Approach to the patients with chest pain and their management Prof Dr. S. N. Ojha M.D Ph.D Principal Dr. D. Y. Patil Ayurvedic College Pune http://drojha.wordpress.com/

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Approach to the patients with chest pain and
their management Prof Dr. S. N. Ojha M.D
Ph.DPrincipalDr. D. Y. Patil Ayurvedic College
Pune http//drojha.wordpress.com/
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ACUTE MYOCARDIAL INFARCTION
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• Defination
• AMI occurs when the blood supply to the part
  of hearth is interrupted. The resulting ischemia
  (restriction in blood supply) and oxygen
  shortage, If left untreated for a sufficient
  period, can cause and/or Death (Infarction) of
  heath muscle tissue (Myocardium)

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• Magnitude of the problem
• 32 Death in India attributed to cardio vascular
  disease compared to 12 due to respiratory
  infection, 9 due to diarrhoeal disease and 5
  due to tuberculosis.
• Prevalence is higher in south India .
• Urban India(3.45-9.45) is affected more in
  comparison to rural India(2-4)

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• Risk factor
• Risk factor for atherosclerosis are generally
  risk factor for MI
• -Old age
• -Male sex
• -Hypercholestrolemia
• -Tobacco smoking
• -DM with or without insulin resistency)
• -High BP
• -Obesity
• -Stress
• -Hyperhomocysteinemia
• -Women using OCP have increased risk of MI
• -Periodontal disease may be linked to coronary
  heart disease

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• 
  SYMPTOMS
• -Chest Pain
• -Levines sign Chest pain is localized by
  clenching fist over sternum.
• -Dyspnoea
• -Diaphoresis
• -Weakness
• -Light Headedness
• -Nausea
• -Vomiting
• -Palpitation
• -Loss of consciousness
• -Sudden Death
• Most common symptoms of MI in Women include
  Dyspnoea, Weakness and Fatigue.
• In DM, difference in Pain threshold, Autonomic
  neuropathy and psychological factors have been
  cited as possible explanation for silent MI.
• Probably because the donor heart is not
  connected to nerves of the host MI in heart
  transplanted person is silent.

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• PHYSICAL EXAMINATION
• -General appearance may vary the patient may
  be comfortable or restless and in severe distress
  with increased respiratory rate.
• -Low grade Fever (38-39 degree celsius )
• -BP maybe elevated or decreased.
• -Pulse can become irregular
• -If Heart failure ensues
• increased JVP
  
  hepatojugular reflux,
  
• swelling legs due peripheral oedema.
• -Cardiac bulge with a pace different from
  pulse rhythm can be felt on precordial
  examination.

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• -On auscultation
• -3rd and 4th heart sound.
• - Systolic murmur
• - Paradoxical splitting of 2nd heart sound
  
• - Precordial friction rub
• - Rales over lung

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• DIAGNOSIS
• -History of present illness
• - Physical Examination
• - ECG
• - Cardiac Marker CKMB- Troponin
• -Coronary angiogram
• - Echo cardiogram
• - Nuclear medicine (technetium 99m
  2-methoxyisobutylisonitrite Or Thallium-201
  Chloride)

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Some features differentiating cardiac from
Non-cardiac chest pain Favoring Ischaemic
Origin Against Ischaemic
origin 1.Character of Pain Constricting
Dull ache Squeezing
Knife
Like,Sharp Burning
stabbing,jabs Heaviness, heavy
feeling Aggravated Respiration 2.
Location of Pain Substernal In the left
submamary area Across Mid Thorax, In the Left
hemithroax Anteriorly In both arms,
shoulders In the Neck, Cheeks, Teeths In the
Forearms, Fingers In the interscapular region
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Some features differentiating cardiac from
Non-cardiac chest pain Favoring Ischaemic
Origin Against Ischaemic
origin 3. Factors Provoking Pain Exercise Pa
in after completion of exercise Excitement Prov
oked by a specific body motion Other forms of
Stress Cold Weather After Meals
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Index Disease Duration Quality Provocation Relief Location
1. Effort angina 5-15 mins Visceral/pressure type During effort or emotion Rest Nitroglycerine Sternal radiating
2. Rest Angina Or Unstable Angina 5-15 mins Visceral/pressure type Spontaneous Nitroglycerine Substernal radiating
3. Mitral Valve Prolapse Mins to Hours Superficial Spontaneous(No Pattern) Time Left Anterior
4. Oesophageal Reflux 10 mins- 1 hour Visceral Recumbency Lack Of Food Food, Antacid Substernal Epigastric
5. Peptic Ulcer Hrs Visceral, Burning Type Lack Of Food, Acid Food Food Antacid Epigastric Substernal
6. Oesophageal Spasm 5-60mins Visceral Spontaneous, Cold Liquids Exercise Nitroglycerine Substernal Radiating
7. Biliary Disease Hrs Visceral, Severe Spontaneous, Food- Fatty food Time Analgesic Epigastric, Radiated To Rt. Scapular Tip
8. Cervical Disc Prolapse Variable (Gradually Subsides) Superficial Head Neck Movements Time Analgesic Neck Arm(Radiculopathy)
9. Hyperventillation 2-3mins visceral Emotions Tachypneoa Stimulus Removal Substernal
10. Musculoskeletal Pain Variable Superficial Movement Palpation Time Analgesic Multiple Sites
11. Pulmonary Causes 30 mins Visceral/Pressuretype Often Spontaneous Rest,time bronchodilatation Substernal





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Wall Affected Leads Showing ST Segment Elevation Leads Showing Reciprocal ST Segment Depression Suspected Culprit Artery
Septal V1, V2 None Left Anterior Descending (LAD)
Anterior V3, V4 None Left Anterior Descending (LAD)
Anteroseptal V1, V2, V3, V4 None Left Anterior Descending (LAD)
Anterolateral V3, V4, V5, V6,I, aVL II, III, aVF Left Anterior Descending (LAD), Circumflex (LCX), or Obtuse Marginal
Extensive Anterior (Sometimes called Anteroseptal with Lateral extension) V1, V2, V3, V4,V5, V6, I, aVL II, III, aVF Left main coronary artery (LCA)
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Wall Affected Leads Showing ST Segment Elevation Leads Showing Reciprocal ST Segment Depression Suspected Culprit Artery
Inferior II, III, aVF I, aVL Right Coronary Artery (RCA) or Circumflex (LCX)
Lateral I, aVL, V5, V6 II, III, aVF Circumflex (LCX), or Obtuse Marginal
Posterior (Usually associated with Inferior or Lateral but can be isolated) V7, V8, V9 V1, V2, V3, V4 Posterior Descending (PDA) (branch of the RCA or Circumflex (LCX)
Right ventricular (Usually associated with Inferior) II, III, aVF, V1, V4R I, aVL Right Coronary Artery (RCA)
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• TREATMENT
• First aid
• Aspirin
• Nitrates
• Automated external defibrillator
• In case of cardiac arrest, CPR(cardio pulmonary
  resusitation) can be administered.

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• First line
• Oxygen
• Aspirin
• Nitrates
• Analgesia(morphine)
• Beta blocker
• Anti coagulant like heparin
• Anti platelet agent like clopidogrel

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• Reperfusion
• Thrombolytic therapy
• Percutaneous coronary intervention(PCI)
• Bypass surgery
• Monitoring Arrhythmias
• Anti arrhythmic prophylaxis

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• Secondary prevention
• Beta blocker
• ACE Inhibitor
• Statin therapy
• Angiotensin receptor blocker
• Aldosterone antagonist
• Ca channel blocker
• Omega 3 fatty acids

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• Rehabilitation
• Physical exercise
• Smoking cessation
• Restricted diet
• Limitations of alcohol intake
• Can resume sexual activity after 3 to 4 weeks.

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Following drugs are used and found effective in
vatika hridroga. Further scientific clinical
trial is needful. 01) Drug acting on amasahit
meda Marich, Chitrak, Daruharidra, Rason,
Tulasi, Vacha, Pushkarmul, Punarnava, Shuddha
shilajeeta 02) Drug acting on rasvaha strotas
Amalaki, Haritaki, Punarnava, Shatavari,
Marich Shilajeet 03) Drug acting on vata dosh
Haritaki, Rason, Guggul, Pushkarmul , Amalaki
, Punarnava , Marich , Shilajeet, Chitrak,
Tulsi Shatavari. 04) Medhya drug Bramhi, Vacha,
Shatavari, Haritaki. 05) Drugs dissolute grathit
rakta Kamalkshar , Darbha or Kusha or
Paravatshakrut. 06) Hruddya Arjun, Bramhi,
Tulasi, Guggul, Punarnava, Rason Shatavari
. 07) Combination of drugsArjun, Vacha, Bramhi,
Marich, Chitrak, Tulasi, Haritaki Amalaki,
Daruharidra, Punarnava, Shatavari, Rason,
Shuddhhashilajit- sambhag(equal part)
puskarmul-2-bhag(2-part) shuddhha
guggul-4-bhag(4-part)

Matra 1GM
TDS Anupan Udak(jal), Madhu.
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AnginaThe English word angina refers to a
painful constriction tightness somewhere in the
bodyand may refer to Angina pectoris
Abdominal angina
Ludwigs angina
Prinzmetals angina
Vincents angina
Angina tonsillaris
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• Angina pectoris, commonly known as angina, is
  severe chest pain due to ischemia (a lack of
  blood and hence oxygen supply) of heart muscle,
  generally due to obstruction or spasm of the
  coronary arteries.
• The term derives from the Greek ankhon
  (Strangling) and the Latin Pectus (chest),
  and can therefore be translated as a strangling
  feeling in the chest.

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• Symptoms
• Chest discomfort
• the discomfort is usually described as a
  pressure, heaviness, tightness, squeezing,
  burning, or choking sensation.,
• anginal pains may also be experienced in the
  epigastrium ,back, neck, jaw, or shoulders,
  following skin dermatomes.
• It is typically precipitated by exertion or
  emotional stress.
• It is exacerbated by having a full stomach
  and by cold temperatures.
• Pain may be accompanied by breathlessness,
  sweating and nausea.
• It lasts for about 3 to 5 minutes, and is
  relieved by rest or specific anti-angina
  medication.

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• Risk Factors
• cigarette smoking,
• diabetes,
• high cholesterol,
• high blood pressure,
• sedentary lifestyle and
• family history

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• Pathophysiology

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• Subtypes
• Stable angina is typically presented as chest
  discomfort and associated symptoms precipitated
  by some activity (running, walking etc.) with
  minimal or non-existent symptoms at rest.
• Unstable Angina
• It occurs at rest (or with minimal
  exertion), usually lasting gt 10 min
• it is severe and of new onset (i.e., within
  the prior 4-6 weeks)
• it occurs with a crescendo pattern (i.e.,
  distinctly more severe, prolonged, or frequent
  than previously).

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• Diagnosis
• Electrocardiogram (ECG)
• Exercise ECG Test (Treadmill Test)
• Thallium Scintigram
• Stress Echocardiography
• Coronary Angiogram

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• Treatment
• Aspirin (75 mg. to 100 mg.)
• Beta blockers (eg. Carvedilol, propranolol,
  atenolol etc.)
• Short-Acting nitroglycerin
• Calcium Channel Blockers (Nifedipine
  amlodipine)
• Isosorbide mononitrate
• Nicorandil
• If inhibitor- Ivabradine provides pure hear rate
  reduction
• ACE inhibitors are also vasodilators.
• Statins are the most frequently used lipid /
  cholesterol modifiers
• Exercise is also a very good long term treatment.

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• Ludwigs angina (angina ludovici) is a serious
  potentially life-threatening cellulitis infection
  of the tissues of the floor of the mouth, usually
  occurring in adults with concomitant dental
  infections.
• Cause
• is usually a bacterial infection.

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• Symptoms
• swelling,
• pain on raising of the tongue,
• swelling of the neck and the tissues of the
  submandibular and sublingual spaces,
• malaise,
• fever,
• dysphagia
• in severe cases, stridor
• Signs
• patient not being able to swallow his / her
  own saliva
• audible stridor as these strongly suggest that
  airway compromise is imminent.

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• Treatment
• Antibiotic medications,
• Monitoring and protection of the airway in
  severe cases,
• and where appropriate, urgent maxillo-facial
  surgery
• dental consultation to incise and drain the
  collections.

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• Abdominal angina (a.k.a. bowelgina)
• is postprandial abdominal pain that occurs in
  individuals with insufficient blood flow to meet
  mesenteric visceral demands .
• Pathophysiology
• The most common cause of bowelgina is
  atherosclerotic vascular disease.
• It can be associated with
• Carcinoid
• Aortic coarctation
• Antiphospholipid syndrome

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• Clinical
• Disabling midepigastric or central abdominal pain
  within 10-15 minutes after eating.
• Physical examination
• The abdomen typically is scaphoid and soft,
• . weight loss
• signs of peripheral vascular disease,
• Causes
• Smoking is an associated risk factor.
• Treatment
• Stents have been used in the treatment of
  abdominal angina.

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• Prinzemtals angina( variant angina or angina
  inversa,) is a syndrome typically consisting of
  angina (cardiac chest pain) at rest that occurs
  in cycles.
• Cause by vasospasm, a narrowing of the coronary
  arteries caused by contraction of the smooth
  muscle tissue in the vessel walls rather than
  directly by atherosclerosis
• Features
• Symptoms typically occur at rest, rather than on
  exertion (attacks usually occur at night).

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• Diagnosis
• Patients who develop cardiac chest pain are
  generally treated empirically as an acute
  coronary syndrome, and are generally tested for
  cardiac enzymes such as creatine kinase
  isoenzymes or troponin l or T. These may show a
  degree of positivity, as coronary spasm too can
  cause myocardial damage. Echocardiography or
  thallium scintigraphy is often performed.
• The gold standard is coronary angiography.
• ECG finding will more often show ST segment
  elevation than ST depression.

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• Treatment
• Prinzmetal angina typically responds to nitrates
  and dihydrophyridine calcium channel blockers.

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• Acute necrotizing ulcerative gingivitis
• Polymicrobial infection of the gums leading
  to inflammation, bleeding, deep ulceration and
  necrotic gum tissue.
• Symptoms
• fever and halitosis.
• Causes
• Anaerobes such as Bacteroides and
  Fusobacterium a
• Treatment
• Oral cleaning and salt water or hydrogen
  peroxide-based rinses.
• Chlorhexidine or metronidazole
• Penicillin is also indicated at 250 mg. every 6
  to 8 hours.
• Dental care.

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