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Chest Pain/ MI/Shock Victor Politi, M.D., FACP Medical Director SVCMC PA program Approximately 1 million hospitalized patients each year have MI as a principal diagnosis Approximately 200,000 - 300,000 people in US die from MI’s each year MI Risk Factors Smoking HTN High fat diet High LDL Diabetes Stress Inactivity Male gender Age/Heredity – Elevated homocysteine and C-reactive protein levels A patient presents with chest pain What do you do? Stable angina, unstable angina, ACI, AMI An indistinguishable spectrum – beginning with stable lumen-restricting coronary artery plaques – results in plaque fissuring – initiates platelet adhesion & fibrin plugs w/overlying but non-occlusive thrombus – results in plaque disruption, occlusive thrombus composed of fibrin, platelets & erythrocytes Most heart attacks are caused by the build up of atherosclerotic plaque inside the arterial wall - which can trigger the formation of a thrombus Frequency of “Silent” AMIs Framingham Study: largest long term prospective study of cardiovascular disease Cohort of 5,127 participants 708 (13%) suffered AMI 213 (30%) were not recognized during AMI Only 1/2 demonstrated classic AMI S/Sxs allowing identification of AMI in retrospect Classic Presentation Retrosternal, epigastric chest pain or tightness SOB Diaphoresis Nausea, vomiting Levine’s sign Atypical Symptoms of AMI Admits chest discomfort- denies pain A little sweating previously - now gone Previous indigestion - now ok May or may not have mild SOB Can’t describe symptoms - uses vague terms EKG normal or non-specific changes present – In fact - an atypical presentation is the most typical presentation Symptoms pain Chest pain– typically below the sternum – intense/severe/subtle – squeezing sensation/heavy pressure Angina not relieved by rest or nitroglycerin Back pain Abdominal pain Pain radiating to – shoulder/arms/chest – neck/teeth/jaw – back Pain that is prolonged > 20 min Other Symptoms Bad Indigestion Dyspnea Cough Syncope Nausea or vomiting Diaphoresis Anxiety Physical Exam Rapid pulse BP - varies may reveal abnormal chest sounds on auscultation Diaphoresis Studies ECG Echocardiography Coronary angiography Stress test – EST – Nuclear – Studies which show heart damage or high risk Troponin I / troponin T CK and CK-MB Myoglobin-serum Additional Lab Tests CBC 6 Pt/Ptt Chest x-ray What is first in your work-up? 12 lead ECG Is it useful ? A “normal” ECG Studies show that as many as 15% of ECGs are completely normal and 60% of ECGs are normal or show nonspecific changes even in the presence of an evolving AMI When are ECGs useful ? Treatment Continuous ECG Continuous BP IV - fluids/meds oxygen Pulse ox Blood work urinary catheter - to monitor fluid status ASA Aspirin 40% relative reduction in mortality What’s the right dose? Probably the single most important thing we can do Irreversible - inhibit platelet aggregation Aspirin -Contraindications ASA Allergy GI bleed Bleeding disorder Nitrates When should nitrates be given? Who should receive nitrates? Who should not receive nitrates? Dose – SL NTG – Spray – Paste – IV Morphine MSO4 Does morphine reduce pain? Yes Does morphine reduce mortality/morbidity? NO Morphine vs NTG Glycoprotein IIB/IIA Inhibitors Utilized in ACISs without AMI Action is to “de-couple” platelets Three FDA-approved – Integrillin - eptifibatide – Aggrestat - tirobifan hydrochloride – Repro-abciximab Heparin When should heparin be given? Who should receive heparin? What is the right way to give heparin? – Is there a wrong way to give heparin? Other forms of heparin, anticoagulants? Therapeutic monitoring Oral anticoagulation – Warfarin – Coumadin Low-molecular weight heparin Enoxaparin dosed 1mg/kg SQ Q 12 hr No PTT monitoring necessary – potential of fewer labs drawn, run No IV necessary – fewer IV starts, no pumps, outpatient treatment Fragmin The ESSENCE Trial Efficacy & safety of SQ Enoxaparin in non-Qwave coronary events Significant relative risk reductions (RRR) & cost savings compared to unfractionated heparin >15% relative risk reduction in incidence of death, AMI, recurrent angina & combined triple endpoints 10% relative risk reduction in CABG 21% relative risk reduction in PTCA Decreased resource utilization resulting in cost savings exceeding $1000 per patient Beta-blocker IVP When should beta blockers be given? Who should receive beta blockers? Who should not receive beta blockers? What is the right dosing regimen? Primary, secondary benefits? B1-B2 Blocker Ace Inhibitors Studies show decreased mortality if given in first few days after AMI Benefit due to effects on myocardium remodeling long term benefits show increased EF and decreased incidence of CHF Cholesterol Lowering Agents Current thinking; the lower the total and LDL cholesterol - the better ! Many types available -currently the statins seem to show the best reduction Thrombolysis: Eligibility Criteria No age limit Clinical Chest pain, chest pain-equivalent c/w AMI of < 12 hrs from onset or < 24hrs if “stuttering” EKG 1mm or > ST elevation in 2 or + limb leads 2mm or > ST elevation in 2 or + precordial leads New onset bundle branch block Contraindications to Thrombolytics History of CVA/TIA within 6 months Recent head trauma, known intercranial mass Surgery, PTCA, severe trauma in past 2 weeks Recent GI bleed or ulcer Persistent, uncontrollable SBP >200, DBP>110 Non-compressible venous or arterial puncture CPR greater than 10 minutes Aortic dissection Dx=> CT of thorax Pericarditis Thrombolytics TPA Retavase Streptokinase Door -to-Drug Time Time is Muscle! Goal of Treatment Stabilize patient Stop the progression of heart attack – prevent further heart damage Reduce demands on heart – so it can heal Prevent complications Other cardiac conditions Bradycardia Systolic rate < 60 Symptomatic Atropine Isopril Pacemaker What medications has the patient taken? Atrial Arrythmia A Fib A flutter SVT PAT PAC Atrial Flutter AV Blocks 1st degree AVB 2nd degree AVB – Type 1 – Type 2 3rd degree AVB Ventricular Arrythmias PVC V Tach V Fib Torsades Ventricular escape beat An 84 year old lady with hypertension-First degree AV block Cardiogenic Shock Symptomatic blood pressure <90 systolic due to low cardiac output Goal of treatment - increase perfusion to vital organs Treatment options include Dopamine/Dobutamine/Levophed/ balloon pump (aortic counterpulsation) Cardiac Tamponade Hypotension caused by reduction of cardiac output secondary to inability of the ventricle to provide adequate stroke volume due to fluid in the pericardial sac Questions ???