‘Taxi Driver in Pain’

Tiara Gill

Carrie Ross

Mark Hambly

Patient Presentation 1

Mr O, 45 year old Nigerian taxi driver

P/CSevere central chest pain

HPCArrived by ambulance to A&E at 0310On high flow O2, GTN and aspirin in ambulance

Differential Diagnoses 1

Immediately life threatening causes of acute chest pain:

• Acute Coronary Syndrome (ACS)

• Tension pneumothorax

• Pulmonary embolism

• Aortic dissection

• Oesophageal rupture

Patient Presentation 2

• S - Central chest• O - Sudden, one hour ago [at rest]• C - Stabbing• R - None• A - Sweating• T - Constant• E - Eased by GTN• S - 10/10 eased to 6/10

Chest pain characteristics

Patient Presentation 3

Cardiac risk factorsSmoker with 25 pack year historyHypertension since 2001 - untreatedNo previous MI or AnginaNo relevant family historyNo diabetes or hyperlipidaemiaBMI < 25No alcohol or recreational drugs

Past Medical History

None. No medications

Patient Presentation 4

Observations

• HR 72 bpm - BP 134/73 mmHg

• RR 12 min-1 - Sats 96% on air

• GCS 15/15

Examination

• Physical examination in all systems was normal.

Differential Diagnoses 2History and examination highly suggestive ACS

Unstable angina

Myocardial infarction

12 Lead ECG - Inferior Leads

Inferior leads II, III, AVF- area supplied by right coronary artery- 1mm ST elevation in adjacent limb leads- can affect SA and AV nodes

12 Lead ECG - Lateral Leads

Lateral leads - I, aVL, 5, 6- Area supplied by Circumflex Artery1mm ST- ST depression in aVL - reciprocal changes

12 Lead ECG - Anterior Leads

Anterior leads - 2, 3, 4- Area supplied by anterior descending artery- No abnormalities

Diagnosis

• Inferior ST elevation myocardial infarction

Why?

• Appropriate chest pain history

• Diagnostic ECG changes

• Trop T negative on admission

Immediate Investigations

• Haematology - FBC, Clotting

• Biochemistry - U&E, Trop T, - glucose, lipid profile

• CXR

• In this case, all these investigations were normal.

Acute Management

• Thrombolysis - Tenecteplase iv

• Anticoagulate - Heparin iv

• Analgesia - Diamorphine iv

• Anti-emetic - Metaclopramide iv

• ß blockade - Atenolol

• ECG - CONTINUE MONITORING

Treatment Complications

• BP: 65/30

• HR: 30

• ß blocker effect - referred to Cardiology

• Fluid replacement (gelofusin)

• Atropine

• Transfer to CCU

• BP: 120/66

Right Coronary Angiogram

• Note - there was also 40% occlusion of the circumflex artery (off left main stem)

RCA Post Angioplasty and Stent

Case summary

• 45 year old Nigerian man presented with chest pain and ECG changes consistent with acute inferior ST elevation MI

• He was thrombolysed

• Troponin T was positive at 12 hours

• Angiography revealed a 90% stenosis in the RCA which has been stented

Rationale for Treatment of MI and Secondary Prevention of

Ischaemic Cardiac Events

ThrombolysisPrimary aims - Save life, save myocardium• Only shown to have prognostic benefit in

ST elevation MI and acute LBBB• Traditionally streptokinase, but recently

TPA - no difference in therapeutic benefit• Risk of bleeding - screening questions

FTT Collaboration, Lancet 1994;343:311-322 ISIS-3 Lancet 1992;339:753-770

Effects of Thrombolysis on Mortality

Source: FTT Collaboration, Lancet 1994;343:311-322

7,000

9,000

14,000

3,000

12,000

0

10

20

30

40

50

0 6 12 18 24

Hours from onset of symptoms to randomisation

Liv

es s

aved

/1,0

00 p

eop

le

Loss of benefit per hour of delay:1.6 ± 0.6 lives per 1,000 people

Secondary Prevention• Reduce risk factors• Medical treatment - Treats symptoms not stenosis

- 4As and nitrates• Surgical - Treats stenosis

- CABG

- Angioplasty with stent

ATC BMJ 1994;308:81-106 HOPE NEJM 2000;342:145-53WOSCOPS NEJM 1995;333:1301-7 4S, Lancet 1994;334:1383-9Teo K JAMA 1993;270:1589-94

Surgical - CABG• CABG gives prognostic benefit and

symptomatic relief over stenting in those with:

- Left mainstem disease, and

- Severe three vessel disease.

• In less severe disease, the risks of CABG outweigh the benefits it has over stenting.

• Associated with personality changes.

Poyen JCS 2003; 44(3):307-12 EAST JACC 2000; 35:1116-21

Surgical - Stenting• Stenting gives symptomatic relief and

similar prognostic benefit to patients with milder disease.

Benefits RisksLocal anaesthetic Restenosis (12%)More minor surgery Acute ischaemicShorter hospital stay event (5.5%)

NICE 1999 report

New developments

• Drug eluting stents

Questions and Comments