Approach to the patients with chest pain and

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/

ACUTE MYOCARDIAL INFARCTION

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)

Magnitude of the problem n n n 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%)

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

Acute coronary syndrome ECG ST- Elevation No ST- Elevation - ve CARDIAC MARKER Unstable angina + ve Myocardial infarction STEMI Q Wave MI NSTEMI Non Q Wave MI

SYMPTOMS -Chest Pain -Levine’s 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.

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.

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

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

Some features differentiating cardiac from Non-cardiac chest pain Favoring Ischaemic Origin Against Ischaemic origin 1. Character of Pain Constricting Squeezing Burning Heaviness, heavy feeling Dull ache Knife Like, Sharp stabbing, jabs Aggravated Respiration 2. Location of Pain Substernal Across Mid Thorax, Anteriorly In both arms, shoulders In the Neck, Cheeks, Teeths In the Forearms, Fingers In the interscapular region In the left submamary area In the Left hemithroax

Some features differentiating cardiac from Non-cardiac chest pain Favoring Ischaemic Origin Against Ischaemic origin 3. Factors Provoking Pain Exercise Excitement Other forms of Stress Cold Weather After Meals Pain after completion of exercise Provoked by a specific body motion

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, Antacid Substernal Epigastric 5. Peptic Ulcer Hrs Visceral, Burning Type Lack Of Food, Acid Food Antacid Epigastric & Substernal 6. Oesophageal Spasm 5 -60 mins Visceral Spontaneous, Cold Nitroglycerine Liquids & Exercise Substernal & Radiating 7. Biliary Disease Hrs Visceral, Severe Spontaneous, Food Time & Analgesic - Fatty food Epigastric, Radiated To Rt. Scapular Tip 8. Cervical Disc Prolapse Variable (Gradually Subsides) Superficial Head & Neck Movements Time & Analgesic Neck & Arm(Radiculopath y) 9. Hyperventillation 2 -3 mins visceral Emotions & Tachypneoa Stimulus Removal Substernal 10. Musculoskeletal Pain Variable Superficial Movement & Palpation Time & Analgesic 11. Pulmonary Causes 30 mins Visceral/Pressuret Often Spontaneous Rest, time & ype bronchodilatation Multiple Sites Substernal

Wall Affected Leads Showing ST Segment Elevation Leads Showing Suspected Culprit Reciprocal ST Artery Segment Depression Septal V 1, V 2 None Left Anterior Descending (LAD) Anterior V 3, V 4 None Left Anterior Descending (LAD) Anteroseptal V 1, V 2, V 3, V 4 None Left Anterior Descending (LAD) Anterolateral V 3, V 4, V 5, V 6, I, a. VL II, III, a. VF Left Anterior Descending (LAD), Circumflex (LCX), or Obtuse Marginal Extensive Anterior (Sometimes called Anteroseptal with Lateral extension) V 1, V 2, V 3, V 4, V 5, V 6, I, a. VL II, III, a. VF Left main coronary artery (LCA)

Wall Affected Leads Showing ST Segment Elevation Leads Showing Suspected Culprit Reciprocal ST Artery Segment Depression Inferior II, III, a. VF I, a. VL Right Coronary Artery (RCA) or Circumflex (LCX) Lateral I, a. VL, V 5, V 6 II, III, a. VF Circumflex (LCX), or Obtuse Marginal Posterior (Usually V 7, V 8, V 9 V 1, V 2, V 3, V 4 Posterior Descending (PDA) (branch of the RCA or Circumflex (LCX) II, III, a. VF, V 1, V 4 R I, a. VL Right Coronary Artery (RCA) associated with Inferior or Lateral but can be isolated) Right ventricular (Usually associated with Inferior)

TREATMENT First aid Aspirin n Nitrates n Automated external defibrillator n In case of cardiac arrest, CPR(cardio pulmonary resusitation) can be administered.

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

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

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

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

Following drugs are used and found effective in vatika hridroga. Further scientific clinical trial is needful. 01) 02) 03) 04) 05) 06) 07) Drug acting on amasahit meda = Marich, Chitrak, Daruharidra, Rason, Tulasi, Vacha, Pushkarmul, Punarnava, Shuddha shilajeeta Drug acting on rasvaha strotas = Amalaki, Haritaki, Punarnava, Shatavari, Marich & Shilajeet Drug acting on vata dosh = Haritaki, Rason, Guggul, Pushkarmul , Amalaki , Punarnava , Marich , Shilajeet, Chitrak, Tulsi& Shatavari. Medhya drug= Bramhi, Vacha, Shatavari, Haritaki. Drugs dissolute grathit rakta= Kamalkshar , Darbha or Kusha or Paravatshakrut. Hruddya= Arjun, Bramhi, Tulasi, Guggul, Punarnava, Rason & Shatavari. Combination of drugs=Arjun, 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= 1 GM TDS Anupan= Udak(jal), Madhu.

Angina The English word angina refers to a painful constriction tightness somewhere in the body and may refer to : Angina pectoris Abdominal angina Ludwig’s angina Prinzmetal’s angina Vincent’s angina Angina tonsillaris

n n 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. ”

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.

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

Pathophysiology Coronary Atherosclerosis Thrombosis Narrowing Of coronary Myocardial Ischaemia Chest Pain I. H. D.

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 > 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).

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

Treatment n n n n n 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.

Ludwig’s 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.

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.

n 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.

n 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 : n Carcinoid n Aortic coarctation n Antiphospholipid syndrome n

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

n n Prinzemtal’s 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 n Features Symptoms typically occur at rest, rather than on exertion (attacks usually occur at night).

Diagnosis n n n 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.

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

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 n n 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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