Can't Miss Diagnoses for Chest Pain?

Chest Pain

1. Acute MI
2. Pneumothorax
3. Aortic Dissection
4. Pulmonary Embolism
5. Esophageal Rupture
6. Cardiac Tamponade

Rule out

• Aortic Dissection
  • Xray Normal aorta/mediastinum LR 0.3
  • Bilateral Blood Pressure
• Tamponade
  • Xray Cardiomegaly: 89% Sensitive
• Pneumothorax
  • Xray

Our Patient's Xray

Pulmonary Embolism?

Wells Score

https://www.mdcalc.com/wells-criteria-pulmonary-embolism

CTPA
No
PE

Myocardial Injury?

Myocardial Injury?

Detection of an elevated cTn value above the 99th percentile URL is defined as myocardial injury. The injury is considered acute if there is a rise and/or fall of cTn values.

Myocardial Infarction?

Myocardial Infarction

• Detection of a rise and/or fall of cTn values with at least one value above the 99th percentile URL and with at least one of the following:

• Symptoms of acute myocardial ischaemia;

• New ischaemic ECG changes;

• Development of pathological Q waves;

• Imaging evidence of new loss of viable myocardium or new regional wall motion abnormality in a pattern consistent with an ischaemic aetiology;

• Identification of a coronary thrombus by angiography including intracoronary imaging or by autopsy. (Not for Type 2/3)

What are the different types of MI?

DDx of myocardial injury?

Classic Cardiac Risk Factors?

Cardiac RFs

Text

Premature CAD?

• Male age <55
• Female age <65

Typical Cardiac Chest Pain?

Cardiac Chest Pain

(>95% chance of CAD in patients over 65)

1. Retrosternal
2. Increased with exertion or emotion
3. Relived by rest

What are ischemic changes on ECG?

STEMI

STEMI

• >1 mm in all leads but V2-V3
• V2-V2
  • Men >40 = 2mm
  • Men <40 = 2.5mm
  • Women = 1.5mm
• STEMI Equivalents (ie. new LBBB with Sgarboss, de Winters T waves, Wellen's Sign)

UA/NSTEMI

NSTEMI

• New/horizontal or downsloping ST depression (>0.5mm) in 2 contiguous leads
• T wave inversion >1mm in 2 anatomically contiguous leads with prominent R wave or R:S>1

Our Patient's ECG

Manage NSTEMI?

A
B (O2 if hypoxic)
C

ASA 81mg

ASA 81mg

CHEW

Second Antiplatelet

In patients with ACS (STEMI or NSTEMI) who receive PCI: 1. We recommend DAPT with ASA 81 mg daily with either ticagrelor 90 mg BID or prasugrel 10 mg once daily over clopidogrel 75 mg once daily for 1 year

Angina Control

• Nitro spray/patch/infusion
• Beta blockers
• Calcium Channel Blockers
• If all else fails: reperfusion

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Morphine is way down here. Can be when above contraindicated.

Blood Thinner

• Heparin infusion
• Enoxaparin
• Fondaparinux (DVT Prophylaxis Dose!!!)

Angiography

• Immediate
• Early Invasive
• Conservative

Immediate

• Hemodynamic Instability
• Severe LV Dysfunction or HF
• Recurrent or persistent angina despite meds
• Mechanical Complications
• Sustained VT

Early Invasive

• TIMI Score - High Risk
• Grace Score >140

Conservative

• Medical Management
• Risk stratify with non-invasive imaging (echo + stress test)

Meds to go home?

Meds

• Ace Inhibitor
• High Dose Statin
• ?Beta Blocker