perforation)Vomiting (Boerhaaves Syndrome): retching followed by severe chest and epigastric pain, tachypnoea, dyspnoea, fever, cyanosis, shockCaustic ingestion, pill esophagitis, Barretts, oesophageal ulcers in HIV patients

  • Oesophageal rupture: Diagnosis

    CXR: early shows mediastinal or free peritoneal airHours to days later: widening of mediastinum, pleural effusion

  • Oesophageal rupture:CT scan: Oesophageal oedema, extra oesophageal air, perioesophageal fluidOesophagram: Extravasation of contrastNO role for endoscopy which introduces more air into mediastinum

  • Oesophageal rupture: TreatmentManagement variable and depends on size, location, rapidity of diagnosis and underlying diseaseTreatment surgicalComplications: mediastinitis , sepsis, shock, death

  • Chest PainNon CardiacCardiacPEPTXOesophageal disasterAortic diseaseMyo/pericardiumCoronary diseaseCoronary spasmObstructive CADACSStable angina

  • Aortic dissection: PresentationSharp, tearing anterior or posterior chest and back pain. Typically sudden onset and severeChest pain more common with type A dissectionsComplicated by CVA, syncope, MI (RCA) or HF

  • Aortic dissection: DiagnosisGenerally suspected by history/physical Variations in pulses or blood pressure (>20 mmHG difference between R and L arm)ECG: variable depending on complicationsImaging when stableCXR: mediastinal wideningCT chest, TEE, MRI other options and all superior to TTE

  • Aortic Dissection:Predisposing factors:Aortic aneurysmHTNVasculitisMarfans or other collagen diseasesCABG/cardiac catheterizaionDrugs (crack cocaine)Trauma

  • Aortic dissection: Classification

  • Aortic dissection

  • Aortic dissection

  • Aortic Dissection: ManagementType A: SurgicalType B and uncomplicated: MedicalType B and complicated (major branch involved, continued expansion or aortic ruptureLong term management includes B blocker, serial imaging at 3, 6 and 12 months and reoperation if indicated

  • Acute ManagementICU admissionPain control: MorphineReduction of SBP to 100-120 or lowest tolerated, HR
  • Chest PainNon CardiacCardiacPEPTXOesophageal disasterAortic diseaseMyo/pericardiumCoronary diseaseCoronary spasmObstructive CADACSStable angina

  • PericarditisChest pain (anterior chest, sharp, pleuritic, exacerbated by inspiration, can decrease with leaning forward, radiation to trapezius)Often first sign of other systemic diseaseMultiple possible etiologies, viral and autoimmune most common in USConsider TB outside US

  • Pericarditis: DiagnosisTypically need 2/4:Chest painFriction rubECG changes (wide spread ST elevation with PR depression)Pericardial effusionConsider tamponade (sinus tachycardia, JVD, pulsus paradoxus, Kussmauls sign)

  • Pericarditis: ECG:

  • Pericarditis: TreatmentNSAIDs are mainstay of therapy (IBU or high dose ASACan also use colchicine or glucocorticoidsTamponade: conservative management with monitoring, serial echo, volume expansion and treatment of underlying cause vs. pericardiocentesis

  • MyocarditisPresentation variableViral most common etiology in developed countriesPresents with HF, chest pain, sudden cardiac death or arrhythmiasWorkup with biomarkers, ECG, CXR, TTE, cardiac MR and endomyocardial biopsyConsider in young male with new onset HF

  • Chest PainNon CardiacCardiacPEPTXOesophageal disasterAortic diseaseMyo/peri