Chest Pain/ MI/Shock

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Chest Pain/ MI/Shock

• Victor Politi, M.D., FACP
• Medical Director SVCMC PA program

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• Approximately 1 million hospitalized patients
  each year have MI as a principal diagnosis
• Approximately 200,000 - 300,000 people in US die
  from MIs each year

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MI Risk Factors

• Smoking
• HTN
• High fat diet
• High LDL
• Diabetes
• Stress
• Inactivity
• Male gender
• Age/Heredity
• Elevated homocysteine and C-reactive protein
  levels

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A patient presents with chest pain

• What do you do?

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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

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• Most heart attacks are caused by the build up of
  atherosclerotic plaque inside the arterial wall -
  which can trigger the formation of a thrombus

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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

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Classic Presentation

• Retrosternal, epigastric chest pain or tightness
• SOB
• Diaphoresis
• Nausea, vomiting
• Levines sign

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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
• Cant describe symptoms - uses vague terms
• EKG normal or non-specific changes present
• In fact - an atypical presentation is the most
  typical presentation

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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 gt 20 min

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Other Symptoms

• Bad Indigestion
• Dyspnea
• Cough
• Syncope
• Nausea or vomiting
• Diaphoresis
• Anxiety

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Physical Exam

• Rapid pulse
• BP - varies
• may reveal abnormal chest sounds on auscultation
• Diaphoresis

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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

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Additional Lab Tests

• CBC
• 6
• Pt/Ptt
• Chest x-ray

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What is first in your work-up?

• 12 lead ECG
• Is it useful ?

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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 ?

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Treatment

• Continuous ECG
• Continuous BP
• IV - fluids/meds
• oxygen
• Pulse ox
• Blood work
• urinary catheter - to monitor fluid status

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ASA
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Aspirin

• 40 relative reduction in mortality
• Whats the right dose?
• Probably the single most important thing we can
  do
• Irreversible - inhibit platelet aggregation

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Aspirin -Contraindications

• ASA Allergy
• GI bleed
• Bleeding disorder

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Nitrates

• When should nitrates be given?
• Who should receive nitrates?
• Who should not receive nitrates?
• Dose
• SL NTG
• Spray
• Paste
• IV

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Morphine MSO4

• Does morphine reduce pain? Yes
• Does morphine reduce mortality/morbidity? NO
• Morphine vs NTG

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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

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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

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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

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The ESSENCE Trial

• Efficacy safety of SQ Enoxaparin in non-Q-wave
  coronary events
• Significant relative risk reductions (RRR) cost
  savings compared to unfractionated heparin
• gt15 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

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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

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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

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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

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Thrombolysis Eligibility Criteria

• No age limit
• Clinical
• Chest pain, chest pain-equivalent c/w AMI of lt 12
  hrs from onset or lt 24hrs if stuttering
• EKG
• 1mm or gt ST elevation in 2 or limb leads
• 2mm or gt ST elevation in 2 or precordial leads
• New onset bundle branch block

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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 gt200, DBPgt110
• Non-compressible venous or arterial puncture
• CPR greater than 10 minutes
• Aortic dissection Dxgt CT of thorax
• Pericarditis

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Thrombolytics

• TPA
• Retavase
• Streptokinase
• Door -to-Drug Time
• Time is Muscle!

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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

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Other cardiac conditions
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Bradycardia

• Systolic rate lt 60
• Symptomatic
• Atropine
• Isopril
• Pacemaker
• What medications has the patient taken?

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Atrial Arrythmia

• A Fib
• A flutter
• SVT
• PAT
• PAC

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Atrial Flutter
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AV Blocks

• 1st degree AVB
• 2nd degree AVB
• Type 1
• Type 2
• 3rd degree AVB

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Ventricular Arrythmias

• PVC
• V Tach
• V Fib
• Torsades
• Ventricular escape beat

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An 84 year old lady with hypertension--First
degree AV block
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Cardiogenic Shock

• Symptomatic blood pressure lt90 systolic
• due to low cardiac output
• Goal of treatment - increase perfusion to vital
  organs
• Treatment options include Dopamine/Dobutamine/Levo
  phed/ balloon pump (aortic counterpulsation)

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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

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Questions ???