Upload
melinda-griffith
View
221
Download
4
Tags:
Embed Size (px)
Citation preview
‘Taxi Driver in Pain’
Tiara Gill
Carrie Ross
Mark Hambly
Patient Presentation 1
Mr O, 45 year old Nigerian taxi driver
P/CSevere central chest pain
HPCArrived by ambulance to A&E at 0310On high flow O2, GTN and aspirin in ambulance
Differential Diagnoses 1
Immediately life threatening causes of acute chest pain:
• Acute Coronary Syndrome (ACS)
• Tension pneumothorax
• Pulmonary embolism
• Aortic dissection
• Oesophageal rupture
Patient Presentation 2
• S - Central chest• O - Sudden, one hour ago [at rest]• C - Stabbing• R - None• A - Sweating• T - Constant• E - Eased by GTN• S - 10/10 eased to 6/10
Chest pain characteristics
Patient Presentation 3
Cardiac risk factorsSmoker with 25 pack year historyHypertension since 2001 - untreatedNo previous MI or AnginaNo relevant family historyNo diabetes or hyperlipidaemiaBMI < 25No alcohol or recreational drugs
Past Medical History
None. No medications
Patient Presentation 4
Observations
• HR 72 bpm - BP 134/73 mmHg
• RR 12 min-1 - Sats 96% on air
• GCS 15/15
Examination
• Physical examination in all systems was normal.
Differential Diagnoses 2History and examination highly suggestive ACS
Unstable angina
Myocardial infarction
12 Lead ECG - Inferior Leads
Inferior leads II, III, AVF- area supplied by right coronary artery- 1mm ST elevation in adjacent limb leads- can affect SA and AV nodes
12 Lead ECG - Lateral Leads
Lateral leads - I, aVL, 5, 6- Area supplied by Circumflex Artery1mm ST- ST depression in aVL - reciprocal changes
12 Lead ECG - Anterior Leads
Anterior leads - 2, 3, 4- Area supplied by anterior descending artery- No abnormalities
Diagnosis
• Inferior ST elevation myocardial infarction
Why?
• Appropriate chest pain history
• Diagnostic ECG changes
• Trop T negative on admission
Immediate Investigations
• Haematology - FBC, Clotting
• Biochemistry - U&E, Trop T, - glucose, lipid profile
• CXR
• In this case, all these investigations were normal.
Acute Management
• Thrombolysis - Tenecteplase iv
• Anticoagulate - Heparin iv
• Analgesia - Diamorphine iv
• Anti-emetic - Metaclopramide iv
• ß blockade - Atenolol
• ECG - CONTINUE MONITORING
Treatment Complications
• BP: 65/30
• HR: 30
• ß blocker effect - referred to Cardiology
• Fluid replacement (gelofusin)
• Atropine
• Transfer to CCU
• BP: 120/66
Right Coronary Angiogram
• Note - there was also 40% occlusion of the circumflex artery (off left main stem)
RCA Post Angioplasty and Stent
Case summary
• 45 year old Nigerian man presented with chest pain and ECG changes consistent with acute inferior ST elevation MI
• He was thrombolysed
• Troponin T was positive at 12 hours
• Angiography revealed a 90% stenosis in the RCA which has been stented
Rationale for Treatment of MI and Secondary Prevention of
Ischaemic Cardiac Events
ThrombolysisPrimary aims - Save life, save myocardium• Only shown to have prognostic benefit in
ST elevation MI and acute LBBB• Traditionally streptokinase, but recently
TPA - no difference in therapeutic benefit• Risk of bleeding - screening questions
FTT Collaboration, Lancet 1994;343:311-322 ISIS-3 Lancet 1992;339:753-770
Effects of Thrombolysis on Mortality
Source: FTT Collaboration, Lancet 1994;343:311-322
7,000
9,000
14,000
3,000
12,000
0
10
20
30
40
50
0 6 12 18 24
Hours from onset of symptoms to randomisation
Liv
es s
aved
/1,0
00 p
eop
le
Loss of benefit per hour of delay:1.6 ± 0.6 lives per 1,000 people
Secondary Prevention• Reduce risk factors• Medical treatment - Treats symptoms not stenosis
- 4As and nitrates• Surgical - Treats stenosis
- CABG
- Angioplasty with stent
ATC BMJ 1994;308:81-106 HOPE NEJM 2000;342:145-53WOSCOPS NEJM 1995;333:1301-7 4S, Lancet 1994;334:1383-9Teo K JAMA 1993;270:1589-94
Surgical - CABG• CABG gives prognostic benefit and
symptomatic relief over stenting in those with:
- Left mainstem disease, and
- Severe three vessel disease.
• In less severe disease, the risks of CABG outweigh the benefits it has over stenting.
• Associated with personality changes.
Poyen JCS 2003; 44(3):307-12 EAST JACC 2000; 35:1116-21
Surgical - Stenting• Stenting gives symptomatic relief and
similar prognostic benefit to patients with milder disease.
Benefits RisksLocal anaesthetic Restenosis (12%)More minor surgery Acute ischaemicShorter hospital stay event (5.5%)
NICE 1999 report
New developments
• Drug eluting stents
Questions and Comments