1

APPROACH TO A PATIENTWITH

CHEST PAINMPPRC CONFERENCE

Group 3 MED 2C

2

GENERAL INFORMATION

Name: B.C.Age: 60 years oldGender: MaleCitizenship: Filipino Religion: Roman CatholicOccupation: FarmerAddress: BulacanSource: PatientCHIEF COMPLAINT: CHEST PAIN

3

2 years

1 month

Chest pain- grade 3/10- substernal- heaviness- effort related (3km walk)- relieved after 4 minutes of rest- recurs once a month

Chest pain- grade 6/10- 10- 20 meters walk- radiation to the left arm

Consult and admission

4

PAIN ASSESSMENT AND ALGORITHM

P - precipitating, aggravating, relief

Q - quality

R - radiation, location

S - severity (1-10)

T - timing

5

PAST MEDICAL HISTORY

• (+) Hypertension for 10 years– Highest BP 200/100 – Usual BP 140-150/90 – On irregular intake of metoprolol 50mg

• No previous surgical illness requiring hospitalization

6

FAMILY HISTORY

• Father: (+) HPN, (+) DM, sudden death at 55y/o

• Mother: (+) HPN, stroke at 60y/o

• Brother: (+) HPN, (+) DM

• Sister: (+) HPN, (+) DM

7

PERSONAL AND SOCIAL HISTORY

• Patient is a rice farmer in Bulacan• Fond of eating tuyo, bagoong, alamang• 50-pack year smoking history• Drinks 1-2 bottles of gin 3x a week• No illicit drug use

8

REVIEW OF SYSTEMS

• General Survey– No significant weight loss– No loss of consciousness and headache

• HEENT– No blurring of vision– No ear discharge or tinnitus

• Respiratory– No cough – No colds – No dyspnea

9

REVIEW OF SYSTEMS

• Gastro-intestinal– No epigastric pain – No diarrhea– No constipation – No melena– No hematochezia

• Genitourinary– No dysuria – No frequency – No urgency – No pollakiuria

10

REVIEW OF SYSTEMS

• Musculo-skeletal– No joint pains

• Endocrine/Metabolism– No polyuria – No polydypsia – No polyphagia– No heat or cold intolerance

11

PHYSICAL EXAMINATION

• General Survey– Conscious– Coherent – Normosthenic – Not in Cardiopulmonary distress

• Vital Signs– BP 160/90– PR 100/min regular– RR 19/min – T 37oc

12

PHYSICAL EXAMINATION

• Anthropometric Measurements– Height: 1.5 m– Weight: 52.6 kg– BMI: 23

• HEENT– Pink palpebral conjunctiva – Anicteric sclera – No nasal nor aural discharge – Moist buccal mucosa– No neck mass

13

PHYSICAL EXAMINATION• Respiratory

– Symmetrical chest expansion – No retraction – Resonant, unimpaired transmission of vocal and tactile fremiti– Clear breath sounds

• Gastrointestinal– Abdomen flabby – Normoactive bowel sounds – Tympanitic, nontender – Liver dullness 10cm – Traube’s space not obliterated

• Extremities– Pulses ++ on all extremities– No pedal edema

14MV

TV

PVAV

S1 S2 S1 S2

CAP

JVP 4.5cm at 45 deg

Adynamic precordium, apex beat 6th LICS AAL,

(-) heaves

15

CHIEF COMPLAINT:

Chest Pain“An unpleasant sensation in the anterior wall of the thorax associated with actual or potential tissue damage and mediated by specific nerve fiber to the brain where conscious appreciation may be modified by various factors. “

Stedmans Medical Dictionary, 27th edition

16

17

ORGAN SYSTEMS THAT COULD BE INVOLVED

Reference: Mosby’s Guide to Physical Examination, 6th edition

18

ORGAN SYSTEMS THAT COULD BE INVOLVED

Reference: Mosby’s Guide to Physical Examination, 6th edition

19

20

SALIENT FEATURES (SUBJECTIVE)Pertinent Positive (+)- 60 y/o male- Farmer- Chest pain- Hypertension- Preference for salty foods- 50 pack year smoking history- Alcohol drinkerFamily History- Hypertension- Diabetes mellitus- stroke

Pertinent Negative (-)- Fatigue- Dyspnea- Palpitations- Weight loss- Cough- Epigastric pain- Joint pain- Polyuria, polydypsia, polyphagia- Heat and cold intolerance

21

SALIENT FEATURES

Objective

- BP 160/90- Apex beat 6th LICS AAL

22

PATHOPHYSIOLOGY

23

24

MYOCARDIAL ISCHEMIA

• occurs when myocardial oxygen demand exceeds oxygen supply

25

PATHOGENESIS OF ATHEROSCLEROSIS

26

GeneticGeneticHyperlipidemiaHyperlipidemiaEndocrine (DM)Endocrine (DM)

Functional Impairment of EndotheliumFunctional Impairment of Endothelium

Increased LDL or other lipid influxIncreased LDL or other lipid influx

Initiation of InflammationInitiation of InflammationMonocyte InfluxMonocyte Influx

Initiation of InflammationInitiation of InflammationMonocyte InfluxMonocyte Influx

Inadequate Wound HealingSmooth muscle cell proliferation

Matrix DepositionAtheroma FormationThrombus Formation

Inadequate Wound HealingSmooth muscle cell proliferation

Matrix DepositionAtheroma FormationThrombus Formation

Occlusion of arteryOcclusion of artery

MECHANISM OF OCCLUSION

27

28Development of atherosclerotic plaque

29

MAJOR RISK FACTORS•Age: male > 45 y/o female > 55 y/o•Family history in a first degree relative of premature CAD (acute MI) male relative < 55 y/o female relative < 65 y/o•Diabetes mellitus•Chronic smoking•Hypertension•Obesity•Dyslipidemia

MINOR RISK FACTORS•Sedentary lifestyle•Chronic infection/ inflammation•hyperhomocysteinemia

Reference: ATP III

30

PATHOLOGY

31

Showing yellowish atherosclerotic plaques

GROSS SPECIMEN OF THE HEART

Image retrieved from: http://library.med.utah.edu/WebPath/CVHTML/CV005.html

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HYPERTROPHIED HEART

Image retrieved: http://www.studentconsult.com/common/cfm

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34

NORMAL CORONARY ARTERY

Image retrieved from: http://library.med.utah.edu/WebPath/CVHTML/CV005.html

35

Abn. >75% narrowing, assoc. w/ angina

Image retrieved from: http://library.med.utah.edu/WebPath/CVHTML/CV005.html

narrowing of the lumen due to build up of atherosclerotic plaque

CORONARY ARTERY WITH ATHEROSCLEROSIS

36

Normal myocardium Cardiac muscle w/ ischemia

Image retrieved: http://www.studentconsult.com/common/cfm and http://library.med.utah.edu/WebPath/TUTORIAL/MYOCARD/MI031.html

•central nuclei •syncytial arrangement of the fibers•pale pink intercalated disks

•myocytes hypertrophied•large, dark nuclei

37

PLAQUE STABILIZATIONUnstable plaque

Thinner vs thickerfibrous cap

Lipid core

•Greater lipid content and loose necrotic tissue create less echo on an ultrasound (hypoechogenicity), while dense fibrous tissue in more stable plaque creates more echo

(hyperechogenicity)

Stable plaque

More vs fewerinflammatory cells

Toschi V et al. Circulation. 1997;95:594-599; Libby P. Circulation. 1995;91:2844-2850; Schartl M et al. Circulation. 2001;104:387-392.

38

LV hypertrohy

Increase myocardial

oxygen demand

Necrosis

Hypoxia

Ischemia

CHEST PAINIncrease Lactic Acid

Increase anaerobic

respicration

39

REFERRED PAIN

40

41

• Stimulus PGE2, H+ ions, bradykinin, K+ ischemia• Primary viscerosensory fibers terminate in Lamina I

& V• Spinal segments also receive cutaneous

somatosensory input from dermatomes of the chest wall and arm

• Tract cells in the posterior horn that receive somatosensory input may also be activated

• Response Cerebral cortex interprets the pain as originating from the surface of the body

42

RADIOLOGIC AND ANCILLARY TESTS

43

DIAGNOSTIC TESTS

• Chest X ray• ECG• Ancillary test

- Lipid profile- fasting blood sugar

Reference: Harrison’s Principles of Internal Medicine 17 th Edition

44

X-RAYImportant in the diagnosis of the following:• cardiac enlargement• ventricular aneurysm• signs of heart failure

Important in assessing the degree of cardiac damage

Reference: Harrison’s Principles of Internal Medicine 17 th EditionReference: Harrison’s Principles of Internal Medicine 17 th Edition

45

X-RAY

46

NORMAL ECG ACTIVATIONNORMAL ECG ACTIVATION

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S-T SEGMENT ELEVATIONS-T SEGMENT ELEVATION

48

S-T SEGMENT DEPRESSIONS-T SEGMENT DEPRESSION

49

T-WAVE INVERSIONT-WAVE INVERSION

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ANCILLARY TESTS

• Lipid Profileo TC: < 200 mg/dLo LDL: < 130 mg/dLo HDL: > 60 mg/dL

• Fasting Blood Sugaro 70-99 mg/dL

Reference: Harrison’s Principles of Internal Medicine 17 th Edition

5151

PHARMACOLOGY

5252

TREATMENT GOALS

• Relieve symptoms of angina pectoris

– Correction of O2 delivery and demand imbalance for myocardial cells

– Increasing delivery– Decreasing O2 demand

• Treat any modifiable risk factors

5353

BASIC PHARMACOLOGY

• Four approved drug groups:

1. Organic Nitrates2. Ca2+ Channel Blockers3. ß-Blockers4. pFOX inhibitors

5454

NITROGLYCERINNO

cGMP

VASODILATION

GUANYLYL CYCLASE

NITRITES & NITRATES

• NITROGLYCERIN• MOA:

• Direct results:relaxation of veins preload, CO

• Indirect results: stimulation of guanylyl cyclase in platelets to platelet aggregation

• Increase myocardial O2 delivery

Reference: Bertram Katzung, MD. Basic and Clinical Pharmacology. 10th editionReference: Bertram Katzung, MD. Basic and Clinical Pharmacology. 10th edition

5555

Ca2+ CHANNEL BLOCKERS

• MOA:

– Inhibition of Ca2+ entry

– Ca2+ transmembrane current

– Vasodilation, vascular resistance

– myocardial contractile force

• Relieves and prevents focal coronary artery spasms

• LV wall stress declines

• cardiac contractility O2 requirement

Reference: Bertram Katzung, MD. Basic and Clinical Pharmacology. 10th editionReference: Bertram Katzung, MD. Basic and Clinical Pharmacology. 10th edition

5656

ß-BLOCKERS

• Management of angina with effort

• Not used for vasodilation

• O2 requirement

• MOA:

ß1 ANTAGONIST

HR, BPCONTRACTILITY

DIASTOLIC PERFUSION TIME

CORONARY PERFUSION

Reference: Bertram Katzung, MD. Basic and Clinical Pharmacology. 10th editionReference: Bertram Katzung, MD. Basic and Clinical Pharmacology. 10th edition

5757

OTHER ANTIANGINAL DRUGS

• pFOX inhibitors: partially inhibit FA oxidation pathway

• Shift myocardial metabolism toward use of glucose instead of FA

• O2 requirement

• RANOLAZINE

Reference: Bertram Katzung, MD. Basic and Clinical Pharmacology. 10th edition.Reference: Bertram Katzung, MD. Basic and Clinical Pharmacology. 10th edition.

58

CLINICAL PHARMACOLOGYDRUG INDICATION NORMAL DOSE CONTRAINDICATIONS

Nitrates

Sublingual NTG Angina 0.3-0.6 mgintolerance of side effects: flushing, headache, ishchemia on withdrawal

Oral NTG Angina 2.5-5 mg q4-6h as aboveCa2+ Channel Blockers

AmlodepineAngina, Hypertension

5-10 mg once daily

intolerance to side effects: edema, constipation, hypotension

Nifedipine Angina, Hypertension 30-90 mg daily hypotension, constipation

Beta-Blockers

PropranololAngina, Hypertension 20-80 mg qid

Asthma, AV conduction block, heart failure

Clopidogrel Anti-Platelet 75 mg daily GI bleeding

Statins Hyperlipidemia 10-80 mg Liver disease

Platelet Aggregation Inhibitors

Anti-Hyperlipidemic Drugs

Reference: Harrison’s Principles of Internal Medicine, 17th EditionReference: Harrison’s Principles of Internal Medicine, 17th Edition

5959

NON-PHARMACOLOGICAL APPROACH

• risk for myocardial ischemia associated with in age• Risk: Men > Women (pre-menopausal)

• Cease smoking• Maintenance of a proper diet• Exercise regularly• Decrease alcohol consumption

60

THANK YOUTHANK YOU

MACALMA, GLENNMACAPAGAL, JUSTIN ROMEOMADRID, BIANCAMALABANAN, MICHELLEMALACA, JOSEPH CHESTERMALLARI, ROMINA GRIZELDAMALVAR, ALFREDMAMAUAG, MARY JOYMANAHAN, JOYCEMANALO, VICTORIA CAMILLEMANANSALA, PRINCESSMANCOL, MATILDE CLAIREMANDAPAT, JANICEMARANAN, REAGAN

MACALMA, GLENNMACAPAGAL, JUSTIN ROMEOMADRID, BIANCAMALABANAN, MICHELLEMALACA, JOSEPH CHESTERMALLARI, ROMINA GRIZELDAMALVAR, ALFREDMAMAUAG, MARY JOYMANAHAN, JOYCEMANALO, VICTORIA CAMILLEMANANSALA, PRINCESSMANCOL, MATILDE CLAIREMANDAPAT, JANICEMARANAN, REAGAN