AMI & Chest Pain Management PDF

19/08/2024 AMI and Chest Pain Management BY SHER GRAAN REVIEWED BY KAYLEIGH BUTTON AUGUST 2023 Intended Learning Outcomes  Define acute coronary syndromes  Discuss concept of myocardial supply to demand ratio  Identify risk factors for ischaemic heart disease  Discuss systemati...

19/08/2024 AMI and Chest Pain Management BY SHER GRAAN REVIEWED BY KAYLEIGH BUTTON AUGUST 2023 Intended Learning Outcomes  Define acute coronary syndromes  Discuss concept of myocardial supply to demand ratio  Identify risk factors for ischaemic heart disease  Discuss systematic assessment of a patient with chest pain including objective and subjective data  Discuss differential diagnosis of chest pain  Discuss diagnostic procedures including;  ECG  Biochemical markers  Other diagnostic tools  Discuss management of a patient with acute chest pain  Discuss management of unstable angina/non STEMI and STEMI  Briefly explore re-vascularisation options What do we mean by acute coronary syndrome? 1  19/08/2024 Definitions  Acute coronary syndromes (ACS) include “a broad spectrum of clinical presentations, spanning ST-segment-elevation myocardial infarction, through to an accelerated pattern of angina without evidence of myonecrosis” 2006 Guidelines  Acute coronary syndromes are “the result of unstable atheromatous plaques or endothelial disruption with associated transient or permanent thrombotic occlusion of the coronary vascular tree leading to myocardial ischaemia and infarction” 2016 Guidelines Definitions  Stable angina (not an ACS): attacks have a trigger (such as stress or exercise) and stop within a few minutes of rest  Unstable angina: attacks are more unpredictable (may not have a trigger) and can continue despite resting  NSTEMI: Presentation with clinical symptoms consistent with ACS, with an elevation in serum troponin levels. No ST segment elevation  STEMI: Presentation with clinical symptoms consistent with ACS together with ST segment elevation on ECG  Video Library - One Heart Cardiology What are some other possible causes of chest pain? 2  19/08/2024 Differential Diagnoses Potentially Life-Threatening Non-life Threatening  Aortic dissection  Colic  Myocarditis  GORD  Pericarditis  Peptic ulcer disease  Cardiac Tamponade  Pneumonia  Pulmonary Embolism  Pleurisy  Valvular Disease  Musculoskeletal  Stress cardiomyopathies  Anxiety disorders  Tension pneumothorax  Trauma (eg rib fracture)  Oesophageal rupture  Shingles History  Risk factors (Non-modifiable)  Risk factors (Modifiable)  Age  Hypertension  Gender (earlier in men)  High Cholesterol  Family history (genetic  Smoking predisposition)  Diabetes  Race (higher in non-white  Obesity population)  Physical inactivity  Stress and anxiety History 3  19/08/2024 Subjective Pain Assessment  What is quality of pain?  Where does pain radiate?  What was happening at the onset of symptoms?  How severe was pain at onset of symptoms?  How long did pain lasted?  Any other symptoms? Mnemonic PQRST P: Provocative or palliative features  What activity or emotions provoke pain?  What interventions relieve pain?  Angina:  Induced by stress, exercise or eating  Relived by rest or nitrates  Unstable angina, NSTEMI  Provoked by exertion, stress, eating, or occurs at rest  Gradually increasing in intensity, last < 20min  STEMI  Provoked by exertion, stress, eating, or occurs at rest  Lasts >30min, more severe, + associated symptoms Mnemonic PQRST Q: Quality of discomfort, as described by patient  Typical: Pressure, tightness, heaviness, dull, constricting, squeezing, aching, fullness, burning and crushing  Atypical: Knifelike, stabbing, sharp, tingling  Ischaemia: chest discomfort, shoulder / arm / jaw / upper abdominal pain, shortness of breath, nausea, vomiting and sweating (diaphoresis)  Acute pericarditis: sharp retrosternal, worse with inspiration, aggravated with change position  Aortic dissection: excruciating ripping pain, anterior of chest, sudden onset, radiating to back 4  19/08/2024 Mnemonic PQRST R: Region, location and radiation  Get patient to point out or touch areas of pain  Cardiac: central chest → neck, jaw, epigastrium, shoulders, or left arm  Aortic dissection: anterior of chest → back  Gallbladder: epigastric, RUQ → R) shoulder  Pancreatitis: epigastric, substernal → belt  Pneumothorax: unilateral, sudden onset, with dyspnoea Mnemonic PQRST S: severity  Numeric rating scale 1 (no pain) to 10 (worst imaginable)  Visual rating scale Mnemonic PQRST T: Temporal nature of symptoms  Angina: 2-10 min,  Unstable angina, NSTEMI  Gradually increasing in intensity, last < 20min  Symptoms might come and go  STEMI  Lasts >30min, more severe  Not relived by rest or nitrates 5  19/08/2024 Symptoms Typical Atypical  Discomfort and pain  Dizziness  Shortness of breath  Hyperventilation  Diaphoresis  Heartburn  Nausea  Heat sensation  Light-headedness  Indigestion  Loss of appetite  Palpitations  Unusually scared  Weakness  Unusual fatigue Associated Symptoms  Palpitation  Anxiety  Cough  Nausea, vomiting  Cold and clammy skin  Cyanosis  Dizziness, syncope  Fatigue Associated Symptoms  Dyspnoea  Exertional Dyspnoea  Orthopnoea (supine position)  Paroxysmal nocturnal dyspnoea (severe dyspnoea that forces patient to get up from sleep and gasp for breath)  Oedema  Location  Weight gain  Duration 6  19/08/2024 Tests  ECG  Full blood test  FBE  U&E  Clotting profile  Cardiac enzymes  CXR CK-MB and Cardiac Troponin  CK-MB  Rise within 6hrs  Peak at 24hrs  Sensitivity 90% 3hrs after ED admission, non-specific  Other causes for elevation: skeletal muscle disease, overexertion of muscles and cocaine use  More useful as a prognostic value than diagnostically, in determining infarct size, left ventricular dysfunction, early complications and mortality CK-MB and Cardiac Troponin  Cardiac Troponin (Troponin I or T) Sensitive Troponin  Disintegration of contractile proteins in necrotic myocardium  Detectable within 3-6 hrs of pain onset  Peak at 12-24hrs  Remain in serum for 7-10 days  Sensitivity 90-100%, specificity 76-91% 7  19/08/2024 ECG  All patients presenting with ACS must have an ECG within 10 minutes of first acute clinical contact and be reviewed by an ECG-experienced clinician (ie cardiologist)  Regular?  Rate  P  PR interval  QRS  T  ST segment  Leads group / territory 8  19/08/2024 ECG potential changes  QRS – may be widened (new LBBB)  T wave – inversion, peaked T waves  ST segment  ST depression or no ST changes (NSTEMI)  ST elevation – (STEMI!)  Leads group / territory  Anterior: STE V3-V4  Septal: STE V1-2  Lateral: STE V5-6, I, aVL  Inferior: STE II, III, aVF Coronary Angiography  Gold standard  Access via femoral or radial artery  Dye injected into coronary arteries (LM, RCA)  Picture of arteries  Stenosis, irregularities  Ventriculogram  Video Library - One Heart Cardiology Coronary Angiography 9  19/08/2024 Management  Pain relief;  Morphine  Nitrates  Aspirin  Antithrombin therapy  LMWH (Clexane)  Heparin  Platelets antagonists  Abciximab (Reopro)  Eptifibatide (Integrillin)  Clopidogrel (Plavix)  Ticagrelor (Brilinta)  Tirofiban (Aggrastat) Management  Angiotensin-Converting Enzyme (ACE) Inhibitor (e.g. Ramipril)  Block conversion angiotensin I to angiotensin II  Preventing vasoconstriction  Prevention of fluid retention  Reduced workload of heart  Prevention of onset of heart failure Management  Beta Blocker (e.g. metoprolol, bisoprolol)  decreasing cardiac workload and myocardial oxygen demand  slowing heart rate helps increase time of diastole which helps coronary artery filling time  Calcium Channel Blockers (e.g. amlodipine)  inhibiting myocardial and vascular muscle contraction  vasodilatation  slowing of atrioventricular conduction and sinus node automaticity  Decrease in myocardial oxygen demand 10  19/08/2024 Reperfusion Therapy Fibrinolytic Therapy  Advantages  No Cath Lab access required  Proven efficacy  Treat the underlying problem of central occluding thrombus  Disadvantages  Contraindications  Not effective for haemodynamic instability  Residual stenosis  Complications  Assessment of reperfusion is not 100% Reperfusion Therapy Agents:  Streptokinase  Alteplase  Reteplase  Tenecteplase Complications:  Bleeding  Allergic reaction Reperfusion Therapy Absolute Contraindications: Relative contraindications:  Intracranial bleed  Poorly controlled hypertension  Ischaemic stroke (within 3/12)  Ischaemic stroke (greater 3/12)  Suspected aortic dissection  Trauma  Active bleed  Surgery (less 3/52)  Recent internal bleed (within 2-4 weeks)  Pregnancy  Active peptic ulcer 11  19/08/2024 Reperfusion Therapy Percutaneous Coronary Intervention  Percutaneous Transluminal Coronary Angioplasty (PTCA)  Balloon angioplasty  Coronary stents  Bare metal stents  Drug eluting stents  Distal Embolic Protective Devices Reperfusion Therapy Percutaneous Coronary Intervention  Percutaneous Transluminal Coronary Angioplasty (PTCA)  Balloon angioplasty  Coronary stents  Bare metal stents  Drug eluting stents  Distal Embolic Protective Devices Indications for CABG  CABG surgery multiple narrowing in multiple coronary artery branches (LAD, LCX, RCA)  Diffuse disease not amendable to treatment with a PCI  CABG surgery improves  Long-term survival in patients with significant narrowing of left main  Patients with significant narrowing of multiple arteries with decreased LV function (low ejection fraction, or diabetes mellitus) 12  19/08/2024 Donor  Saphenous vein  Radial artery  Mammary artery  Gastroepiploid artery CABG Complications  Difficulty breathing  Bleeding (blood loss from ICC)  Infection  Hypertension  Arrhythmias, particularly atrial fibrillation  Kidney failure  Heart attack 5-10%  Stroke 1-2%  Death 3-4%  Higher risks in patients with diabetes, older patients, and patients with other major health problems Lifestyle changes  Eating a healthy diet  Quitting smoking  Monitoring blood pressure  Monitoring diabetes closely  Regular exercise 13  19/08/2024 References 1. Elliott, D., Aitken L., and Chaboter (Ed) (2014). ACCCN’s Critical Care Nursing. Sydney: Elsevier. 2. Finkelmeier, B. & Marolda, D. (2001). Aortic dissection. The Journal of Cardiovascular Nursing, 15(4): 15-24. 3. Finkelmeier, B. (2000). Cardiothoracic surgical nursing. 2nd ed. Philadelphia: Lippincott. 4. Moser, D.K., Riegal, B. (2008). Cardiac Nursing: a companion to Braunwald’s heart disease. St Louis: Saunders Elsevier. 5. A. Bersten & N. Soni (Eds.) (2003). Oh’s intensive care manual. (5th ed.). Edinburgh: Butterworth Heinemann. 6. Urden, L., Lough, M. & Stacy, K. (2013). Thelan’s Critical care nursing: Diagnosis and management. (7th ed.). St. Louis: Mosby. 7. Woods, S., Sivarajan Froelicher, E. & Underhill Motzer, S. Cardiac nursing. (4th ed.). Philadelphia: Lippincott. 8. https://www.nhs.uk/conditions/angina/ 9. https://litfl.com/chest-pain-ddx/ 10. Popa D.M., Macovei, L., Moscalu, M., Sascau R.A., & Statescu, C. (2023). The Prognostic Value of Creatine Kinase-MB Dynamics after Primary Angioplasty in ST-Elevation Myocardial Infarctions. Diagnostics (Basel, Switzerland), 13(19), 3143. 14