Pain, chest NOS

Chest pain is a common and often alarming symptom that can have a variety of causes, ranging from benign to life-threatening. Accurate diagnosis and management are crucial.

Causes:

  • Cardiovascular Causes:
    • Coronary Artery Disease (CAD): Including angina and myocardial infarction (heart attack).
    • Pericarditis: Inflammation of the pericardium.
    • Aortic Dissection: A tear in the aorta’s wall.
    • Myocarditis: Inflammation of the heart muscle.
  • Respiratory Causes:
    • Pulmonary Embolism (PE): Blood clot in a lung artery.
    • Pneumonia and Pleurisy: Lung infections and inflammation.
    • Pneumothorax: Collapsed lung.
  • Gastrointestinal Causes:
    • Gastroesophageal Reflux Disease (GORD): Acid reflux.
    • Esophageal Spasm: Sudden, painful contractions of the esophagus.
    • Peptic Ulcers or Gastritis: Stomach or upper intestinal ulcers.
  • Musculoskeletal Causes:
    • Costochondritis: Inflammation of the rib cage cartilage.
    • Muscle Strain: In the chest wall muscles.
  • Psychogenic Causes:
    • Anxiety or Panic Attacks: Can mimic heart attack symptoms.

Diagnosis:

  • History and Examination: Assessing the nature, location, and radiation of the pain, and associated symptoms like shortness of breath, nausea, or sweating.
  • Electrocardiogram (ECG): To detect heart problems.
  • Blood Tests: Including cardiac enzymes (troponins) to check for heart muscle damage.
  • Chest X-Ray: To look at the lungs, heart, and chest wall.
  • CT Scan: Particularly for suspected PE (CTPA) or aortic dissection.
  • Echocardiogram: Ultrasound of the heart.
  • Stress Tests or Cardiac Catheterization: To evaluate CAD.

Differential Diagnosis:

  • Cardiac vs. Non-Cardiac Pain: Cardiac pain often radiates to the arm or jaw, is exertional, or associated with shortness of breath.
  • GORD vs. CAD: GORD pain often occurs after eating and may respond to antacids.
  • Panic Attacks: May mimic heart attack but are often associated with hyperventilation.

Management:

  • Emergency Care for Suspected Heart Attack or PE: Immediate medical attention is crucial.
  • Medications:
    • CAD
      • Nitrates
      • Aspirin,
      • Clopidogrel,
      • Enoxaparin or Unfractionated Heparin
      • Beta-blockers
      • Thrombolysis if STEMI and PCI not available within 120 minutes
    • PE
      • Anticoagulants
        • Enoxaparin short term
        • NOAC or Warfarin long term
    • GORD
      • Antacids
      • Histamine H2 blockers
      • Proton Pump Inhibitors (PPIs) 
  • Surgical Interventions:
    • ACS
      • PCI (Per Cutaneous Intervention) ie Angioplasty
      • CABG (Coronary Artery Bypass Surgery)
    • Surgery for aortic dissection.
  • Physiotherapy: For musculoskeletal causes.
  • Psychological Therapy: For anxiety-related chest pain.

Prevention:

  • Regular Check-Ups: Especially for those with risk factors for heart disease.
  • Lifestyle Modifications: Smoking cessation, diet and exercise changes, stress management.
  • Managing Chronic Conditions: Like hypertension, diabetes, and high cholesterol.

Follow-Up:

Regular monitoring is important, especially for patients with diagnosed heart or lung conditions. The management plan may need to be adjusted based on the response to treatment and any changes in symptoms.

Acute Coronary Syndrome

Acute Coronary Syndrome (ACS) is a term used to describe a range of conditions associated with sudden, reduced blood flow to the heart. It encompasses three clinical presentations:

  1. ST-Elevation Myocardial Infarction (STEMI),
  2. Non-ST Elevation Myocardial Infarction (NSTEMI), and
  3. Unstable Angina.
  • Pathophysiology: ACS typically occurs due to rupture of an atherosclerotic plaque in a coronary artery, leading to thrombus (blood clot) formation. This clot can partially or completely block the blood flow in the coronary artery, leading to ischemia (reduced blood supply) and damage to the heart muscle.
  • Symptoms: Common symptoms include chest pain or discomfort, which may radiate to the arms, neck, jaw, or back. Nausea, indigestion, shortness of breath, sweating, and lightheadedness are also common.
  • Diagnosis: Key diagnostic tools are
    • ECG (electrocardiograms) to detect electrical changes in the heart and
    • Troponin which is released during heart muscle damage.
  • Management:
  • Initial Treatment:
    • Oxygen therapy if SaO2 < 94%
    • Pain relief (usually with nitrates and morphine)
    • Antiplatelet agents (like aspirin and P2Y12 inhibitors)
    • Anticoagulants (like enoxaparin)
    • Beta-blockers.
  • Definitive Treatment: Depends on the type of ACS:
    • STEMI: Requires immediate reperfusion therapy, typically with percutaneous coronary intervention (PCI) or, if not available, thrombolytic therapy.
    • NSTEMI/Unstable Angina: Managed with medications and often followed by coronary angiography and possible PCI or coronary artery bypass grafting (CABG) depending on the severity and risk assessment.
    • Note: We see a troponin rise in NSTEMI but not in Unstable Angina
  • Risk Factors: Include smoking, high blood pressure, high cholesterol, diabetes, obesity, and a sedentary lifestyle. A family history of heart disease also increases risk.
  • Prognosis and Prevention: The prognosis depends on the extent of heart damage and the promptness of treatment. Long-term prognosis often requires lifestyle changes, medications, and, in some cases, surgical interventions. Preventive measures include managing risk factors, such as maintaining a healthy diet, regular exercise, smoking cessation, and controlling hypertension and diabetes.

ACS is a medical emergency, and prompt treatment is crucial to improve outcomes and reduce the risk of serious complications like heart failure or cardiac arrest.

The management of Non-ST Elevation Myocardial Infarction (NSTEMI) and ST-Elevation Myocardial Infarction (STEMI) are critical aspects of cardiology and emergency medicine. These conditions represent different spectrums of the same disease – acute coronary syndrome (ACS). Management strategies differ based on the presentation, diagnosis, and severity of the condition.

  1. Initial Management:
    1. Assessment and Stabilization: On presentation, both NSTEMI and STEMI require immediate assessment, including history taking, physical examination, and vital signs monitoring.
    2. Electrocardiogram (ECG): A 12-lead ECG is crucial for differentiating between STEMI and NSTEMI. STEMI is characterized by ST-segment elevation, while NSTEMI typically does not have ST elevation but may have ST depression or T-wave changes.
    3. Biomarkers: Cardiac biomarkers, particularly troponins, are essential for diagnosis.
  2. Medical Management:
    1. Antiplatelet Therapy: Aspirin and P2Y12 inhibitors (like clopidogrel, ticagrelor, or prasugrel) are standard for both NSTEMI and STEMI.
    2. Anticoagulation: Heparin (unfractionated or low molecular weight heparin) is commonly used.
    3. Beta-Blockers: These are indicated unless there are contraindications like heart failure, bradycardia, or hypotension.
    4. ACE Inhibitors: Often started within the first 24 hours, particularly in patients with reduced left ventricular ejection fraction, hypertension, or diabetes.
    5. Statins: High-intensity statin therapy is recommended irrespective of baseline cholesterol levels.
    6. Nitrates: Used for symptom relief, particularly in the presence of ongoing ischemia or hypertension.
    7. Analgesia: Morphine is often used for pain management.
  3. Reperfusion Strategy:
    1. STEMI:
      1. Immediate reperfusion therapy is critical.
      2. The preferred method is percutaneous coronary intervention (PCI) if it can be performed within recommended time frames (120 minutes)
      3. If PCI is not available or delayed, thrombolytic therapy is considered (weight based tenacteplase)
    2. NSTEMI:
      1. The approach to reperfusion is more individualized.
      2. Urgent angiography and possible PCI are recommended in high-risk patients.
      3. In others, a conservative strategy with medical management and delayed angiography may be appropriate.
  4. Risk Stratification:
    1. NSTEMI: Risk assessment using tools like the GRACE score helps guide the timing of invasive strategies.
    2. STEMI: The primary focus is on the rapidity of reperfusion.
  5. Post-Acute Care:
    1. Cardiac Rehabilitation: Both STEMI and NSTEMI patients benefit from cardiac rehabilitation.
    2. Secondary Prevention: Lifestyle modifications, management of risk factors (like hypertension, diabetes, smoking), and adherence to medication regimens are vital.
    3. Follow-Up: Regular follow-up with a healthcare provider is essential for monitoring and adjusting treatment plans.
  6. Special Considerations:
    1. Cardiogenic Shock: May require more aggressive interventions, including mechanical support.
    2. Multivessel Disease: May influence the revascularization strategy ie CABG rather than PCI
  7. 7. Patient Education:
    1. Informing patients about their condition, the importance of medications, lifestyle changes, and follow-up care is crucial.
  8. 8. Monitoring and Follow-Up:
    1. Regular monitoring for complications, medication adherence, and lifestyle changes is essential.

In practice, the management of NSTEMI and STEMI requires a multidisciplinary approach, including cardiologists, emergency medicine physicians, nursing staff, and possibly cardiothoracic surgeons, among others. Treatment should be individualized based on patient factors, hospital resources, and the presence of comorbidities.

NSTEMI Management

  1. Initial Presentation and Stabilization:
    1. Clinical Assessment: A detailed history to identify characteristic chest pain, risk factors for coronary artery disease, and previous cardiac history.
    2. ECG: Repeated ECGs are often necessary as changes can evolve over time.
    3. Cardiac Biomarkers: Serial measurements of troponins, as rises and falls in these biomarkers confirm myocardial injury.
  2. Risk Stratification:
    1. Tools like the GRACE score assess the risk of death and myocardial infarction, guiding the urgency of treatment.
  3. Medical Management:
    1. Dual Antiplatelet Therapy (DAPT): Combines aspirin with a P2Y12 inhibitor. The choice of P2Y12 inhibitor (clopidogrel, ticagrelor, prasugrel) depends on various factors, including bleeding risk and planned management strategy.
    2. Anticoagulants: Options include unfractionated heparin, enoxaparin, or fondaparinux.
    3. Beta-Blockers: To reduce myocardial oxygen demand. Contraindications must be evaluated.
    4. High-Intensity Statin Therapy: Initiated as early as possible.
  4. Invasive Strategy:
    1. Coronary Angiography: Followed by revascularization (PCI or CABG) depending on the findings.
      1. Timing depends on risk stratification
      2. High-risk features may necessitate urgent angiography.

STEMI Management

  1. Initial Presentation and Stabilization:
    1. Immediate Assessment: Identifying STEMI on ECG is critical for timely management.
    2. Reperfusion Therapy: Primary PCI is the preferred treatment if it can be performed within 90 minutes of first medical contact. If PCI is not available within 120 minutes, thrombolytic therapy should be considered.
  2. Reperfusion Therapy:
    1. Primary PCI: Involves balloon angioplasty and stent placement.
    2. Thrombolysis: Used when PCI is not available, with attention to contraindications to avoid bleeding complications.
  3. Adjunctive Medical Therapy:
    1. Antiplatelet Agents: Aspirin and a P2Y12 inhibitor are administered.
    2. Anticoagulation: Typically with heparin during PCI.
    3. Beta-Blockers: Unless contraindicated, to reduce myocardial oxygen consumption.
    4. ACE Inhibitors: Introduced within the first 24 hours in patients with anterior infarction, heart failure, or ejection fraction less than 40%.
  4. Post-Reperfusion Management:
    1. Monitoring for Complications: Such as arrhythmias, heart failure, and mechanical complications.
    2. Risk Factor Modification: Control of hypertension, diabetes, and lipid levels.

Post-Acute Care for Both NSTEMI and STEMI

  • Cardiac Rehabilitation: Critical for recovery, involving exercise, lifestyle education, and psychological support.
  • Secondary Prevention:
    • Lifestyle Changes: Smoking cessation, dietary modifications, and regular physical activity.
    • Medication Adherence: Continued use of DAPT, statins, beta-blockers, ACE inhibitors, and other relevant medications.
  • Long-Term Monitoring and Management:
    • Regular follow-up for medication management, lifestyle adherence, and monitoring for ischemic symptoms.
  • Psychosocial Aspects:
    • Addressing anxiety, depression, and other emotional factors that can impact recovery.

Special Considerations

  • Elderly Patients: May present atypically and have a higher risk of complications.
  • Diabetes: Aggressive management of glucose levels and cardiovascular risk factors.
  • Renal Impairment: Adjustments in medication dosages and careful monitoring.

Conclusion

Management of NSTEMI and STEMI requires a comprehensive approach that includes rapid diagnosis, risk stratification, appropriate use of pharmacologic therapies, timely reperfusion, and a focus on secondary prevention and long-term management. Individualized care based on patient characteristics and comorbidities is essential for optimal outcomes. Regular updates in clinical guidelines should be referred to for the most current evidence-based practices.