4. Chest Pain in Emergency-1.pptx.medical

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1. Life Threatening Causes of Chest Pain By Dr. Radwa Muhammad Ashour Lecturer of Emergency Medicine

2. Patient 1 : Joe Joe a 50-year-old male presents to the ED by ambulance complaining the first time ever of severe  chest pain that just started while running on the treadmill. He immediately called 911. Vitals: BP = 140/90, P = 80, RR = 24, T = 98.3F, O2 sat = 98%. Patient 2: Mary  Mary a 69-year-old female presents to the emergency department via triage complaining of worsening shortness of breath, chest and epigastric pain x 24 hrs. She has nausea/vomiting, weakness, and fatigue. She “feels terrible.” Vitals: BP = 140/90, P = 80, RR = 24, T = 98.3F, O2 sat = 98%.

3. Chest Pain

4. ILOS Identify Life Threatening Causes of Chest Pain. Recognize Interpretation of Chest Pain. Explain Management of Acute Coronary Syndrome. Explain Management of Pulmonary Embolism. Upon completion of this Lecture, you will be able to:

5. What's Your Greatest Fear?

6. Life Threatening Causes of Chest Pain

7. A cute coronary syndrome T ension Pneumothorax Pulmonary E mbolism Aortic D issection Mediastinitis e.g. Esophageal Rupture ( H ole) DEATH Life Threatening Causes of Chest Pain Pericardial T amponade

8. Most Common Causes of Chest Pain

9. Most Common Causes of Chest Pain Cardiac causes: Acute heart failure. Stable angina. Valvular heart disease: prolapse – stenosis. Pericarditis, myocarditis, and endocarditis. Arrhythmias.

10. Most Common Causes of Chest Pain Pulmonary causes: Infections: pneumonia. Asthma exacerbations. Pleural effusions.

11. Most Common Causes of Chest Pain GIT causes: GERD. Esophageal rupture ( Boerhaave's syndrome) Sliding hiatal hernia. Pancreatitis “referred”.

12. Most Common Causes of Chest Pain Musculoskeletal causes: Rib fractures. Intercostal muscle strains. Costochondritis

13. Most Common Causes of Chest Pain Psychiatric causes: Panic attack (diagnosis of exclusion). Other conditions Herpes Zoster. Referred pain.

14. Interpretation of Chest Pain

15. History Analyses of pain:

16. History Risk Factors of IHD: Dyslipidemia HTN DM Smoker Family History Obesity Examination Investigation ECG CXR Vitals Monitor IPPA

17. Acute Coronary Syndrome

18. Acute Coronary Syndrome ST-elevation MI (STEMI) Non-ST-elevation ACS (NSTE-ACS) Non-ST-elevation myocardial infarction (NSTEMI). Unstable angina

19. When to exclude ACS in ED?

20. Rule out ACS: If serial troponins are negative and HEART score low ≤ 3

21. Score 0-3: Discharge Home Score 4-6: Admit for Clinical Observation Score 7-10: Early Invasive Strategies

22. Acute Myocardial Infarction (4 th Universal Definition of MI) Detection of a rise and/or fall of cTn + At least one value above the 99 th percentile + At least one of the following: (1 of 5) Symptoms of acute myocardial ischemia. New ischemic ECG changes. Development of pathological Q waves.

23. Acute Myocardial Infarction (4 th Universal Definition of MI) Detection of a rise and/or fall of cTn + At least one value above the 99 th percentile + At least one of the following: (1 of 5) Imaging: new loss of viable myocardium or new SWMA. Identification of a coronary thrombus: by angiography or by autopsy.

24. Clinical Presentation Typical Presentation: Chest Pain: SOCRATES Central retrosternal chest pain. Radiates to the arms, neck, or jaw. Sudden Onset , constant chest pain.

25. Clinical Presentation Typical Presentation: Chest Pain: SOCRATES Associated symptoms: sweating, nausea, vomiting, and breathlessness. Similar to previous angina pectoris but is much more severe, longer duration and unrelieved by GTN.

26. Clinical Presentation Atypical Presentation: (common 1/3 patients) Have a high level of suspicion Shortness of breath without chest pain. Epigastric abdominal pain or indigestion. Fatigue or generalize weakness. Mental status change - Collapse or syncope . Be especially suspicious in: older, ♀, DM, Heart Failure.

27. Examination Monitor: BP – HR – ECG Monitor (arrhythmia or cardiogenic shock). Listen to the heart (murmurs or third heart sound). Listen to the lung fields (LVF, pneumonia, pneumothorax). Direct examination towards searching for complications and excluding alternative diagnoses.

28. Examination Check peripheral pulses (aortic dissection). Check legs for evidence of deep vein thrombosis (DVT) (PE). Palpate for abdominal tenderness or masses (cholecystitis, pancreatitis, perforated peptic ulcer).

29. ECG Changes The 12-lead ECG, which should be acquired and interpreted within 10 minutes of arrival to a medical facility Normal ECG on arrival doesn’t rule out MI. If the initial ECG is normal, but symptoms are suspicious, repeat the ECG after 15min and re- evaluate Review old ECGs for comparison.

30. ECG Changes STEMI: ST elevation in ≥ 2 contiguous leads. +/- Reciprocal ST-segment depression.

31. ECG Changes STEMI:

32. ECG Changes STEMI ECG Changes Over Time:

33. ECG Changes NSTEMI/UA : ST depression: New horizontal or down-sloping ≥ 0.5 mm in 2 contiguous leads. T wave inversion: ≥ 1 mm in 2 contiguous leads with prominent R wave or R wave > S wave.

34. ECG Changes Localization of MI :

35. ECG Changes STEMI Equivalent : V7-8-9 Pathological Q ST Elevation > 0.5mm T wave Inversion

36. ECG Changes STEMI Equivalent : Pathological R ST depression Upright T wave

37. A. Posterior MI

38. Cardiac Markers Troponin T ( cTnT ) and troponin I ( cTnI ): Proteins virtually exclusive to cardiac myocytes. ↑↑ within 2-3 h and normalize within 7 days. CK-MB: The best alternative. ↑↑ within 2 h and normalize within 2 days.

39. Management of STEMI ABCDE Approach. Time = Muscle. Monitor – Defibrillator.

40. MONA: M: Morphine Sulfate: Dose: 1-5 mg IV / 5 min “Max: 30 mg” ↓ Pain - ↓ Anxiety - ↓ Preload Avoid NSAID – Selective Cox II inhibitor. Management of STEMI O: Oxygen: Give O2 if needed maintain oxygen 94-98%.

41. MONA: N: Nitroglycerin: Dose: 0.4 mg SL or PO / 5 min “Max: 3 times” / 5-200 μ g/min IVI. Avoid in hypotension, suspecting right ventricular infarction, if phosphodiesterase inhibitor taken within 24 hours. Management of STEMI

42. MONA: A: Antiplatelets: (DUAL) Aspirin: loading dose 300mg. P2Y12 receptor inhibitor: any of Ticagrelor: loading dose 180mg PO. Clopidogrel: loading dose 300-600 mg PO. Prasugrel: loading dose 60 mg PO. Management of STEMI

43. MONA: A: Anticoagulants Unfractionated heparin (UFH): 60 IU/kg (max 5000 IU). “if PCI is likely” Enoxaparin: 30 mg IV bolus. “in Fibrinolytics not followed by PCI” Fondaparinux: 2.5mg SC “in Fibrinolytics not followed by PCI”. Management of STEMI

44. Reperfusion Therapy: Primary PCI (Door to Balloon 60-90 min) STEMI + Ischemic symptoms onset < 12 h. STEMI + Ischemic symptoms onset > 12 h + one of “Cardiogenic Shock – hemodynamic instability - Heart Failure – ongoing ischemia - life-threatening arrhythmia”. Management of STEMI

45. Reperfusion Therapy: STEMI + evidence of failed reperfusion after fibrinolytic therapy (Rescue PCI) Management of STEMI Primary PCI (Door to Balloon 60-90 min)

46. Reperfusion Therapy: Fibrinolytic (Door to Needle 30 min) Primary PCI is not immediately available + Delay from hospital presentation to PCI is anticipated to be > 120 minutes. Management of STEMI

47. Reperfusion Therapy: Management of STEMI 35% have failed reperfusion. 10% have ineffective reperfusion. Fibrinolytic (Door to Needle 30 min)

48. Reperfusion Therapy: Alteplase: > 67 kg: 15 mg IV bolus - 50 mg over 30 min - 35 mg over 60 min. < 67 kg: 15 mg IV bolus – 0.75 mg/kg over 30 min – 0.5 mg/kg over 60 min. Management of STEMI Fibrinolytic (Door to Needle 30 min)

49. Reperfusion Therapy: Streptokinase: 1.5 million IU over 60 min Management of STEMI Fibrinolytic (Door to Needle 30 min)

50. Betablocker: Metoprolol tartrate “25 mg PO” - Atenolol. Avoid in signs/at risk of heart failure or signs of hemodynamic compromise, bradycardia, or severe reactive airway disease. Management of STEMI

51. Management of NSTE-ACS ABCDE Approach. Monitor – Defibrillator. MONA: M: Morphine Sulfate. O: Oxygen. N: Nitroglycerin. A: Antiplatelets: (DUAL) A: Anticoagulants

52. Reperfusion Therapy: PCI In all patient s within 72 h. Immediate within 2 h if: Malignant ventricular arrhythmias – Hemodynamic instability – Severe chest pain – severe heart failure. Early within 24 h if: High risk TIMI ≥ 4 – High Troponin – Dynamic ECG changes – STE not meeting STEMI. Management of NSTE-ACS

53. Reperfusion Therapy: PCI within 25-72 h if: Intermediate risk TIMI 2-3 – Recurrent angina despite therapy – EF < 40% in DM, Renal insufficiency, Prior CABG, PCI within 6 months. Management of NSTE-ACS Betablocker: avoid IV

54. Pulmonary Embolism

55. Pulmonary Embolism Hemodynamically Stable Hemodynamically Unstable Cardiac arrest. Obstructive shock. Persistent hypotension.

56. Clinical Presentation Always consider PE in patients with unexplained hypoxia or Dyspnea. Typical Presentation: Dyspnea. Syncope with cyanosis. Chest Pain: pleuritic. Hemoptysis. Tachycardia. Tachypnoea. Pyrexia following lung infarction. 30% of all patients with PE have normal SpO2.

57. Assess Clinical Probability of PE Modified Wells Score for PE Signs of DVT (minimum of objective leg swelling & tenderness) 3 PE is the most likely diagnosis 3 HR >100 1.5 Prior PE or DVT diagnosis 1.5 Immobilization > 3 days or surgery (within 4 weeks) 1.5 Active Cancer 1 Haemoptysis 1

58. Investigation ECG: Sinus tachycardia “ most common ” N on- specific ST- / T wave changes in anterior chest leads. The classical changes of acute corpulmonale : S1Q3T3, RAD, or RBBB. Less common: atrial flutter or AF.

59. Investigation Laboratory Investigation ABG: Hypoxemia “ ↓ PaO2 - ↓ SaO2”. Respiratory alkalosis “ ↓ PaCO2” (due to tachypnoea) Metabolic acidosis (due to shock).

60. Investigation CBC: Leukocytosis Cardiac Enzymes: Mildly elevated CK, troponin. Kidney Function Test.

61. Investigation Radiological Investigation CXR: Focal pulmonary oligemia (Westermark’s sign)

62. Investigation CXR: Palla’s Sign. Hampton's Hump. Normal CXR + severe respiratory compromise = highly suggestive of PE.

63. Investigation Echocardiography: (Exclude other causes) RV dilatation. Global hypokinesia, with apical sparing (McConnell’s sign). PA dilatation. Tricuspid/ pulmonary regurgitation. Thrombus in the PA may be visible.

64. Investigation Duplex venous system Diagnostic Imaging CT pulmonary angiography (CTPA) Ventilation– perfusion (V/ Q) scanning.

65. Pulmonary Embolism Severity Simplified pulmonary embolism severity index (PESI) score

66. Pulmonary Embolism Severity

67. Management

68. Management In patients with high or intermediate clinical probability of PE, while diagnostic workup is in progress. LMWH or fondaparinux is recommended (over UFH) for most patients.

69. Management Enoxaparin: 1 mg/kg/12 h or 1.5 mg/kg/24 h. (SC) Fondaparinux: 5 mg (< 50kg) – 7.5 (50-100 kg) – 10 mg (> 100 kg) / 24 h. (SC) Unfractionated heparin: 80 units/kg bolus, then 18 units/kg/h.

70. Management Reperfusion “Fibrinolytics”: Streptokinase: 250000 IU loading over 30 min, then 100000 IU/h over 12-24 h. (Accelerated: 1.5 million IU over 2 h) rtPA : 100 mg over 2 h. (Accelerated: 0.6 mg/kg over 15 min (maximum 50 mg) High-risk pulmonary embolism: (unstable)

71. Management Anticoagulation Therapy (either parenteral or oral). Intermediate-risk pulmonary embolism

72. Management Treatment of RV Failure:

73. Management Low-risk pulmonary embolism Early Discharge. Continuation of Anticoagulant Therapy. Consider if “Low risk - No conditions need hospitalization - Proper outpatient care”

74. Management Low-risk pulmonary embolism Rivaroxaban (Xarelto®): 15 mg BID for 21 d, then 20 mg/d. Apixaban (Eliquis®):10 mg BID for 7 days, then 5 mg BID. Dabigatran (Pradaxa®): 150 mg BID “require heparin for 5–10 d”

75. Any Question? 10 9 8 7 6 5 4 3 2 1

76. Life Threatening Causes of Chest Pain: DEATH = Dissection – Embolism – ACS – Tension Pneumothorax – Tamponade – Hole “Mediastinitis”. Interpretation of Chest Pain: Analysis of pain – risk factors of IHD – examination to exclude life-threatening causes – investigations including ECG & CXR. Exclude ACS if: low HEART score – negative serial troponin. Acute coronary syndrome: including STEMI – NSTE-ACS. Summary

77. 4 th Universal Definition of MI: Detection of a rise and/or fall of cTn. + At least one value above the 99 th percentile. + At least one of the following: (Symptoms of acute myocardial ischemia - New ischemic ECG changes - pathological Q waves – Imaging of new loss of viable myocardium or new SWMA - Identification of coronary thrombus). Typical Presentation of ACS: Sudden Onset - central retrosternal chest pain - Radiates to the arms, neck, or jaw – associated with nausea, sweating. Summary

78. STEMI: STE ≥ 1 mm in ≥ 2 contiguous leads except V2, V3. NSTE-ACS: STD ≥ 0.5 mm or TW inversion ≥ 1 mm in ≥ 2 contiguous leads. Management of ACS: ABCDE – Monitor – MONA – Reperfusion. Diagnosis of PE depending on: Hemodynamics – TTE - PE probability using Wells Score – D Dimer – CTPA. PE severity depending on: Hemodynamics – PESI score – RV function – Troponin. Summary

79. High risk PE: TTT with reperfusion. Intermediate risk PE: TTT with anticoagulants. Low risk PE: Discharge – oral anticoagulants. Summary

80. Thank You