ACUTE THORACIC PAIN

2004-2005
 CLASSIFICATION

A. Pain of cardiac origin

1. Coronary artery disease
2. Acute aortic dissection
3. Pulmonary embolism
4. Acute pericarditis
B. Mediastinal pain
C. Retrosternal pain of digestive origin
D. Thoracic pain
1. pleuro-pulmonary
2. rheumatic
3. neuromuscular
4. abdominal
5. psychosomatic
 1. ANGINA

A. ANGINA with NORMAL ECG

anginal pain
positive family history
CV RF
other factors: anxiety, spasm, oesophagus reflux,
peptic ulcer, acute pancreatitis
B. RECENT ANGINA + ECG CHANGES:

ST elev./ depression > 0,5 mm

T wave inverted

ACUTE CORONARY SYNDROME

UNSTABLE ANGINA
MI with ST depression (non Q ?)
MI with ST elevation (transmural ?)
C. PROLONGED ANGINA > 20 min
D. RESTING ANGINA + ST CHANGES

E. ANGINA + MITRAL REGURGITATION

(recent or aggravated)

F. X SYNDROME
 F. X Coronary Syndrome

effort angina
ET +
normal coronarography
stress ECHO: contractility alterations
 CLINIC
TYPICAL ANGINA NON-TYPICAL ANGINA

1. RETROSTERNAL PAIN
2. TRIGGER
effort
emotional stress
3.VANISH
 at rest  NTG
Coronary pain has 2 of 3 features
Non-coronary pain has 1 or none of the 3 features
 ISCHEMIC CASCADE
•flow alteration.  flow visualising
• metabolic alteration  PET
•diastolic dysfunction  ECO Doppler
•kinetics  ECO de stress
•Ions channels changes  ECG
•sympathetic activation  ANGINA (clinic)
MYOCARDIAL NECROSIS
 Clinical case
M.A. 72 years (M)
Symptoms for 3 weeks:
Non-typical angina – epigastric pain irradiated in the
right hipocondrium, no fixed timing, no effort angina,
improves slowly at NTG
In the last days – 6 tb NTG/day
RF:

smoker
 TC = 204, TG = 125,
LDL = 148, HDL = 32 (mg/dl)
ECG in crises
 Therapeutic approach

PTCA (stent RCA)

Antiplatelet
Statin
Beta-blocker
Smoking cessation
 INVESTIGATIONS
•Resting ECG
•Stress test
•Rhythm Holter
•Doppler echo
•Stress echo - dobutamine
•Isotopic ventriculography
•Myocardial scintigraphy
•PET
•Angiocoronarography
Stress testing (ST)= widespread method with
standardized protocols and low costs to
assess CAD.

S.U.A. – 1991,1992 – 6,2 mil ST

27% CAD
 ACC/AHA guidelines – ST indications:

Absolute indications:
1. Dg: men with typical / untypical
symptoms and cumulated RF
2. Prognosis: assess functional capacity in
stable angina and after AMI
3. Prognosis: assess functional capacity after
revascularization procedures
4. Dg: symptomatic arrhythmias at stress
 ACC/AHA guidelines – ST indications:

Relative indications:
1. Dg: women with typical / untypical angina
2. Therapy monitoring in CAD or HF
3. Screening: asymptomatic men > 40 years
with cumulated RF
4. Vasospastic angina evaluation
 ET = generally a safe procedure;
- AMI, SCD: rate 1:2500

High risk:
- recent AMI
- malignant ventricular arrhythmias
 ET CONTRAINDICATIONS
ABSOLUTE: RELATIVE:
- Recent AMI (2 days) - left main stenosis
- Unstable angina - moderate aortic stenosis
- Uncontrolled arrhythmias
- Severe aortic stenosis - dyselectrolitemias
- Decompensated HF - uncontrolled HT
- Pulmonary embolism ( SBP>200mmHg,
- Aortic dissection DBP>110mmHg)
- Acute myopericarditis - pulmonary hypertension
- Peripheral thrombosis - CMHO
- Infirmities - high degree AV block
Modificat dupa Fletcher et al si Gibbons et al.
 Criteria for HR in a ST :
- Target stress = Max HR = 220 – age (years)
- Submaximal stress = 80 – 85 % Max HR
- Closely to maximal stress = 90 % Max HR
- Maximal effort symptom - limited
 ST FINISHING CRITERIA
ABSOLUTE: - decrease of SBP >10 mmHg from normal with ischemic
changes
- moderate or severe angina
- ataxia
- low cerebral perfusion signs
- sustained VT
- technical difficulties
- patient‘s request
- ST depression > 2 mm
RELATIVE: - decrease SBP >10 mmHg from normal without ischemic
changes
- ST depression > 1 mm
- arrhythmias, other than sustained VT
- progressive pain increase
- hypertensive behaviour (SBP > 230 mmHg or/and DBP> 115
mmHg)
- fatigue, claudicatiuon, wheezing
 ST INTERPRETATION:
1 Symptoms
2 Stress capacity (METS)
3 Hemodynamic behavior :
HR max x BP = double product
4 ECG: specific – ST changes at stress
 EFFORT ST CHANGES:
Patients with normal ECG:
positive Stress Test: > 1mm ST variations, 60 – 80 ms from
the J point
 ST depression
 ST elevation: coronary spasm
- V1: ischemia
- in regions with MI: aneurism / wall dyskinesia;
- no MI: transmural ischemia or critical stenosis.

ST variation in precordial leads = more exact than in

inferior leads
 LIMITATIONS:
Relatively diminished sensitivity:

 monovascular disease
 women
 elderly
 significant comorbidities
 no available data on LV function
 MYOCARDIAL PERFUSION
SCINTIGRAPHY:
With: - Thalium 201
- Technetium 99m

Indications
- monovascular CAD
- teritory assessment in CAD
- assessment of viability of
myocardium
 STRESS ECHOCARDIOGRAPHY:
With Dobutamine:
- risks + side effects

INTERPRETATION:
ST DEPRESSION DURING DOBUTAMINE PERFUSION IN PATIENTS
WITH NORMAL ECG HAS A MODERATE PREDICTIVE POWER FOR
CAD

Useful in patients with: history of MI or altered wall kinetics,

pacemakers, renal impairment, dilated cardiomyopathy, LVH,
LBBB.
 CHOOSE THE RIGHT TEST

 ST: - dg in patients with normal resting ECG

- patients with intermediary pre-test
probability for CAD
- known CAD
 Pharmacological stress (Dobutamine): LBBB
 Topography and extension of CAD:
- myocardial scintigraphy;
- stress echo.
Dobutamine stress test
PET scan
Glucose utilization during PET
ScintigraphyTc-99m
MRI
Contrast ultrasound
 Not every thoracic pain is
coronary pain

Thoracic pain + ST variations + positive Thoracic pain ± ECG changes, but no

markers = Acute coronary syndrome positive markers = assess acute risk

Main goal: Reperfusion

Troponin +ECG every 6 hours

Positive = high Negative = continue

ST elevation = ST depression + risk / reperfusion evaluation
tthrombolysis or positive markers =
PCI (±stent) IIb/IIIa inhibitors
ST and other

Positive = Negative =
coronarography discharge
 Diagnosis of AMI in the emergency room

• History of precordial pain/ thoracic pain

• ST elevation or a new LBBB
• Increased levels of necrosis markers (CK-MB, troponins)
! Don’t wait for results to initiate reperfusion
• 2D Echography and scintigraphy useful in differential
diagnosis of AMI
 Emergency treatment

• Opioids I.V. (4-8 mg morphin, then 2 mg every 5 min)

• O2 (2-4 l/min)

• Beta-blocker i.v. or nitrate when opioids are not effective

• Tranquilizers may be useful

 Before hospital and early in hospital treatment
Reperfusion therapy recommendation Class Evidence
I IIa IIb III level

reperfusion therapy is indicated in all patients with history X A

of thoracic pain/ less than < 12 hours and ST elevation or a
new bundle branch block
Primary PCI
- preferably in the first 90 min after diagnosis X A

- patients in shock and those with contarindications for

fibrynolytics X C
- GP IIb/IIIa antagonists and PCI
without stenting X A
with stenting X A
Thrombolysis
-alteplase, tenecteplase X A
 Contraindications for thrombolitic therapy
• Absolute contraindications:
- haemorrhagic stroke
- ischemic stroke in the last 6 months
- CNS disorders
- neoplasias
- traumas/ surgery/ the last 3 weeks
- gastro-intestinal haemorrhage in the last month
- known haemorrhagic disease
- aortic dissection
• Relative contraindications:
- transient ischemic attack in the last 6 months
- oral anticoagulants
- pregnancy or the 1st week postpartum
- severe HT (SBP > 180 mmHg)
- severe liver disease
- infective endocarditis
- active ulcer
 Initial Treatment Combination therapy
Streptokinase 1,5 mil. U in 100 ml 5% dextrose or With or without
(SK) 0,9% NaCl for 30-60 min. heparin I.V.
For 24-48 h
Alteplase 15 mg I.V. in bolus, 0,75 mg/kg for Heparin I.V.
(tPA) 30 min, then 0,5 mg/kg in 60 min For 24-48 h
Do not exceed 100mg
Reteplase 10 U + 10 U I.V. Heparin I.V.
(r-PA) la 30 min For 24-48 h
Tenecteplase Single dose I.V. bolus Heparin I.V.
(TNK-tPA) 30 mg < 60kg For 24-48 h
35 mg 60-70kg
40 mg 70-80kg
45 mg 80-90kg
50mg > 90kg

Most frequent regimen

All patients receive Aspirin (if no contraindications)
 Heparin treatment

• I.V. in bolus:
60 U/kg – max. 4000 U
• I.V. perfusion:
12 U/kg for 24 to 48 hours – max. 1000 U/h.
aPTT target 50-70 ms

• aPTT should be monitored at 3,6,12, 24 hours after treatment

initiation
 Routine recommendations in acute phase
Class Level of
I IIa IIb III evidence

Aspirin 150-325 mg X A
Beta-blockers I.V. if no contraindications X A
- beta-blockers orally
ACEi – from the 1st day
- if no contraindications X A
- in patients with high risk X A
Nitrates X A
Ca channel antagonists X B
Magnesium X A
Lidocaine X B
 Risk stratification and revascularization indications

Myocardial
infarction

Risk eval.

High risk Moderate/low risk

Coronarography LV function eval & ischemia

& effort tolerance

Normal anatomy +
viable myocardium High risk Moderate r. Low risk

Yes
Yes No
REVASC Significant angina Medication

No
 Rehabilitation

• Lifestyle advice
• Active in profession
• Also in patients with significant LV
dysfunction
• Initiated early in hospital
 Recommendations for secondary prevention
Clasa Evidence
I IIa IIb III level

Smoking cessation X C
Plasma glucose control in all diabetics X B
BP control X C
Mediterranian diet X B
Supplementation with 1 g fish oil, n-3 polyunsaturated X B
fat
Aspirin 75-160mg/day X A
Clopidogrel 75 mg/zi (aspirin intolerance) X C
Oral Anticuagulants X B
Beta-blockers (oral) if no contraindications X A
ACEi – from the 1st day X A
Statins (CT > 190 mg/dl and/or LDLc > 115mg/dl) X A
Ca antagonists X B
 2. ACUTE AORTIC DISSECTION
•Spontaneous brutal pain, mediosternal, constrictive and
migrating, with posterior irradiation
•history: HT
•clinic: asymetric pulse, diastolic murmur, acute
(mezenteric, lower limb), shock
•ECG: modest changes
•Negative enzymes
(CPK-MB,GOT,LDH)
•ECHO transthoracic/ transoesophagian
•Before admission: major pain killers
beta-blockers
HT control
 3. PULMONARY EMBOLISM
•Acute pain, with no apparent cause, in a thrombo-embolic
risk context
•Clinic: syncope/lipothymia
• cyanosis, polipnea, RV overload
shock: (BP<90/40 mm Hg, tissular low perfusion, oligo-anuria,
consciousness disorders)
•ECG :sinus tach., T inverted in right precordials ± RBBB
•ECHO : RV dilation, IVC dilation, mobile thrombi in the
right cavities.
•Before admission:
Oxygen
treatmentul of shock-Dobutamine 5-15 microgr/kg
+- thrombolysis
 4. ACUTE PERICARDITIS

•Acute thoracic pain , prolonged, increased in

inspiration + dyspnea + cough

•Clinic: ± pericardial rub

•ECG : concordant changes of the repolarization

phase

•Before admission: etiologic treatment

(antibiotics, NSAIDs)
 4. CONSTRICTIVE CHR. PERICARDITIS

•Pseudo-angina + resting dyspnea + effort liver pain

•Pick pseudocirrhosis: hepatomegaly
early ascites
peripheral oedema
vena cava syndrome
pulmonary stasis
arterial hypotension
•Before admission:
- diuretics
•Indication for surgery
B. MEDIASTINAL PAIN

COMPRESSIONS
 infections
 mediastinal tumors
 pleuro-pericardic cysts

TREATMENT - etiologic
 C. Digestive origin

• Spasm of oesofagus

• Hiatum hernia  pseudo-angina

 associated to angina
 worsens angina

• Peptic Ulcer
• Acute pancreatitis
D. Thoracic origin
1. PLEURO-PULMONARY

(a) acute pneumonia

(b) pleurisy

(c) pulmonary / pleural neoplasia

(d) pneumotorax
 D. Thoracic pain
2. Rheumatic pain
(a) spondilosis
(b) scapulo-humeral periartrytis
(c) Thoracic wall pain
(d) Tietze syndrome
3. Bone pain
leukemia
 multiple myeloma
osteosarcoma
metastasis
TBC
 D. Thoracic origin

4. NEURO-MUSCULAR
(a) nevralgia
(b) radiculitis
(c)Paraneoplasic syndrome