Acute Block Tutorial

Chest Pain
A 63 year old woman presents to the ED at 6pm after developing generalised chest tightness that radiated
into her right arm. She has been working hard in the garden this afternoon and thinks she might have
overdone it. She is concerned because the pain has been getting progressively worse over the last hour and
she has now started to vomit. She has never had this pain before.

She has a 10 year history of diabetes, which is treated with metformin. She has hypertension and elevated
cholesterol. She stopped smoking 5 years ago and drinks alcohol occasionally.

Her medications include metformin, lisinopril and simvastatin. She has no allergies. She lives with her
husband and is a retired school teacher.

On examination

 A – She is able to talk to you.

 B – RR 24, Sats 98% in air. Lungs are clear on auscultation.
 C – Pulse 85, BP 132/71. She has a regular rhythm and her JVP is not elevated. She is peripherally
cool with no pedal oedema.
 D – She is alert, Capillary glucose 9.5, pupils equal and reactive to light
 E – Temp 36.2. She is pale and sweaty.

You are the F1 for admissions seeing the patient in an ED cubicle. The Medical Registrar and SHO have been
called off to an emergency.

What are your top differential diagnoses for this patient’s presentation and why?
Important to ask about family history of heart disease/MI
Ask to point with finger where the pain is – to determine what they mean by chest!!

Differential Reasons for Reasons against

MI MI MI

Unstable angina MI
MI

NSTEMI MI MI
 Acute Block Tutorial

What investigations would you carry out on this patient and why?

 Bedside: ECG (Left circumflex artery)

 Baseline bloods, including FBC, U&E, LFT, lipids and glucose, troponin
 Chest x-ray to investigate for pulmonary oedema and other causes of chest pain
 Echocardiogram once stable to assess the functional damage to the heart, specifically the left ventricular
function

How would you like to manage this patient acutely?

A – Aspirin 300mg

I – Intravenous morphine for pain if required (with an antiemetic, e.g., metoclopramide) MOANAC (morphine, oxygen, aspirin, GTN,
antiemetic, clopidegrol)
N – Nitrate (GTN)
Morphine / Oxygen /
Management of STEMI
Patients with STEMI presenting within 12 hours of onset should be discussed urgently with the local cardiac centre for either:
Percutaneous coronary intervention (PCI) (if available within 2 hours of presenting)
Thrombolysis (if PCI is not available within 2 hours)
Management of NSTEMI
The medical management of an NSTEMI can be remembered with the “BATMAN” mnemonic:
B – Base the decision about angiography and PCI on the GRACE score
A – Aspirin 300mg stat dose
T – Ticagrelor 180mg stat dose (clopidogrel if high bleeding risk, or prasugrel if having angiography)
M – Morphine titrated to control pain
A – Antithrombin therapy with fondaparinux (unless high bleeding risk or immediate angiography)
N – Nitrate (GTN)
What complications is the patient at risk of?

 D – Death
 R – Rupture of the heart septum or papillary muscles
 E – “oEdema” (heart failure)
 A – Arrhythmia and Aneurysm
 D – Dressler’s Syndrome - a localised immune response that results in inflammation of the pericardium,
the membrane that surrounds the heart (pericarditis)

Once fit for discharge what further management does this patient need?
Aspirin 75mg once daily indefinitely
Another Antiplatelet (e.g., ticagrelor or clopidogrel) for 12 months
Atorvastatin 80mg once daily
ACE inhibitors (e.g. ramipril) titrated as high as tolerated
Atenolol (or another beta blocker – usually bisoprolol) titrated as high as tolerated
Aldosterone antagonist for those with clinical heart failure (i.e. eplerenone titrated to 50mg once daily)