Approach to the patients with
chest pain
and their management
Prof Dr. S. N. Ojha
M.D Ph.D
Principal
Dr. D. Y. Patil Ayurvedic College Pune
http://drojha.wordpress.com/
ACUTE MYOCARDIAL INFARCTION
Defination
AMI occurs when the blood supply to the
part of hearth is interrupted. The resulting
ischemia (restriction in blood supply) and
oxygen shortage, If left untreated for a
sufficient period, can cause and/or Death
(Infarction) of heath muscle tissue
(Myocardium)
Magnitude of the problem
32% Death in India attributed to cardio
vascular disease compared to 12% due to
respiratory infection, 9% due to diarrhoeal
disease and 5% due to tuberculosis.
Prevalence is higher in south India .
Urban India(3.45-9.45%) is affected more in
comparison to rural India(2-4%)
Risk factor
Risk factor for atherosclerosis are generally risk factor
for MI
-Old age
-Male sex
-Hypercholestrolemia
-Tobacco smoking
-DM with or without insulin resistency)
-High BP
-Obesity
-Stress
-Hyperhomocysteinemia
-Women using OCP have increased risk of MI
-Periodontal disease may be linked to coronary heart
disease
Acute coronary syndrome
ECG
ST- Elevation
No ST- Elevation
- ve
CARDIAC MARKER
Unstable angina
+ ve
Myocardial infarction
STEMI
Q Wave MI
NSTEMI
Non Q Wave MI
SYMPTOMS
-Chest Pain
-Levine’s sign ; Chest pain is localized by clenching fist over sternum.
-Dyspnoea
-Diaphoresis
-Weakness
-Light Headedness
-Nausea
-Vomiting
-Palpitation
-Loss of consciousness
-Sudden Death
*Most common symptoms of MI in Women include Dyspnoea, Weakness and
Fatigue.
*In DM, difference in Pain threshold, Autonomic neuropathy and
psychological factors have been cited as possible explanation for silent MI.
*Probably because the donor heart is not connected to nerves of the host MI in
heart transplanted person is silent.
PHYSICAL EXAMINATION
-General appearance may vary; the patient may be
comfortable or restless and in severe distress with
increased respiratory rate.
-Low grade Fever (38-39 degree celsius )
-BP maybe elevated or decreased.
-Pulse can become irregular
-If Heart failure ensues ;
increased JVP
hepatojugular reflux,
swelling legs due peripheral oedema.
-Cardiac bulge with a pace different from pulse
rhythm can be felt on precordial examination.
-On auscultation –
-3rd and 4th heart sound.
- Systolic murmur
- Paradoxical splitting of 2nd heart sound
- Precordial friction rub
- Rales over lung
DIAGNOSIS
-History of present illness
- Physical Examination
- ECG
- Cardiac Marker CKMB- Troponin
-Coronary angiogram
- Echo cardiogram
- Nuclear medicine (technetium 99m 2methoxyisobutylisonitrite Or Thallium-201 Chloride)
Some features differentiating cardiac from Non-cardiac chest pain
Favoring Ischaemic Origin
Against Ischaemic origin
1.Character of Pain
Constricting
Squeezing
Burning
Heaviness, heavy feeling
Dull ache
Knife Like,Sharp
stabbing,jabs
Aggravated Respiration
2. Location of Pain
Substernal
Across Mid Thorax,
Anteriorly
In both arms, shoulders
In the Neck, Cheeks, Teeths
In the Forearms, Fingers
In the interscapular region
In the left submamary area
In the Left hemithroax
Some features differentiating cardiac from Non-cardiac chest pain
Favoring Ischaemic Origin
Against Ischaemic origin
3. Factors Provoking Pain
Exercise
Excitement
Other forms of Stress
Cold Weather
After Meals
Pain after completion of exercise
Provoked by a specific body motion
Index
Disease
Duration
Quality
Provocation
Relief
Location
1.
Effort angina
5-15 mins
Visceral/pressure
type
During effort or
emotion
Rest &
Nitroglycerine
Sternal &
radiating
2.
Rest Angina Or
Unstable Angina
5-15 mins
Visceral/pressure
type
Spontaneous
Nitroglycerine
Substernal &
radiating
3.
Mitral Valve
Prolapse
Mins to Hours
Superficial
Spontaneous(No
Pattern)
Time
Left Anterior
4.
Oesophageal
Reflux
10 mins- 1 hour
Visceral
Recumbency &
Lack Of Food
Food, Antacid
Substernal
Epigastric
5.
Peptic Ulcer
Hrs
Visceral, Burning
Type
Lack Of Food,
Acid Food
Food Antacid
Epigastric &
Substernal
6.
Oesophageal
Spasm
5-60mins
Visceral
Spontaneous, Cold Nitroglycerine
Liquids &
Exercise
Substernal &
Radiating
7.
Biliary Disease
Hrs
Visceral, Severe
Spontaneous,
Food- Fatty food
Time & Analgesic
Epigastric,
Radiated To Rt.
Scapular Tip
8.
Cervical Disc
Prolapse
Variable
(Gradually
Subsides)
Superficial
Head & Neck
Movements
Time & Analgesic
Neck &
Arm(Radiculopath
y)
9.
Hyperventillation
2-3mins
visceral
Emotions &
Tachypneoa
Stimulus Removal Substernal
10.
Musculoskeletal
Pain
Variable
Superficial
Movement &
Palpation
Time & Analgesic
11.
Pulmonary Causes
30 mins
Visceral/Pressuret Often Spontaneous Rest,time &
ype
bronchodilatation
Multiple Sites
Substernal
Wall Affected
Leads Showing ST
Segment Elevation
Leads Showing
Suspected Culprit
Reciprocal ST
Artery
Segment Depression
Septal
V1, V2
None
Left Anterior
Descending (LAD)
Anterior
V3, V4
None
Left Anterior
Descending (LAD)
Anteroseptal
V1, V2, V3, V4
None
Left Anterior
Descending (LAD)
Anterolateral
V3, V4, V5, V6,I,
aVL
II, III, aVF
Left Anterior
Descending (LAD),
Circumflex (LCX),
or Obtuse Marginal
Extensive Anterior
(Sometimes called
Anteroseptal with
Lateral extension)
V1, V2, V3, V4,V5,
V6, I, aVL
II, III, aVF
Left main coronary
artery (LCA)
Wall Affected
Leads Showing ST
Segment Elevation
Leads Showing
Suspected Culprit
Reciprocal ST
Artery
Segment Depression
Inferior
II, III, aVF
I, aVL
Right Coronary
Artery (RCA) or
Circumflex (LCX)
Lateral
I, aVL, V5, V6
II, III, aVF
Circumflex (LCX),
or Obtuse Marginal
Posterior (Usually
V7, V8, V9
V1, V2, V3, V4
Posterior
Descending (PDA)
(branch of the
RCA or
Circumflex (LCX)
I, aVL
Right Coronary
Artery (RCA)
associated with
Inferior or Lateral
but can be isolated)
Right ventricular
II, III, aVF, V1,
(Usually associated V4R
with Inferior)
TREATMENT
First aid
Aspirin
Nitrates
Automated external defibrillator
In case of cardiac arrest, CPR(cardio
pulmonary resusitation) can be administered.
First line
Oxygen
Aspirin
Nitrates
Analgesia(morphine)
Beta blocker
Anti coagulant like heparin
Anti platelet agent like clopidogrel
Reperfusion
Thrombolytic therapy
Percutaneous coronary intervention(PCI)
Bypass surgery
Monitoring Arrhythmias
Anti arrhythmic prophylaxis
Secondary prevention
Beta blocker
ACE Inhibitor
Statin therapy
Angiotensin receptor blocker
Aldosterone antagonist
Ca channel blocker
Omega 3 fatty acids
Rehabilitation
Physical exercise
Smoking cessation
Restricted diet
Limitations of alcohol intake
Can resume sexual activity after 3 to 4 weeks.
Following drugs are used and found effective in vatika hridroga.
Further scientific clinical trial is needful.
01)
02)
03)
04)
05)
06)
07)
Drug acting on amasahit meda = Marich, Chitrak,
Daruharidra, Rason, Tulasi, Vacha, Pushkarmul, Punarnava,
Shuddha shilajeeta
Drug acting on rasvaha strotas = Amalaki, Haritaki,
Punarnava, Shatavari, Marich & Shilajeet
Drug acting on vata dosh = Haritaki, Rason, Guggul,
Pushkarmul , Amalaki , Punarnava , Marich , Shilajeet,
Chitrak, Tulsi& Shatavari.
Medhya drug= Bramhi, Vacha, Shatavari, Haritaki.
Drugs dissolute grathit rakta= Kamalkshar , Darbha or Kusha or
Paravatshakrut.
Hruddya= Arjun, Bramhi, Tulasi, Guggul, Punarnava, Rason &
Shatavari .
Combination of drugs=Arjun, Vacha, Bramhi, Marich,
Chitrak, Tulasi, Haritaki Amalaki, Daruharidra, Punarnava,
Shatavari, Rason, Shuddhhashilajit- sambhag(equal part)
+ puskarmul-2-bhag(2-part) +shuddhha guggul-4-bhag(4-part)
Matra= 1GM TDS Anupan= Udak(jal), Madhu.
Angina
The English word angina refers to a painful
constriction tightness somewhere in the
body
and may refer to : Angina pectoris
Abdominal angina
Ludwig’s angina
Prinzmetal’s angina
Vincent’s angina
Angina tonsillaris
Angina pectoris, commonly known as angina, is
severe chest pain due to ischemia (a lack of blood and
hence oxygen supply) of heart muscle, generally due
to obstruction or spasm of the coronary arteries.
The term derives from the Greek ankhon
(“Strangling”) and the Latin Pectus (“chest”), and can
therefore be translated as “a strangling feeling in the
chest.”
Symptoms
Chest discomfort
the discomfort is usually described as a pressure, heaviness,
tightness, squeezing, burning, or choking sensation.,
anginal pains may also be experienced in the epigastrium
,back, neck, jaw, or shoulders, following skin dermatomes.
It is typically precipitated by exertion or emotional stress.
It is exacerbated by having a full stomach and by cold
temperatures.
Pain may be accompanied by breathlessness, sweating and
nausea.
It lasts for about 3 to 5 minutes, and is relieved by rest or
specific anti-angina medication.
Risk Factors
cigarette smoking,
diabetes,
high cholesterol,
high blood pressure,
sedentary lifestyle and
family history
Pathophysiology
Coronary Atherosclerosis
Thrombosis
Narrowing Of coronary
Myocardial Ischaemia
Chest Pain
I.H.D.
Subtypes
Stable angina is typically presented as chest
discomfort and associated symptoms precipitated by
some activity (running, walking etc.) with minimal or
non-existent symptoms at rest.
Unstable Angina
It occurs at rest (or with minimal exertion), usually
lasting > 10 min;
it is severe and of new onset (i.e., within the prior 4-6
weeks);
it occurs with a crescendo pattern (i.e., distinctly
more severe, prolonged, or frequent than previously).
Diagnosis
Electrocardiogram (ECG)
Exercise ECG Test (“Treadmill Test”)
Thallium Scintigram
Stress Echocardiography
Coronary Angiogram
Treatment
Aspirin (75 mg. to 100 mg.)
Beta blockers (eg. Carvedilol, propranolol, atenolol etc.)
Short-Acting nitroglycerin
Calcium Channel Blockers (Nifedipine & amlodipine)
Isosorbide mononitrate &
Nicorandil
If inhibitor- Ivabradine provides pure hear rate reduction
ACE inhibitors are also vasodilators.
Statins are the most frequently used lipid / cholesterol
modifiers
Exercise is also a very good long term treatment.
Ludwig’s angina (angina ludovici) is a serious
potentially life-threatening cellulitis infection of the
tissues of the floor of the mouth, usually occurring in
adults with concomitant dental infections.
Cause
is usually a bacterial infection.
Symptoms
swelling,
pain on raising of the tongue,
swelling of the neck and the tissues of the
submandibular and sublingual spaces,
malaise,
fever,
dysphagia
in severe cases, stridor
Signs
patient not being able to swallow his / her own saliva
audible stridor as these strongly suggest that airway
compromise is imminent.
Treatment
Antibiotic medications,
Monitoring and protection of the airway in
severe cases,
and where appropriate, urgent maxillo-facial
surgery
dental consultation to incise and drain the
collections.
Abdominal angina (a.k.a. bowelgina)
is postprandial abdominal pain that occurs in
individuals with insufficient blood flow to
meet mesenteric visceral demands .
Pathophysiology
The most common cause of bowelgina is
atherosclerotic vascular disease.
It can be associated with :
Carcinoid
Aortic coarctation
Antiphospholipid syndrome
Clinical
Disabling midepigastric or central abdominal pain
within 10-15 minutes after eating.
Physical examination :
The abdomen typically is scaphoid and soft,
. weight loss
signs of peripheral vascular disease,
Causes:
Smoking is an associated risk factor.
Treatment
Stents have been used in the treatment of abdominal
angina.
Prinzemtal’s angina( variant angina or angina
inversa,) is a syndrome typically consisting of angina
(cardiac chest pain) at rest that occurs in cycles.
Cause by vasospasm, a narrowing of the coronary
arteries caused by contraction of the smooth muscle
tissue in the vessel walls rather than directly by
atherosclerosis
Features
Symptoms typically occur at rest, rather than on
exertion (attacks usually occur at night).
Diagnosis
Patients who develop cardiac chest pain are generally
treated empirically as an “acute coronary syndrome”,
and are generally tested for cardiac enzymes such as
creatine kinase isoenzymes or troponin l or T. These
may show a degree of positivity, as coronary spasm
too can cause myocardial damage. Echocardiography
or thallium scintigraphy is often performed.
The gold standard is coronary angiography.
ECG finding will more often show ST segment
elevation than ST depression.
Treatment
Prinzmetal angina typically responds to
nitrates and dihydrophyridine calcium channel
blockers.
Acute necrotizing ulcerative gingivitis
Polymicrobial infection of the gums leading to inflammation,
bleeding, deep ulceration and necrotic gum tissue.
Symptoms –
fever and halitosis.
Causes
Anaerobes such as Bacteroides and Fusobacterium a
Treatment
Oral cleaning and salt water or hydrogen peroxide-based
rinses.
Chlorhexidine or metronidazole
Penicillin is also indicated at 250 mg. every 6 to 8 hours.
Dental care.
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