Chest pain

Question 1

A 61-year-old gentleman has presented to A&E with severe chest pain. He has been sent by his GP who has also provided a past medical history. The gentleman has T2DM, HTN, hypercholesterolaemia and five years ago was treated for colon cancer, for which he underwent a partial colectomy. You have been asked by the medical registrar to go and assess the patient in the resus department. The reg has asked for an ECG and this will be available to view once you have seen the patient.

What are your differential diagnoses for this patient?

Always be systematic

Answer 1

Cardiac:
- Acute coronary syndrome, pericarditis, coronary spasm

Respiratory:
- PE, Pneumothorax, Pneumonia + pleurisy

MSK chest pain

GI system:
- Oesophagitis, pancreatitis, cholecystitis, Boerhaave’s perforation of the oesphagus, peptic ulcer disease

Vascular causes:
- Aortic dissection, aortic aneurysm

Psychiatric
- Anxiety

At least make sure that I say the ones in bold

Question 2

What questions will help you to narrow down your differential diagnosis?

Answer 2

SOCRATES

PMHx: scenario mentioned HTN, hypercholesterolaemia, T2DM

Smoking?

Family history?

Use this question to reiterate that I am thinking about life-threatening conditions
- Constricting pain?
- Pain worse when breathing in?
- Tearing pain / radiating anywhere?
- Any vomiting preceding the chest pain? Haematemesis?

Question 3

What investigations are you going to do for this patient?

Answer 3

Bedside
- Baseline observations
- 12-lead ECG

Bloods
- FBC, U&E + Mg, CRP, LFTs, TFTs, Troponin (o/A and 6-12h after the onset of pain)
- Only would send D-dimer if PE is suspected and the Modified Wells Score suggests PE is unlikely

Imaging
- Chest X ray
- Echocardiogram - will not be done immediately though

Question 4

You are presented with the following ECG:

What does it show and how would you manage this patient?

Answer 4

The ECG shows a regular sinus rhythm with ST depressions in leads I, II, aVL, V2, V3, V4, V5 and V6 (anterolateral leads). There is a possible ST elevation in the aVR lead, likely a reciprocal of the ST depressions. and a deep Q wave in lead III.

Consistent with non-ST elevation myocardial infarction, but I would be looking out for the subtle ST elevation in aVR and escalate if any dynamic changes.

I would manage by starting an ABCDE approach.

A - ensure patent airways
B
- Monitor SpO2, RR
- Give supplemental O2 if SpO2 < 90%
- Auscultate - fluid / creps

C
- Monitor HR, BP, CRT (peripheral and central)
- Fluid status - JVP, peripheral oedema
- Listen to the heart (murmurs)
- Peripheral pulses
- ECG monitoring
- Establish IV access and get bloods

D
- Sugar, temperature

I would base my medical management based on my ABCDE assessment, correcting any urgent findings.

If hypoxic, I would administer oxygen 15L via NRB to target sats of 94-98% or 88-92% if at risk of CO2 retention

Commence medical Mx with a stat does of Aspirin 300 mg, nitrates such as GTN spray or a GTN infusion if chest pain is ongoing

I would also prescribe analgesia with antiemetics - PRN morphine with metoclopramide

If no contraindications, I would also prescribe anticoagulation - heparin-based drug - Fondaparinux 2.5 mg OD SC or LMWH (enoxaparin) 1mg/kg/12h sc

Further Mx would include beta blockers, ACE inhibitors and high dose statins

MONABASH
- Morphine + metoclopramide
- Oxygen
- Nitrates
- Antiplatelets
- Beta-blockers
- Aspirin
- Statins
- Heparin

Question 5

Once the patient is stable what is the next phase of management?

Answer 5

Further management depends on the severity and clinical stability.

Some RFs that would suggest that patient is at high risk of further MACEs include:
* Dynamic ST or T-wave changes
* LVEF < 40%
* Recent PCI
* Prior CABG

but also

High risk features of NSTEMI/UA
* Recurrent angina
* Recurrent ischaemic ECG changes despite medical Rx
* Elevated troponin

If high risk, the patient would need an early diagnostic angiography

Question 6

What would you do if the patient had an ST elevation myocardial infarction, as demonstrated by an ECG?

Answer 6

ABCDE approach, correct anything urgent

All patients with chest pain & STEMI or new LBBB fulfil PCI criteria.

If suspected, this should be discussed immediately with the on call cardiology team.

If PCI not available at the hospital and patient is haemodynamically stable, send them via a blue light ambulance to a hospital that can provide primary PCI.

Question 7

Can you list some common complications of MI?

Answer 7

Death
Aarrhythmia
Rupture
Tamponade
Heart failure
Valve disease
Aneurysm
Dressler’s syndrome
Embolism
Re-infarction

DARTH VADER

Question 8

What do you know about Dressler’s Syndrome?

Answer 8

It is an autoimmune pericarditis, occurring 2-10 weeks post MI.

Simple pericarditis post-MI is more common than Dresslers syndrome and presents 2-4 days post MI.

Management of Dressler’s syndrome is the same as with any acute chest pain.
- ABCDE approach
- ECG may show widespread diffuse sadle-shaped ST elevation across multiple leads
- Echo may show pericardial effusion
- The management is with NSAIDS
- If significant effusion, it can be aspirated

Question 9

You now have one minute to handover the patient in this scenario to your registrar/consultant as if you were at the Acute Medical Handover

Answer 9

NSTEMI
S – This is a 61 year old man who has presented with acute chest pain, with an ECG demonstrating widespread ST depression, consistent with an NSTEMI.

B – He has risk factors for ischaemic heart disease including type 2 diabetes, hypertension and raised cholesterol.

A – Following assessment I have started initial management with morphine, aspirin, high flow oxygen, beta blockers and an ACE inhibitor.

R – I would recommend that this patient is urgently discussed with the Cardiology team, as further interventional management is likely to be required, given he has other co-morbidities and is therefore considered high risk.

STEMI
S – This is a 61 year old man who has presented with acute chest pain, with an ECG demonstrating widespread ST elevation, consistent with an acute STEMI.

B – He has risk factors for ischaemic heart disease including type 2 diabetes, hypertension and raised cholesterol.

A – He was hypoxic on assessment, with ongoing chest pain, but is otherwise haemodynamically stable. I have started initial management with aspirin, nitrates, morphine, and high flow oxygen.

R – This patient requires urgent discussion with cardiology for consideration of primary PCI. If he is not eligible, then medical management should be completed, with further antiplatelets, anticoagulation, and ACE-inhibitors, beta-blockers and statins for secondary prevention.