case scenario 1-chest pain

Case 1Chest Pain

Dina Hazwani binti AzlangIzyan Izzaidah binti Zali

HistoryC/C - a 54 years-old malay man with crushing chest

painHOPI- CS , 54-year-old man with hypertension who presents to the ED

at 5.00a.m with crushing chest pain and difficulty breathing. He awoke at 4.00a.m with substernal pressure that he describes as feeling “as if someone were standing on my chest”. He felt shortness of breath and began to sweat. On the way to the hospital, he received sublingual nitroglycerin 0.4mg with some relief. He vomited once in the ambulance. On arrival to the ED, he still complains of chest pressure that radiates to his neck and jaw. He denies back or abdominal pain. His breathing has improved with oxygen and he has mild nausea. He has never had similar pain and has no history of cardiac disease.

• PMHx: HTN, hypercholesterolemia• Meds: Amlodipine(Norvasc)5mg PO QD,

atorvastatin(Lipitor) 40mg QD• Ahx: NKDA• SHx:occasional alcohol use, no cocaine use, smoked 1ppd for

20 years, quit 10 years ago.• FHx:Father died of cardiac problem at 58 yrs of age• V/S:Temp.37.2 ̊ C, HR 110, BP 95/58, RR 26, SaO2 97% on

15 liters O2.

Provisional ∆:Myocardial infarction

∆∆: Unstable angina

Pulmonary embolism

Tension pneumothorax

What would be the initial management?

Management

CPGs, Management of Acute STEMI, 2007, 2nd Edition, MOH Malaysia.


What investigations would you request to confirm a diagnosis?

• STEMI diagnosed by : Clinical history of ischaemic type chest pain 12 lead ECG changes confirmed later with a rise in cardiac enzymes .

ECG-classic ECG changes of full-thickness MI are:

- ST elevation- T waves begin to invert over 24h and ST elevation resolves- Q waves dev. w/in 24-72h of MI.

Blood testIndicators of myocardial damage-Troponin T and troponin I

-Creatine kinaseU&E-may be deranged or worsen d/t poor fenal perfusion in cardiogenic shockBlood glucose-DM must be control aggresively after MIFBC-anemic may precipitate acute MI in pts who have angina.There is often a leucocytosis after acute MISerum cholesterol-measured w/in 24h of MI

-hypercholesterolemia is RF(must be treated) -chol level fall artificially low level 24h after MI,true reading-obtained 2 mth after MI

chest radiograph -determine cardiac size and look for pulmonary oedema.

ECG of 54 years-old man with crushing chest pain

Acute anterior wall myocardial infarction (MI) ST-elevation (STEMI), consistent with proximal left anterior descending (LAD) occlusion, with Q waves (V1-V3) and ST elevations (V1-V5). Page interventional cardiology, stat!

Cardiac troponins& CKMB – most specific cardiac enzyme - takes about 4-8 hrs after an AMI for them to rise CKMB – is sensitive to AMI at 6 hrs after the onset of chest pain Troponin – is highly specific and sensitive after 12 hrs and remains up to 14 days after an infarct.

*For most pts, blood should be obtained for testing on hospital admission, and again at 12-24hrs.


Final DiagnosisAcute anterior wall myocardial infarction (MI) ST-

elevation (STEMI)


Fibrinolytic therapy• Has been shown to reduce mortality when given

within appropriate time frame.• given within 1 hr from time of onsets of

symptoms-• most beneficial and able to abort the

infarction and reduce mortality by up to 50%.• should made be available in all hospital and

emergency department.


• Symptom consistent with AMI• Presentation within 12 hr of chest pain with:

• ST elevation >2mm in 2 or more chest leads or• ST elevation > 1 mm in 2 or more limb leads or• New or presumably new left bundle branch block.

• Time from onset of symptoms- Less than 6 hrs : most beneficial- 6-12 hrs : lesser but still important benefits-more than 12hrs: no significant benefit except in

pts with ongoing ischemic


Indication for thrombolytic therapy

Fibrinolytic contraindication



Choice of fibrinolytic agent

1)Streptokinase- most widely used agent2) tPA – the used of should be considered for pts who:

- been given streptokinase within the last 2 yrs - allergic to streptokinase - have systolic bp < 90 mmHg * t-PA unlike streptokinase does not coz hypotension

• Complication??- Bleeding- Hypotension- Allergic reaction


1 ̊ PTCA


• > effective• Limited availability• Indication:

– As an alternative reperfusion strategy.

– In pts who have definite c/I for thombolytic therapy.

– In pts presenting with cardiogenic shock.

Education

case scenario 1-chest pain