chest pain
TRANSCRIPT
Chest Pain and Shortness of Breath
Brett Sheridan, M.D., F.A.C.SAssistant Professor
Cardiothoracic SurgeryDepartment of Surgery
Causes of Chest Pain and SOB
• Myocardial Infarction• Pulmonary Embolism• Pneumothorax• Hemopneumothorax• Thoracic Aortic Dissection• Esophageal Rupture• Gastro-esophageal Reflux• Empyema
47 y/o man is jogging with his daughter when he suddenly collapses unconscious……
1) Heart Disease
2) Cancer
3) Stroke
Most common causes of death in the US…
How many people in the US died from cardiovascular disease in 2001?
Do more men or women die from cardiovascular disease?
Acute coronary syndrome (ACS) is defined by EITHER acute myocardial infarction OR unstable angina.
These patients are divided into 3 subsets:ST elevation myocardial infarction (STEMI)non-ST elevation MIUnstable angina
• ECG within 10 minutes• Supplemental O2• IV access continuous ECG monitoring• Sublingual NTG if SBP > 90 mmHG• Morphine• ASA (chewed)• Labs• If ST elevation > 1mV or LBBB then reperfusion
(fibrinolysis or PTCA)
Describe the initial stabilizing treatment for symptomatic ischemic heart disease presenting in the ER
What is AMI management in first 24 hours?
• Limited activity 12 hrs and monitor 24 hrs• No prophylactic antiarrythmics • IV heparin if:
– large anterior MI, – PTCA, LV thrombus or – thrombolytics administered
• SQ heparin for all others• ASA indefinitely• IV NTG x 24 hrs• IV beta-blocker if stable• ACE inhibitor if BP permits• Statin therapy
Why are patients referred for CABG instead of undergoing a PCI approach to coronary artery disease?
Acute coronary Syndrome:On-going myocardial ischemia despite initial Rx
Thrombolytics Revascularization
PCI CABG
Percutaneous coronary angioplasty (PTCA, PCI,…)
Percutaneous coronary angioplasty (PTCA, PCI,…)
Percutaneous coronary angioplasty (PTCA, PCI,…)
Natural history of percutaneous coronary angioplasty…..uh-oh!
Cite 2 prospective randomized trials comparing PCI vs CABG for the treatment of multivessel CAD
• Inclusion Criteria – Symptomatic– Multivessel CAD
– LVEF > 30% • Baseline Characteristics
– Class III/IV angina - 66%– Previous MI - 42%– 3 vessel CAD - 30% – mean LVEF = 60%
Comparison of Coronary-Artery Bypass Surgery and Stenting for the Treatment of Multivessel Disease
(Arterial Revascularization Therapies Study Group)
CABG PCI
Patients (n) 605 600
Late outcome ---------------------1 year-----------------Death 2.8% 2.5%MI 4.0% 5.3% CVA 2.0% 1.5%
Revascularization * 4 % 17%Event-free survival * 88% 74%Symptom-free * 90% 79%
Cost * $13,638 $10,665
14% benefit w/ CABG!
Event –free Survival: CABG vs PCIS
16 % benefit w/ CABG!
Risk of Repeat Revascularization
Risk of Death
3.7 % SURVIVAL benefit w/ CABG!
Conclusions-SoS Trial
• Again, repeat revascularization remains more common after PCI (with or without a stent) in multivessel CAD.
• In this study, higher rate of all cause mortality with PCI
Contrast the difference between “off-pump” CABG versus the typical
cardiopulmonary bypass supported CABG.
Traditional CABG
• General anesthetic• Median sternotomy• Conduit harvest (LITA,
radial, vein)• Institution of
cardiopulmonary bypass (CPB)
• Cardiac arrest• Placement of aorto-coronary
grafts• Seperation from CPB• Close
Advantages - Traditional CABG
• Still Heart
• Exposure and access
• Visualization
• The most intensely scrutinized procedure in US medicine
SAFETY
Disadvantages - Traditional CABG
• Proinflammatory response to CPB
• Suggestion of end-organ injury– CNS – Pulmonary – Renal
• Increased fluid shifts
Off-Pump Stabilizer
Off-Pump- Snare
Off-Pump Stabilizing Devices
Off-Pump Exposure of PDA
List 10 complications of CABG and there relative frequency
• Death 3%• Stroke 1-2%• Bleeding requiring re-op 3-5%• Wound Problems 0.5-5%• Myocardial infarction 2-30%• Arrhythmias 10-60%• Pneumonia 4%• Pneumothorax 1-2%• Cardiac Tamponade 3-6%• Pericardial Inflammation 18%• Renal Insufficiency 15-20%
What four medications prevent MI and death following a myocardial infarction.
“Class I” Indications
• ASA
• Beta-blockers
• ACE inhibitor
• Statins
Risk Of Pneumothorax
• Pain
• SOB ( dyspnea)
• Hypoxia
• Hypotension (embarrassed CO)
• Death
DDX of Underlying Pulmonary Pathology
Spontaneous• Primary
– Subpleural bleb
• Secondary– Chronic Obstructive lung disease– Bullous disease– Cystic fibrosis– Pneumocystis-related – Idiopathic pulmonary fibrosis– Pulmonary embolism– Catamenial– Esophageal perforation
• NeonatalAcquired• Trauma• Iatrogenic
Treatment options
• Observation
• Tube thoracostomy
• Surgery
• Other “dated” options– Needle aspiration– Chemical pleurodesis
Observation
• Asymptomatic
• Pneumothorax less than 20%
• ER for 4-6 hours w/ repeat CXR
• F/U within 48 hours and CXR
• Any doubts --admit
Tube Thoracostomy
• Primary Method of Management
• Prompt re-expansion of lung
• Prevents life-threatening sequelae
• Allows pleural-pleural apposition –sealing injured lung
• Tube removed once air leak resolves for 12 hours
Prognosis
• Usually resolves within 1-2 days
• 30% chance of recurrence
• Increases to 60-70% if second pneumothorax
Surgery- Indications
• Recurrent pneumothorax
• Persistent air leak or incomplete expansion
• Massive air leak with incomplete expansion
• History of bilateral pneumothoraces
• Occupational hazard or lack of access
• Hemopneumothorax
Surgery-Procedure
• Video-assisted thorascopic surgery (VATS)
• Resection of offending bleb
• Mechanical pleurodesis
• Tube thoracostomy
• Chemical pleurodesis– Tetracycline– Talc
Treatment of Secondary Pneumothoraces
• Usually associated with significant comorbid disease and debilitated patients
• Individualize treatment (less is more)
• AIDS and Pneumocystis carinii
• COPD
• Cystic fibrosis
Hemothorax - EtiologiesPulmonary
Bullous emphysemaNecrotizing Infections
• PE with lung infarction• Tuberculosis• AV malformation• Hereditary hemorrhagic telangiectasiaPleural• Neoplasm (mesothelioma)• EndometriosisPulmonary Neoplasm• Primary• Metastatic
– Melanoma– Trophoblastic tumors
Blood Dyscrasia• Thrombocytopenia• Hemophilia• Complication of systemic anticoagulation• Von Willebrand’s diseaseAbdominal Pathology• Pacreatic pseudocyst• Splenic artery aneurysm• HemoperitoneumThoracic Pathology• Ruptured thoracic aortic aneurysm
Top Causes
Trauma...
CancerPulmonary embolism
Hemothorax- What to do?
• Traumatic– Tube thoracostomy- large bore– IF more than 1500 mL or more than 200 mL/hour
x 3 hours THEN surgical exploration
• Non-Traumatic– Needle aspiration– Cytology– Tube thoracostomy if HCT > 50%
Aortic Dissection…What is it?
• A bad problem to have
• A sudden (usually) intimal tear of the aorta creating a true lumen and a false lumen
• Consequences of this tear are variable depending on location and progression of the dissection
Classification-DeBakey
Histology and Structure
• Normal aorta- 3 layers – intima – tunic media – adventitia
Histology and Structure
• Media- strongest – usually 1.2 mm – most affected by dissection – elastic collagen fibers 20-30 % of aortic wall – smooth muscle cells 5 %– Microfibrils contain the glycoprotein “fibrillin.”
These act as scaffolding for deposition of elastin to produce concentric rings of tunica media.
more….Histology and Structure
• Aortic dissection denotes one or more tears b/w the the aortic lumen and a medial cleavage plane
• May be localized to the point of “primary tear” but often extends.
• Rarely circumferential
• Re-entry tears occur often… providing communication b/w true and false channels.
even more….Histology and Structure
• The dissection usually splits the outer layers of the media and weakens the external coat. The false channel may dilate or rupture.
• The false channel eventually develops an endothelial lining but may contain extensive thrombus.
• Acute stage –14 days• Subacute - 2 months• Chronic - after 2 months
Incidence• Annual estimated @ 2-5 cases per million
• Pathology series the prevalence ranged from 0.2 to 0.8% in Chicago and Boston
• Males > Females 2:1
• Type A - 50-55 years
• Type B - 65 years
Risk Factorspregnancy
Marfan’s
hypertension
aortic coarctation
congenital aortic valve anomalies
Presentation- acute dissection
• Sudden severe chest pain (90%) worst at onset not previously experienced …adjectives such as “ripping” and “tearing”
Presentation- acute dissection
• Sudden severe chest pain (90%) worst at onset not previously experienced …adjectives such as “ripping” and “tearing”
• History of hypertension
• Type A- pain mid-sternal
• Type B-pain inter-scapular
• If extension… neurologic deficit, abdominal pain, or peripheral extremity ischemia
Differential Dx- acute dissection
• Coronary ischemia/ myocardial infarction
• Aortic aneurysm w/o dissection
• Musculoskeletal
• Pericarditis
• Biliary colic
• Pulmonary embolism
Physical exam- acute dissection
• Blood pressure usually elevated• Hypotension associated w/ pericardial tamponade,
rupture, aortic insufficiency, or massive MI• New pulse deficit- 60%• Diastolic decrescendo murmur @ LSB- aortic
regurgitation• Diminished left-sided breath sounds- hemothorax• Neurologic exam
– mental status, – focality --peripheral vs central
Diagnostic studies- acute dissection
• CXR
– deformity of Aortic knob,
– widened mediastinum,
– left pleural effusion, etc.
• EKG- chest pain w/ normal EKG sine qua non
Diagnostic studies- acute dissection
Echocardiography currently thought to be the preferred diagnostic test –rapid and accurate. Evaluates aortic valve, segmental wall function, pericardial effusion. Unfortunately operator dependent.
Diagnostic studies- acute dissection
CT- expeditious w/ reasonable sensitivity and specificity
Diagnostic studies- acute dissection
MRA-excellent sensitivity and specificity but slow
Diagnostic studies- acute dissection
Aortography - lacks sensitivity as imaging requires blood flow which may not occur in false lumen. Indication for coronary angiogram remains controversial.
DeBakey, Surgery, 1982
Medical Treatment
Type A• 24 hrs72%• 2 wks 43%• 5 yrs 34%• 10 yrs28%
Type B
100%
92%
76%
56%
Masuda, Circulation, 1991
Medical Treatment- Aortic Dissection
Masuda, Circulation, 1991
Medical vs Surgical - Type B Ao Dissection
Glower, Ann Surg, 1991
Conclusion
• Aortic dissection is a bad problem to have
• High index of suspicion
• Control heart rate and blood pressure URGENTLY
• Type A requires immediate surgery
• Type B - best served w/ medical treatment
• If ischemic complications, the patient faces a grim prognosis with (or without) surgery therefore a surgical approach may be advocated.
Esophageal Rupture- Causes
• Iatrogenic– Esophageal endoscopy /dilation– Paraesophageal surgery
• Boerhaave syndrome
• Trauma
• Foreign Body
• Caustic
• Proximal to the upper esophageal sphincter
• Gastric cardia
• Esophageal stricture
Esophageal Rupture- Most common sites of iatrogenic perforation
Untreated perforation
• Medianstinitis
• Death
Nonoperative Management of Esophageal perforation
Criteria– Disruption contained within the mediastinum– Free drainage back into the esophagus– Minimal symptoms– Minimal signs of sepsis
• Nasogastric decompression• Percutaneous drainage• IV antibiotics (oral flora)• Parenteral nutrition
Esophageal Rupture-Principles of surgical treatment
• Debridement
• Treat the underlying problem– Cancer– Stenosis– Reflux
• Repair of perforation
• Drainage
Gastroesophageal Reflux Disease
• 50% of asthma patients have objective evidence of esophageal reflux
• Pathophysiology: Reflux vs Reflex
• Anti-reflux surgery improves asthma symptoms– 90% of children
– 70% of adults
GERD – Diagnostic evaluation
• History and Physical Exam• Tests
– 24 hour ambulatory pH Monitoring
– Manometry
– Barium swallow
– Upper endoscopy
GERD- Complications
• Stricture 4-20%
• Barrett’s esophagus 10-15%
• Esophageal ulcer 2-7%
• Hemorrhage 2%
GERD- Pathophysiology
• More frequent and prolonged relaxations of the lower esophageal sphincter
• Increased exposure of esophageal mucosa to acid, pepsin and bile salts
• Hiatal hernia ???
GERD- Goals of treatment
• Heal the injured mucosa
• Eliminate symptoms
• Prevent or treat complications of GERD
GERD – Treatment Options
• Lifestyle modifications
• H2 Blockers
• Proton Pump Inhibitors
• Surveillance for persistent symptoms
• Endoscopy
• Anti-reflux surgery
Empyema
• Infection of the pleural space
• Usually a complication of a bacterial pneumonia or lung abscess
Empyema- Common organisms
• Staphylococcus aureus (most common)
• Streptococcus
• Pseudomonas
• Klebsiella pneumoniae
• E. Coli
• Proteus
• Bacteroides
Empyema - Diagnosis
• History and Physical Exam
• Chest radiograph
• Chest CT scan
• Needle aspiration
Empyema- Treatment Goals
• Resolve sepsis• Complete expansion of lung
• Antibiotics• Drain the space (abscess) – Chest tube
– Child vs Adult
• Decortication– VATS– Thoracotomy