Chest Pain MIShock Victor Politi M D FACP

Chest Pain/ MI/Shock Victor Politi, M. D. , FACP Medical Director SVCMC PA program

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

MI Risk Factors n n n n n Smoking HTN High fat diet High LDL Diabetes Stress Inactivity Male gender Age/Heredity – Elevated homocysteine and C-reactive protein levels

A patient presents with chest pain n What do you do?

Stable angina, unstable angina, ACI, AMI n 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

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

Frequency of “Silent” AMIs n n n 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

Classic Presentation Retrosternal, epigastric chest pain or tightness n SOB n Diaphoresis n Nausea, vomiting n Levine’s sign n

Atypical Symptoms of AMI n n n Admits chest discomfort- denies pain A little sweating previously - now gone Previous indigestion - now ok May or may not have mild SOB Can’t describe symptoms - uses vague terms EKG normal or non-specific changes present – In fact - an atypical presentation is the most typical presentation

Symptoms pain n Chest pain– typically below the sternum – intense/severe/subtle – squeezing sensation/heavy pressure n n Angina not relieved by rest or nitroglycerin Back pain Abdominal pain Pain radiating to – – – n shoulder/arms/chest neck/teeth/jaw back Pain that is prolonged > 20 min

Other Symptoms Bad Indigestion n Dyspnea n Cough n Syncope n Nausea or vomiting n Diaphoresis n Anxiety n

Physical Exam Rapid pulse n BP - varies n may reveal abnormal chest sounds on auscultation n Diaphoresis n

Studies ECG n Echocardiography n Coronary angiography n Stress test n – EST – Nuclear – Studies which show heart damage or high risk n Troponin I / troponin T n CK and CK-MB n Myoglobin-serum

Additional Lab Tests CBC n 6 n Pt/Ptt n Chest x-ray n

What is first in your work-up? 12 lead ECG n Is it useful ? n

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 n When are ECGs useful ? n

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

ASA

Aspirin 40% relative reduction in mortality n What’s the right dose? n Probably the single most important thing we can do n Irreversible - inhibit platelet aggregation n

Aspirin -Contraindications ASA Allergy n GI bleed n Bleeding disorder n

Nitrates When should nitrates be given? n Who should receive nitrates? n Who should not receive nitrates? n Dose n – SL NTG – Spray – Paste – IV

Morphine MSO 4 Does morphine reduce pain? Yes n Does morphine reduce mortality/morbidity? NO n n Morphine vs NTG

Glycoprotein IIB/IIA Inhibitors Utilized in ACISs without AMI n Action is to “de-couple” platelets n Three FDA-approved n – Integrillin - eptifibatide – Aggrestat - tirobifan hydrochloride – Repro-abciximab

Heparin n When should heparin be given? Who should receive heparin? What is the right way to give heparin? – n n n Is there a wrong way to give heparin? Other forms of heparin, anticoagulants? Therapeutic monitoring Oral anticoagulation – Warfarin – Coumadin

Low-molecular weight heparin Enoxaparin dosed 1 mg/kg SQ Q 12 hr n No PTT monitoring necessary n – potential of fewer labs drawn, run n No IV necessary – fewer IV starts, no pumps, outpatient treatment n Fragmin

The ESSENCE Trial n n Efficacy & safety of SQ Enoxaparin in non-Qwave coronary events Significant relative risk reductions (RRR) & cost savings compared to unfractionated heparin >15% relative risk reduction in incidence of death, AMI, recurrent angina & combined triple endpoints n 10% relative risk reduction in CABG n 21% relative risk reduction in PTCA n n Decreased resource utilization resulting in cost savings exceeding $1000 per patient

Beta-blocker IVP When should beta blockers be given? n Who should receive beta blockers? n Who should not receive beta blockers? n What is the right dosing regimen? n Primary, secondary benefits? n B 1 -B 2 Blocker n

Ace Inhibitors Studies show decreased mortality if given in first few days after AMI n Benefit due to effects on myocardium remodeling n long term benefits show increased EF and decreased incidence of CHF n

Cholesterol Lowering Agents n Current thinking; the lower the total and LDL cholesterol - the better ! n Many types available -currently the statins seem to show the best reduction

Thrombolysis: Eligibility Criteria No age limit n Clinical n n n Chest pain, chest pain-equivalent c/w AMI of < 12 hrs from onset or < 24 hrs if “stuttering” EKG 1 mm or > ST elevation in 2 or + limb leads n 2 mm or > ST elevation in 2 or + precordial leads n New onset bundle branch block n

Contraindications to Thrombolytics n n n n n 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 >200, DBP>110 Non-compressible venous or arterial puncture CPR greater than 10 minutes Aortic dissection Dx=> CT of thorax Pericarditis

Thrombolytics TPA n Retavase n Streptokinase n n Door -to-Drug Time n Time is Muscle!

Goal of Treatment Stabilize patient n Stop the progression of heart attack n – prevent further heart damage n Reduce demands on heart – so it can heal n Prevent complications

Other cardiac conditions

Bradycardia Systolic rate < 60 n Symptomatic n Atropine n Isopril n Pacemaker n What medications has the patient taken? n

Atrial Arrythmia A Fib n A flutter n SVT n PAC n

Atrial Flutter

AV Blocks 1 st degree AVB n 2 nd degree AVB n – Type 1 – Type 2 n 3 rd degree AVB

Ventricular Arrythmias PVC n V Tach n V Fib n Torsades n Ventricular escape beat n

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

Cardiogenic Shock Symptomatic blood pressure <90 systolic n due to low cardiac output n Goal of treatment - increase perfusion to vital organs n Treatment options include Dopamine/Dobutamine/Levophed/ balloon pump (aortic counterpulsation) n

Cardiac Tamponade n 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

Questions ? ? ?