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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 • • • • • • • • 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 • • • • • Thrombolysis - Tenecteplase iv Anticoagulate - Heparin iv Analgesia - Diamorphine iv Anti-emetic - Metaclopramide iv ß blockade - Atenolol • ECG - CONTINUE MONITORING Treatment Complications • • • • • • • 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