Chest pain( CAD/Stable Angina and ACS)

Problem: chest pain

Primary Impression: Unstable Angina/NSTEMI, (What wall based on ECG), Killips
classification?
Patients presenting symptom is chest pain, which is typically located in the
substernal/ sometimes in the epigastrium, that radiates to the back, left shoulder, or
left arm. It is rest pain, post-MI, prior ASA, DM. Dyspnea and/or epigastric discomfort
might be present. The patient also had a history of prior chest pains, diagnosed with
hypertension, or had history of high lipid levels. Although the patients physical
exam is unremarkable, patient may present with diaphoresis, cool skin, sinus
tachycardia, S3 sound, or rales. Since diagnosis of UA is based largely on the clinical
presentation, hence, this is my primary consideration. Risk factors: >65 yrs old, 3 or
more risk factors for CAD, 2 or more episodes with the 24hrs, elevated cardiac
marker, ST dev >.5mm, DM, LV dysfunction, renal dysfunction, elevated BNP and
CRP. ECG also revealed injury to what wall? Patient belongs to Killips Class? ( Class Ino signs of pulmonary congestion, II-moderate heart failure, bibasal rales, s3 gallop,
tachypnea, inc JVP, hepatic congestion, III- severe heart failure. >50% of lung fields
or pulmonary edema, IV-shock with <90mmHg systolic pressure, confusion, oliguria)
Unstable angina vs stable angina: stable: associated with physical exertion, 510mins, unstable: occurs at rest, severe and new onset, crescendo pattern
Differentials:
1. HACVD, with or without failure refers to complications of systemic BP
elevations on the heart. In the absence of heart failure, hypertension of the
patient with our without enlargement is symptomless. Typical symptoms
include fatigue, irregular pulse, palpitations, dyspnea, swelling of feet or
ankles, orthopnea, and weight gain.
2. Stable Angina/Angina Pectoris/STEMI- STEMI is considered if there are ST
wave elevations. Exertional pain is the main clinical finding of angina
pectoris. Risk factors might be present like HPN, DM, CAD. Cardiac markers
and ECG are usually negative with stable angina and angina pectoris.
3. Myocarditis/Pericarditis is a heart disease caused by infection, autoimmune
disorders with genetic and environmental predispositions. Patients may have
clinical history of HPN or acute heart decompensation. Symptoms include
chest pain, fever, sweats, chills, dyspnea.
4. Esophagitis
5. Asthma
Unstable Angina/ NSTEMI
Diagnostics:
Definitive: ECG An important tool to assess myocardial injury that may show ST-

segment depression, elevations, and T wave inversions in 30-50% of patients.

Repeat for persistent chest pains
Supportive:
1. CK-MB- may be elverated; to rule out AMI/STEMI
2. Troponin T positive in the presence of microinfarcts which suggests a poorer
prognosis
3. CBC assess hematologic status of the patient
4. Potassium maybe elevated due to increased leakage on intracellular potassium
to extracellular space after injury
5. Serum Creatinine/ Urinalysis assess kidney status and function
6. Chest X-ray determine chest pathologies and rule out respiratory tract problems
as the source of chest pains
Therapeutics:
Definitive: Medical therapy involves simultaneous anti-ischemic treatment and
antithrombotic treatment
1. Nitrates: Nitroglycerin 0.4mg SL up to 3 doses every 5 mins to provide relief
and prevention of recurrence of chest pains
2. Anti-thrombotics: Aspirin 325mg tab stat dose then 80mg 1 tab BID PC
with/without Clopidogrel 75mg tab OD, after loading dose of 300mg
Supportive:
1. Beta-blockers: Metoprolol 50mg to 1 tab every 8-12 hrs to control BP and
as adjunct for nitrates
2. Heparin for patients at high risk for complications: prolonged ongoing chest
pains, clinical heart failure, angina with hypotension
3. Morphine 4mg IV stat- for pain relief
4. Diet: soft, low-salt diet
5. Activity: Bed Rest with or without toilet priviledges
6. IVF: D5W or PNSS at KVO rate
7. Vital signs every hour then 4 hours if stable; I/O every shift

HACVD, in failure/not in failure

Hypertensive heart disease, and its subcategories: hypertensive heart disease with
heart failure and hypertensive heart disease without heart failure are distinguished
from chronic rheumatic heart diseases, other forms of heart disease and ischemic
heart diseases. HPN contributes to 75% of patients with heart failure. Both CAD and
hypertension interact to augment the risk of HF, as does diabetes mellitus. Cardinal
symptoms are fatigue and shortness of breath if in failure and symptomless if not in
failure and may present as CAD and/or ACS. Please refer to NYHA functional
classification.
Diagnostics:

Definitive: 2D-Echo/Doppler can provide a semiquantitative assessment of LV size

and function as well as the presence or absence of valvular and regional wall motion
abnormalities.
Supportive:
1. ECG 12 lead is recommended to assess cardiac rhythm and determine
presence of LV hypertrophy or a prior MI. A normal ECG excludes LV systolic
dysfunction.
2. Chest XRay provides useful information about cardiac size and shape as
well as the state of pulmonary vasculature, and may identify noncardiac
causes of patients symptoms.
3. CBC assess patients hematologic status
4. Na/K values maybe elevated in the face of myocardial injury or hypertrophy
5. Serum Creatinine assess kidney excretory and filtration function
6. Urinalysis
Therapeutics:
Definitive: For patients who have developed LV dysfunction but remain
asymptomatic (Class I) goal is to slow disease progression. For patients who have
symptoms (ClassII-IV), goals of treatment is to alleviate fluid retention, lessen
disability, and reduce risk of further disease progression
Supportive:
1.
2.
3.
4.
5.
6.
7.
8.

Give Oxygen at 2-4lpm via nasal cannula

Diet: Soft, low salt diet
Limit dietary sodium for <2gm/day
Limit total fluid intake to 1-1.2 L/day
Activity: CBR without TP
Position: High back rest especially if acute
Diuretics: Furosemide 20-40mg IV then maintain on PO later for ACUTE HF
Vasodilators: Captopril 25mg to 1 tab every 6-12 hours an ACE inhibitor is
the first line treatment. Alternate drug if with cough, Losartan 50mg 1tab OD
9. Beta-blockers: Carvedilol 6.25mg tab BID indicated for patients with
symptomatic or asymptomatic HF and a depressed EF; given in concert with
ACE inhibitor
10.Monitor VS every hour then every 4 if stable; I/O every shift
Acute MI/STEMI
Entry criteria would be prolonged ischemic discomfort at rest, and ACS would be the
working diagnosis. Triggers or preceding factors are physical exercise, emotional
stress, or medical or surgical illness. Pain is the most common complaint in patients
with STEMI, described as heavy, squeezing, and crushing; although same as angina
pectoris but more severe and lasts longer. Pain that radiates to the trapezius

suggests pericarditis. Painless STEMI is greater in patients with DM, and it increases
with age. Combination of substernal pain >30min and diaphoresis strongly suggests
this diagnosis. Other findings include anxiety, restlessness, apical impulse that is
difficult to palpate, s3/s4 sounds, decreased intensity of first heart sound, and
sometimes fever.

Diagnostics:
Definitive: ECG primary pivotal diagnostic and triage tool since it detects ST
segment changes associated with STEMI
Supportive:
1. Troponin T/Troponin I- preferred biochemical markers for MI
2. ESR elevated during the first week and may remain elevated for one or two
weeks
3. 2D-Echo shows abnormalities in wall motion of the heart
4. Chest X-ray detects chest abnormalities; rule out other pathologies
5. CBC
6. Serum Creatinine and Urinalysis
7. Lipid Profile increased values increases risk for STEMI
Therapeutics:
Definitive: Primary PTCA patients with ST elevation abnormalities can undergo
angioplasty of the infarct related artery within 12 hours of onset of symptoms or
beyond
12
hours
if
symptoms
persists
Early Coronary Angiography/ Interventional Therapy for patients with
persistent/recurrent episodes of symptomatic ischemia
1.
2.
3.
4.
5.
6.
7.
8.
9.

Oxygen at 2-4lpm via nasal cannula- maintain oxygen sat at >95%

Diet: Low salt, low fat diet
Activity: CBR without TP
Position: Moderate High Back rest
IVF: PNSS at KVO rate
Anti-embolic stockings
Monitor V/S every hour, temp every hrs; I/O every shift
Nitroglycerin 0.4mg SL up to 3 doses every 5min for chest pain relief
Aspirin 160-325 mg stat dose then 80mg tab BID PC with or without
Clopidogrel 75mg tab OD
10.Consider thrombolytic therapy
11.Heparin for large anterior wall MI, atrial fib, and persistent chest pains, or
presence of LV thrombus
12.Beta blockers: Metoprolol 50mg to 1tab every 8-12 hours should be
continued indefinitely if without contraindications
13.ACE inhibitors: Captopril 25mg tab every 12hrs
14.Consider statins: Atorvastatin 20mg OD

Pericarditis
Most common pathologic process involving the pericardium, classified as
acute(<6weeks), subacute, and chronic(>6months). Four principal diagnostic
features: chest pain, which is often pleuritic, relieved by sitting up and leaning
forward, intensified by lying down; pericardial friction rub; ECG changes; and
pericardial effusion
Diagnostics:
Definitive: Transesophageal 2D Echo(TEE) - most widely used imaging technique
with 90% sensitivity; can identify accompanying cardiac tamponade and cardiac
thickening
Supportive:
1. Chest Xray may show Ewarts sign which is compression of the base of left
lung due to tamponade; water-bottle configuration
2. CBC detect hematologic status and rule out infectious process
3. Urinalysis to detect complications and asses kidney function

Therapeutics:
Definitive: Pericardial resection be carried out early in the course
Supportive:
1. Diet : DAT
2. Decrease sodium intake to <2gm/day
3. Diuretics