CHEST PAIN

B elgian I nter disciplinary W orking group of A cute C ardiology Claeys MJ Vandekerckhove Y Bossaert L Calle P Martens P Hollanders G Vrints C Van de Werf F Renard M De Raedt H De Meester A De Smedt J ...

Thoracic pain

aneurysm dissecans pneumothorax gastric ulcer, oesofagitis Acute coronary syndrome AMI / angina pectoris pulmonary embolism pericarditis, pleuritis hyperventilation

AMI - Prognosis MEN

28 d. Case Fatality

WHO MONICA 1985-1990

49% (35-60%) 40 30 20 10 0 pr e ho sp .

ho sp ita l

WOMEN

51% (34-70%) pr e ho sp ho sp ita l

Case-Fatality in Ghent during 1983-1999 in men 25-69 years 60 50 40 30 20 10 All Hospitalised cases 0 83 84 85 86 87 88 89 90 91

Year

92 93 94 95 96 97 98 99

Prof. G. De Backer, Ghent

AMI- case fatality

PRE - HOSPITAL IN - HOSPITAL Sudden death arrhytmia VF cardiac failure no/late reperfusion !!!!! T I M E = L I F E !!!!!!

Prevention - AMI Case Fatality

PRE - HOSPITAL IN - HOSPITAL Sudden death NO DELAY cardiac failure VF recognition VF treatment Reperfusion Therapy

EMERGENCY DEPT.

AMBULANCE HOSPITAL GP TEL 100 HOME COMPLETE DIAGNOSIS

Chest pain and the patient When should I seek medical help ?

Who should I contact?

Early recognition of Alarming symptoms !!!

Duration > 20 min and/or recurrent attack >1x/u

!!!! MEDICAL URGENCY !!!!

Call General Physician OR Call “100”

Risk stratification (by call): History of cardiac disease

and/or

Associated symptoms

: dyspnoe, fainting, nausea, diaphoresis and / or

age (>40 y) High risk

Call Medical transport emergency system (MUG - SMUR)

No-High risk

Call standard transport emergency system Unless overruled by GP

Management high risk patient 1. Check vital signs 2. Establish ECG monitoring + defibrillator 3. Give oxygen (3-5 lit/min) 4. Establish IV access 5*. Take 12-lead ECG 6*. Give short acting nitrate sublingual 7*. Give acetylsalicylic acid 150-300 mg po / IV 8*. Give Opioid analgesic (e.g. morfine 1-4mg IV) 9*. Consider pre-hospital thrombolysis if ST elevation AMI and time to hospital > 30 min * only in the presence of authorized medical doctor

MUG/SMUR Where to transport ???

Majority of patients

hospital with coronary care unit/ intensive cardiac care unit

Cardiogenic shock

hospital with 24-hour facilities coronary intervention

Early-in-hospital Management 1. Check vital signs 2. Establish ECG monitoring + defibrillator 3. Give oxygen (3-5 lit/min) 4. Establish IV access 5. Take 12-lead ECG 6. Obtain serum cardiac markers 7. Cardiological assessment: ST elevation AMI ACS without ST elevation ACS doubtful or non cardiac pathology

< 3‘ < 10‘ < 20‘

ST- Elevation AMI 1. Check intake ASA / nitrates SL 2. Give Beta blockers 3. Initiate Reperfusion therapy

Thrombolyse PTCA

Primaire PTCA and hospital time

% mort.

7 6 6,4 3 2 5 4 1 1 3,7 4 0 t<60 min 61-75 min 76-90 min t>90 min N =104 n = 109 n = 76 n = 14O Berger et al, Circulation, 1999 (Gusto II substudy) Time to PTCA

ST-elevation AMI: reperfusion therapy

Thrombolytic therapy

!! door to drug time < 30’!!

OR Direct PTCA

!! door to ballon time < 90  30’!!

Depending on hospital facilities BUT: refer for primary PTCA if - cardiogenic shock or - contra-indication for thrombolysis.

Acute coronary syndrome without ST elevation 1. Check intake ASA 2. Check intake nitrates SL 3. Start heparin (LMWH sc or unfractionated IV) 4. Start nitrate IV (if bloodpressure > 100 mmHg) 5. Start Beta-Blockers Consider II b/ III a blockers and invasive evaluation in patients at high risk for thrombotic events (recurrent or ongoing ischemia, troponin +)

Chest pain without immediate diagnosis

Cardiac pathology

Angina, pericarditis, infarction serial cardiac markers ST segment monitoring echocardiography stress stest

Non-Cardiac pathology

Pulmonary embolism pneumothorax aneruysmam dissecans gastric ulcer. Oesofagitis hyperventilation.

CHEST PAIN CLINIC