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 Mediastinal pain Retrosternal pain of digestive origin Thoracic pain 1. pleuro-pulmonary 2. rheumatic 3. neuromuscular 4. abdominal 5. psychosomatic

B. C. D.

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
kPTCA (stent RCA) kAntiplatelet kStatin kBeta-blocker kSmoking 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: - Recent AMI (2 days) - Unstable angina - Uncontrolled arrhythmias - Severe aortic stenosis - Decompensated HF - Pulmonary embolism - Aortic dissection - Acute myopericarditis - Peripheral thrombosis - Infirmities RELATIVE: - left main stenosis - moderate aortic stenosis - dyselectrolitemias - uncontrolled HT ( SBP>200mmHg, DBP>110mmHg) - pulmonary hypertension - CMHO - 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 - patientµs 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 2 3 4 Symptoms Stress capacity (METS) Hemodynamic behavior :
HR max x BP = double product

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 markers = Acute coronary syndrome

Thoracic pain ECG changes, but no positive markers = assess acute risk

Main goal: Reperfusion

Troponin +ECG every 6 hours

ST elevation = tthrombolysis or PCI (±stent)

ST depression + positive markers = IIb/IIIa inhibitors

Positive = high risk Negative = continue / reperfusion evaluation

ST and other

Positive = coronarography

Negative = 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 I reperfusion therapy is indicated in all patients with history 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 - patients in shock and those with contarindications for fibrynolytics - GP IIb/IIIa antagonists and PCI without stenting with stenting Thrombolysis -alteplase, tenecteplase X A X A X IIa Class IIb III Evidence level A

X X X

C A 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 Streptokinase (SK) Alteplase (tPA) Reteplase (r-PA) Tenecteplase (TNK-tPA) 1,5 mil. U in 100 ml 5% dextrose or 0,9% NaCl for 30-60 min. 15 mg I.V. in bolus, 0,75 mg/kg for 30 min, then 0,5 mg/kg in 60 min Do not exceed 100mg 10 U + 10 U I.V. la 30 min Single dose I.V. bolus 30 mg < 60kg 35 mg 60-70kg 40 mg 70-80kg 45 mg 80-90kg 50mg > 90kg

Combination therapy With or without heparin I.V. For 24-48 h Heparin I.V. For 24-48 h Heparin I.V. For 24-48 h Heparin I.V. For 24-48 h

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
I Aspirin 150-325 mg Beta-blockers I.V. if no contraindications - beta-blockers orally ACEi ± from the 1st day - if no contraindications - in patients with high risk Nitrates Ca channel antagonists Magnesium Lidocaine X X Level of IIa IIb III evidence A A Class

X X X X X X

A A A B A 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 Yes Yes
REVASC

High risk

Moderate r.

Low risk

Significant angina

No

Medication

No

Rehabilitation
‡ Lifestyle advice ‡ Active in profession ‡ Also in patients with significant LV dysfunction ‡ Initiated early in hospital

Recommendations for secondary prevention
Clasa I Smoking cessation Plasma glucose control in all diabetics BP control Mediterranian diet X X X X IIa IIb III Evidence level C B C B B A C B A A A X X B A

Supplementation with 1 g fish oil, n-3 polyunsaturated X fat Aspirin 75-160mg/day Clopidogrel 75 mg/zi (aspirin intolerance) Oral Anticuagulants Beta-blockers (oral) if no contraindications ACEi ± from the 1st day Statins (CT > 190 mg/dl and/or LDLc > 115mg/dl) Ca antagonists Nitrate (no angina) X X X X X X

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