Chest Pain

1
Chest Pain Unstable Angina Eugene Yevstratov
MD
Based on UCLA protocol of the management of Chest
Pain Unstable Angina
2
Diagnostic criteria for acute myocardial
infarction
1 ST elevation gt 1 mm in 2 or more contiguous
limb or precordial leads 2 Left bundle branch
block, not known to be old 3 ECG findings useful
for establishing the likelihood of coronary
artery disease ST segment depression gt 1
mm Inverted T-waves gt 1 mm in two or more
contiguous leads
3
The major factors in the initial history and
physical exam that relate to the likelihood of
coronary artery disease

• Chest pain assessment by physician (definite
  angina, probable angina, probably not angina)
• Prior myocardial infarction or documented
  coronary artery disease
• Number of risk factors (diabetes, smoking,
  hypercholesterolemia, hypertension, post
  menopausal)
• Age

4
Likelihood of significant coronary artery disease
in patients with symptoms suggesting unstable
angina

• Low Likelihood (e.g., 0.01-0.14) Chest pain,
  "probably not angina" in patients with one or no
  risk factors, but not diabetes. T wave flat or
  inverted lt 1 mm. Normal ECG.
• Intermediate Likelihood (e.g., 0.15-0.84)
  "Definite angina" in patients with no risk
  factors for CAD.
• High Likelihood (e.g., 0.85-0.99) Known history
  of prior MI or CAD. "Definite angina" in male gt
  60 or
• females gt 70. Transient hemodynamic or ECG
  changes during pain. ST elevation or
  depression of gt 1 mm.
• Marked symmetrical T wave inversion in multiple
  leads.

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Risk Assessment

• Low risk Nonresting angina with increased
  frequency, severity, or duration. Angina provoked
  at a lower threshold. New onset angina 2 weeks to
  2 months. Normal or unchanged ECG.
• Intermediate risk Rest angina now resolved. Rest
  angina lt 20 minutes in duration, angina with
  dynamic T wave changes. New onset angina lt 2
  weeks at minimal exertion. Age gt 65 years. Q
  waves or ST depression on ECG.
• High risk Ongoing rest pain gt 20 minutes. Angina
  with pulmonary edema, S3, or rales. Angina with
  new or worsening mitral regurgitation. Rest
  angina with dynamic ST changes gt 1 mm. Angina
  with hypotension.

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The most important factors related to short term
and long term survival in patients with acute
myocardialinfarction or unstable angina
1. Left ventricular function (LVEF) 2. Extent of
coronary artery disease 3. Age 4. Co-morbid
conditions 5. Unmodified coronary risk factors
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The treatment of acute myocardial infarction is
detailed in the UCLA Acute Myocardial Infarction
Practice
1. Activate the CLOT team (CCU fellow) 2. All
patients should receive regular ASA 325 mg as
soon as possible unless a definite
contraindication is present (evidence of ongoing
life-threatening hemorrhage or a clear history of
severe hypersensitivity to ASA). Have patient
chew the aspirin. All patients should receive
clopidogrel 300 mg dose in combination with
aspirin, unless contraindicated. If aspirin
allergic, use clopidigrel 300 mg loading dose
alone.
8
The treatment of acute myocardial infarction is
detailed in the UCLA Acute Myocardial Infarction
Practice
3. Patients in which acute pericarditis or aortic
dissection is not suspected, have no evidence of
major or lifethreatening hemorrhage, and no
significant predisposition to hemorrhage should
be given an intravenous bolus of heparin 4.
Patients without contraindications should be
treated with intravenous followed by oral beta
blockers (exclude cardiogenic shock, hypotension,
decompensated heart failure prior to treatment)
9
The treatment of acute myocardial infarction is
detailed in the UCLA Acute Myocardial Infarction
Practice
5. Patients with ongoing chest pain despite SL
NTG and beta blockers, with SBP gt 90 mmHg should
be started on an intravenous nitroglycerine
drip 6. The rapid initiation of therapy aimed
at reperfusion (direct
catheterization or thrombolytic therapy) should
not be delayed. Direct catheterization is the
preferred treatment strategy
10
Unstable Angina General Care
Monitoring Patients should remain on continuous
ECG monitoring for ischemia and
arrhythmia detection. Oxygen Patients with
obvious cyanosis, respiratory distress, or high
risk features should receive supplemental oxygen.
A finger pulse oximeter check should
be used to confirm adequate
oxygenation. If pulse oximeter sat lt 92 full
assessment including arterial blood gas
determination should be considered prior to
initiating oxygen. Routine use of oxygen in all
patients is not indicated. .
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Unstable Angina General Care
Activity Patients should be placed at bed rest
during the initial phase of medical
management. Diet Patients should remain NPO
except for meds until clinical stability
demonstrated and necessity/timing of cardiac
catheterization determined.
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Initial Pharmacologic Treatment

• Antiplatelet Therapy
• Intravenous Heparin or Low Molecular Weight
  Heparin
• Beta blockers
• Glycoprotein IIb/IIIa Receptor Antagonists
• Nitroglycerin
• Morphine sulfate
• Calcium channel blockers
• Thrombolytic therapy
• Intra-aortic balloon counterpulsation

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Laboratory Testing
ECG initially, with ongoing or recurrent
symptoms, with relief of chest pain, and 6 hours
after admission. CBC with platelets. PT
(INR), PTT. Serum creatinine, glucose. Lipid
panel on admission (nonfasting) unless patient
has had a recent determination. Troponin I q6 x
2 and CK-MB should be measured q8 hours x 3 (omit
2nd/3rd CK-MB if 6 hour troponin is negative).
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Diagnostic Algorithms
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Diagnostic Algorithms
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Chest Pain

• Initial Therapy
• ASA all patients without contraindications
  should be started on ASA (consider clopidogrel)
• NTG SL prescription and instructions on the prn
  use should be given
• Appointment for stress testing within 72 hours

17
Treatment Stratification
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Patients with coronary artery disease will live
longer when treated with a HMG CoA Reductase
Inhibitor. In the 4S trial there was a 34 risk
reduction in major cardiac events, a 42 risk
reduction in cardiovascular mortality and a 30
reduction in all cause mortality associated with
statin treatment. The LIPID trial demonstrated
that even patients with "low or normal" levels of
total cholesterol and LDL cholesterol (LDL 70-170
mg/dl) have mortality reduction with statin
treatment. Patients should be educated that these
medications are for the treatment of
atherosclerosis, not because the patient has
failed dietary treatment and that use of
these medications lowers the risk of recurrent
events, need for hospitalizations,
revascularization, strokes, and mortality.
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The HOPE trial demonstrated that
in patients with CAD, CVD, PVD or diabetes the
use of an ACE inhibitor was associated with a
reduction in cardiovascular events,
cardiovascular mortality, and all cause
mortality. This benefit was seen in patients
without hypertension and with normal left
ventricular ejection fractions.
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Eugene Yevstratov MD
Phone 0054111540682712 (ARG) Private
0030372236344 / 0030372231698 (UKr) Fax 001 775
796 2780 (USA) Email ostlandfox_at_yahoo.de
ostlandfox_at_medscape.com Link http//myprofile.co
s.com/eugenefox