May 31, 2014 6:18 pm
Today’s topic for discussion is Chest Pain.
I will be discussing here.
Well. Pain is probably the second most important symptom with which patient visit the GP. And chest pain draws the attention of the attending physician.
To be speaking frankly, we the physician first of all categorize the chest pain as: ( For our convenience)
2. Non cardiac
Though, patient always want it to be of cardiac origin !
Certainly, all chest pain of any patient should be assumed to be of cardiac origin until proved otherwise. Because its mortality rate and Socio – economic impact is unquestionable.
When a patient complaints of chest pain, the astute physician don’t jump on him! Rather, he watch him from head to toe. (Because, clues are there whether it is functional or organic).
There should be two groups who we should approach:
1. Male vs Female
2. If male, Old vs Young
If the patient is female, the physician feels a bit comfortable. And later, by asking few questions (will be discussed later) , the physician can reach the provisional diagnosis.
Now, come to those typical questions to be asked to the patient:
2. Type ( chest tightening, compressive, heaviness on chest etc)
3. Radiation (virtually towards any site, jaw, neck, axilla, back, arm etc
4. Associated symptoms (nausea, vomiting, sweating, feeling of impending death, palpitations, presyncope like attack etc.
5. Life style
6. Dietary habit
7. Personal history of alcohol, smoking etc
8. Family history of cardiac disease
9. Recurrence of attack
10. Fate of previous attack (how it was cured)
11. What the patient himself thinks of the cause to be ? etc.
Among these questions, few answers will be in favour of IHD (Ischaemic Heart Disease) and few will be against!
So, physical examination is mandatory.
We frequently ask the patient to locate the area of chest pain. Very often, some of them can locate it with his finger tip. Such pain almost exclude IHD. Later, during palpation, we confirm it by further test (like pressing over the area and looking to his face simultaneously. )
Any kind of re-production of pain or tenderness exclude cardiac origin.
Later, methodical clinical examination of CVS is performed to assure him.
3. Examination of precordium
(Percussion is not usually performed)
Few things to be noted:
1. A physician must try to establish the cardiac cause until proved otherwise
2. A proper counselling to be done (Discuss later)
3. An ECG is mandatory in every patient (not because to diagnose but also patient’s satisfaction)
Other tests will be followed according to the DDs
Possible DD: (according to number of patients attending a GP)
1. Any MSK pain
2. Pleuritc chest pain
3. GERD (Gastro esophageal reflux disease)
4. Non ulcer dyspepsia
5. Functional or atypical chest pain
Other causes are as written in any text according to systems involved, like:
1. Respiratory cause
2. GI cause
3. MSK cause
4. Neurological cause etc.
First I will discuss the non cardiac one:
2. Non pharmacological (counselling)
1. According to cause
* Muscle relaxant+ NSAID for MSK
* PPI (Esomoprazole is preferred)+Domperidone +/- Anti flatulence for GI cause
* NSAID for Pleuritc cause
* Pregabalin, Gabapentin, Amitriptyline for neuropathic cause
* Anti depressants (list is big) for anxiety disorder
Candidates for non cardiac chest pain:
1. Female patients
2. Young male patients
3. Elder patients with definite history and examination findings of such pain (previously Dx as GERD and was getting cured eith Rx)
4. Previously diagnosed as psychiatric illness
(But, there is exception to every rules. Surrounding conditions and other factors will help us decide what to do).
Counselling may be done in the following ways:
(Its the very important part of Mx of chest pain both Cardiac and Non cardiac origin)
1. I have noticed your concern about the chest pain.
2. From ur history (elaboration of complaints) and physical examination (I have done so far), it is very unlikely to be of cardiac origin
3. Now, Im explaining the mechanism (palatable and non scientific way with local language) of ur chest pain
4. Though, it will or may take some time to get relief, you should take this medication and follow my advice
5. Please contact with me if any discomfort you feel or further deterioration u notice
6. Please visit me after few days (7, 5, 10, 30) days
(for those who are over conscious of their symptoms).
To be speaking frankly, Ix should be given:
1. To diagnose the disease
2. To exclude other DD
3. To see the prognosis and monitor the course of illness
4. To see the complications (due to disease itself and due to medication)
But, any doctors must be confident enough to interpret the result of the Ix he will advice! Otherwise, it is the total wastage of money. For example, GP who doesn’t even know how to interpret an ECG, at least IHD, Major arrhythmias etc) should not go for that. And , in such patient (with typical features of IHD) should be referred (to consultant, Seniors, hospitals etc)
Initial Ix for IHD:
2. Troponin I
3. CK MB
4. Serum fasting lipid profile
5. Bloof urea, serum creatinine
6. S. TSH
Later more sophisticated and costly one
Like ETT, Echo, CT CAG, (CT coronary angiogram), Conventioal CAG
(others may be given):
1. CBC with ESR
2. Urine RME etc.
Referral criteria for chest pain:
1. Typical features of IHD
2. Any co morbid patients with Severe HTN, Shock, Uncontrolled DM,
3. Where local facilities of ECG is not available
4. Over conscious (worried ) patients who actually like to have cardiac disease inspite of proper counselling and advice
5. Non cardiac emergency like Pneumothorax, pleural effusion (though pain is less likely), Severe neuropathic pain assumed to be due to Myelitis etc.
Now, come to Mx of typical chest pain of Cardiac origin.
Any patient with ischaemic chest pain should be referred to CCU (Private or public). Sometimes only referral is not enough. Suppose, a patient came to a physician with the features of typical IHD. and the physician referred h8m to his nearby pvt hospital where a duty doctor (junior one) is there and almost no facilities of resuscitation is there.
It will be a total wastage of time and money!!
Priorities in referred hospitals:
1. Having CCU
2. Having defibrillators
3. Having facilities for PCI (percutaneous Coronary Intervention)
4. Having cardiac monitor
5. Having in house consultants
6. Having ICU etc.
If such facilities are not available at a time, the alternatives are:
1. Tertiary hospitals
2. Having ECG
3. Having facilities for antithrombolytics
4. Having adequate stuffs and experienced physician
Core Mx: (Diagnosed case of IHD)
1. First established whether the patient in emergency or not
2. If not, establish whether he has got ACS (Acute Coronary Syndrome) or not
3. If ACS, establish whether it MI or Unstable Angina
4. If MI, establish whether it is STEMI or NSTEMI
Now come to one by one.
A) If emergency:
1. Resuscitation of the patient by establishing A B C D
2. CPR (CAB = Circulation, Airway, Breathing)
3. DC shock
4. Cardiac thump
5. Ready for shifting to ICU after intubation etc.
B) if MI (STEMI):
1. Ready for primary PCI (Rarely done except few centres) if come within few hous
2. IV thrombolytics (only if patient come within 12 hours) and PCI can’t be done
3. Oral medication
* Anti thrombotics (Aspirin , Clopidogrel etc)
* Cardiac vasodilator (Nitrates, oral or S/L Tab or spray)
* Beta blocker (if not in failure)
* Lipid lowering drugs
* ACEi, Angi II receptor blocker etc.
Tab. Aspirin 300 stat (4 tab of Aspirin 75 mg)
Tab. Clopidogrel 4tab stat
Tab. Metoprolol 50 mg divided dose ( half tab b.d)
Tab. Ramipril or Losartan at low dose in normotensives. If HTN is present (previously), then at antihypertensive dose
Tab. Atorvastatin (usually more than 40 mg is needed), but traditionally we give 10-20 mg preparation
Tab. Isodorbid mononitrate/dinitrate or SR (Sustained Release)
Sublingual GTN spray
2 puffs S.O.S
(These are the starting drugs).
But. If you (attending doctor) are unfortunate, the patient may die immediately after having those tablets (just due to cardiac complication of MI, like VT, VF etc.)!! The attending people and relatives may create havoc! !
So, proper counselling is mandatory. Otherwise, just give those medication not in front of the attendants. And never forget to mention the name of drugs in referral shit!
Dose and duration will depend upon the conditions.
But, few drugs are for life long!
Scope of Malpractice (or errors):
1. Ischaemic chest pain confidently diagnosed as non Cardiac pain
2. All female patients are treated as Functional / conversion disorders
3. Minimum investigation (like ECG) is not given
4. Angina equivalent* are treated with Nebulizer and steroids thinking as Br asthma
5. Taking ECG (when normal) as only parametre to declare pain due to non Cardiac origin
6. Don’t attempt serial ECG
7. Requesting for Serum Troponin within few hours (few minutes to 6 hrs) of onset of chest pain. Because, the result may be found negative!
8. Delay in Referral
9. Treating non Cardiac pain as ACS
10. Lack of proper counselling to the attendant
* Angina equivalent = When patient of IHD present with breathlessness in stead of Angina (pain)
(To be continued)……..