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‘Taxi Driver in Pain’
Tiara Gill
Carrie Ross
Mark Hambly
Patient Presentation 1
Mr O, 45 year old Nigerian taxi driver
P/C
Severe central chest pain
HPC
Arrived by ambulance to A&E at 0310
On high flow O2, GTN and aspirin in ambulance
Differential Diagnoses 1
Immediately life threatening causes of
acute chest pain:
• Acute Coronary Syndrome (ACS)
• Tension pneumothorax
• Pulmonary embolism
• Aortic dissection
• Oesophageal rupture
Patient Presentation 2
Chest pain characteristics
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•
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•
S
O
C
R
A
T
E
S
- Central chest
- Sudden, one hour ago [at rest]
- Stabbing
- None
- Sweating
- Constant
- Eased by GTN
- 10/10 eased to 6/10
Patient Presentation 3
Cardiac risk factors
Smoker with 25 pack year history
Hypertension since 2001 - untreated
No previous MI or Angina
No relevant family history
No diabetes or hyperlipidaemia
BMI < 25
No alcohol or recreational drugs
Past Medical History
None. No medications
Patient Presentation 4
Observations
• HR 72 bpm
• RR 12 min-1
• GCS 15/15
- BP 134/73 mmHg
- Sats 96% on air
Examination
• Physical examination in all systems was
normal.
Differential Diagnoses 2
History and examination highly suggestive ACS
Unstable angina
Myocardial infarction
12 Lead ECG - Inferior Leads
Inferior leads II, III, AVF
- area supplied by right coronary artery
- 1mm ST elevation in adjacent limb leads
- can affect SA and AV nodes
12 Lead ECG - Lateral Leads
Lateral leads - I, aVL, 5, 6
- Area supplied by Circumflex Artery1mm ST
- ST depression in aVL - reciprocal changes
12 Lead ECG - Anterior Leads
Anterior leads - 2, 3, 4
- Area supplied by anterior descending artery
- No abnormalities
Diagnosis
• Inferior ST elevation myocardial
infarction
Why?
• Appropriate chest pain history
• Diagnostic ECG changes
• Trop T negative on admission
Immediate Investigations
• Haematology
• Biochemistry
- FBC, Clotting
- U&E, Trop T,
- glucose, lipid profile
• CXR
• In this case, all these investigations
were normal.
Acute Management
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Thrombolysis - Tenecteplase iv
Anticoagulate - Heparin iv
Analgesia - Diamorphine iv
Anti-emetic - Metaclopramide iv
ß blockade - Atenolol
• ECG - CONTINUE MONITORING
Treatment Complications
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BP: 65/30
HR: 30
ß blocker effect - referred to Cardiology
Fluid replacement (gelofusin)
Atropine
Transfer to CCU
BP: 120/66
Right Coronary Angiogram
• Note - there was also 40% occlusion of
the circumflex artery (off left main stem)
RCA Post Angioplasty and Stent
Case summary
• 45 year old Nigerian man presented
with chest pain and ECG changes
consistent with acute inferior ST
elevation MI
• He was thrombolysed
• Troponin T was positive at 12 hours
• Angiography revealed a 90% stenosis in
the RCA which has been stented
Rationale for Treatment of MI
and Secondary Prevention of
Ischaemic Cardiac Events
Thrombolysis
Primary aims - Save life, save
myocardium
• Only shown to have prognostic benefit
in ST elevation MI and acute LBBB
• Traditionally streptokinase, but recently
TPA - no difference in therapeutic
benefit
• Risk of bleeding - screening questions
FTT Collaboration, Lancet 1994;343:311-322
ISIS-3 Lancet 1992;339:753-770
Effects of Thrombolysis on
Mortality
Lives saved/1,000 people
50
40
Loss of benefit per hour of delay:
1.6 ± 0.6 lives per 1,000 people
3,000
14,000
30
12,000
9,000
20
10
7,000
0
0
6
12
18
Hours from onset of symptoms to randomisation
Source: FTT Collaboration, Lancet 1994;343:311-322
24
Secondary Prevention
• Reduce risk factors
• Medical treatment - Treats symptoms not
stenosis
- 4As and nitrates
• Surgical
- Treats stenosis
- CABG
- Angioplasty with stent
ATC BMJ 1994;308:81-106
WOSCOPS NEJM 1995;333:1301-7
Teo K JAMA 1993;270:1589-94
HOPE NEJM 2000;342:145-53
4S, Lancet 1994;334:1383-9
Surgical - CABG
• CABG gives prognostic benefit and
symptomatic relief over stenting in those
with:
- Left mainstem disease, and
- Severe three vessel disease.
• In less severe disease, the risks of CABG
outweigh the benefits it has over stenting.
• Associated with personality changes.
Poyen JCS 2003; 44(3):307-12
EAST JACC 2000; 35:1116-21
Surgical - Stenting
• Stenting gives symptomatic relief and
similar prognostic benefit to patients with
milder disease.
Benefits
Local anaesthetic
More minor surgery
Shorter hospital stay
NICE 1999 report
Risks
Restenosis (12%)
Acute ischaemic
event (5.5%)
New developments
• Drug eluting stents
Questions and Comments