An introduction to Chest pain ‘how to mend a broken heart’
An introduction to Chest pain
‘how to mend a broken heart’
Case 1
• 55 year old accountant
• Stressed in a meeting at work
• Sudden onset chest pain
Crushing chest pain…
ECG
Coronary artery thrombus
Immediate treatment
• Oxygen
• Analgesia
• Aspirin
• Thrombolysis ‘clot busting drugs’
• Primary angioplasty ‘hot wiring’
Another Case
• Reg G 61 year old retired suffolk farmer
• Osteoarthritis hip• Undergoes total hip
replace (THR)
4 days post-op
• Initially making good recovery
• Sudden onset SOB and sharp ‘stabbing’ chest pain on commode in the evening
• O2 sats 89% on air
• Pulse 130 bpm irregularly irregular
What may have happened?
Immediate investigations
ECG
Immediate management
D-Dimer
• Specific degradation product released into circulation when cross-linked fibrin undergoes endogenous fibrinolysis
• Low D-dimer has high negative predictive value
• Non-specific elevation in sepsis, pregnancy, MI and post surgery
CXR
Imaging
• CXR – to exclude other causes• CTPA
– CT chest– Give iv iodine and time to fill pulmonary
arteries– Arm vein -> RA -> RV -> PA
• Contrast can– Cause allergic reaction– Damage kidneys
What are we looking for?
Ab
Ab
Imaging – Pulmonary angiogram
Treatment
Treatment
• Oxygen to correct hypoxia
• LMWH – dose according to weight
• Commence warfarin loading
• 6 months treatment with warfarin
What would you warn Reg about the risks of treatment?
Case 3 – Mr AL
• 21 year old man
• Known Marfan’s disease
• Previous aortic valve replacement
• Acutely SOB
• R-sided chest pain
Examination findings
• In pain and distressed
• RR 30 / min
• Oxygen saturation 85% on air
• Hyper-resonant over R lung field
• Increased SOB
Radiology
Right lung:– Black– No
markings– No
mediastinal shift
Sternal wires
Heart valve
Pleura
Treatment
Further radiology – post chest drain
Pleura
What does the future hold
• Must not scuba dive
• High chance of recurrence if at increased altitude – no flying for at least 1/12
• Chance of recurrent pneumothorax high
Any questions?