Tuesday, 11 September 2007

Never Ignore Chest Pain

I would like to start todays discussion with a case vignette. The case is from a colleague in another hospital and all details have been anonymised.

The patient was a 75 year old male who presented with dypsnoea and wheeze.

The patient was normally only able to walk 10 metres before becoming short of breath and needing to rest. On the day of admission, the breathlessness had got worse and wheezing had also commenced.
He had not offered up any other history and only when the doctor directly asked the patient if he had chest pain did he actually say YES!

In fact, the patient had chest pain when he was being seen by the doctor! It was described as 'heavy' and in the centre of his chest and with no radiation to jaw /neck /arms. However, the patient was breathless at rest and he had a 'cold' sweat and he was wiping his forehead with a towel. The pain was described as being similar to that as when he had a myocardial infarction several years before, although it was less painful.

He had also been apparently suffering with asthma for the last 50 years although he had never been hospitalised. Despite this, he was apparently able to lie flat in bed at night.

Previous medical history included: Old MI, Congestive Heart Failure, 'Asthma', Atrial Fibrillation (AF) and Gout.

Medications: Spironolactone, verapamil, anti-histamine, low dose steroid

On examination

The patient looked unwell. Pulse 120/min, RR= 30/min, sats 94% on room air, BP 130/82.

Skin looked atrophic due to long term steroid use. Patient used accessory respiratory muscles. Chest was hyperinflated and bilateral gynaecomastia was evident. JVP was not seen as patient was sitting at 90 degrees. Heart sounds were normal.
Chest percussion revealed a large area of dullness, reduced air entry and reduced vocal resonance consistent with an effusion.
Legs revealed bilateral pitting oedema 1/3 up the lower limbs.

Abdominal examination: Distended, no tender. No organomegally. Bowel sounds present.

An emergency ECG was performed that revealed Right Bundle Branch Block, ST depression in the septal leads and AF.

CXR revealed a large pleural effusion on the right, a large heart, upper lobe diversion and fluid in the horizontal fissure consistent with heart failure. Comparing the CXRs to a previous one taken 1 month earlier, there was evidence of worsening CHF with an enlarging right pleural effusion.

ABG revealed a Compensated Respiratory Alkalosis with hypoxaemia.

Bloods revealed mild renal impairment and slight neutrophilia. CK was normal although this was taken before the chest pain occurred.

The clinical impression was

  • Worsening CHF
  • COPD
  • Unstable Angina


In this case, the physicians were able to diagnose the worsening CHF and COPD. However, it was with direct questioning about chest pain that the patient admitted to having chest pain. In fact, the patient had become so used to experiencing daily chest pain, he had considered it to be a normal occurrence and had not considered telling the doctor !!

Therefore, doctors need to ask the questions of exclusion rather than just asking questions around the area of what the patient describes. In this case, the patient had worsening CHF, but why was it getting worse???
Note that the patient has AF. The commonest cause is ischaemic heart disease and this patient has had an MI previously. Also, hyperthyroidism can worsen heart failure and cause worsening angina in patients with underlying ischaemic heart disease. Moreover, was the patient having small recurrent ischaemic events????

Despite this classic history, the patient was not using a nitrate spray, no anti-platelet agent was being used, no furosemide or ACE/ARB was being used for heart failure or any statin therapy.

This patient was clearly a high cardiovascular risk with a previous MI, hypertension, an ex-smoker and hyperuricaemia.

Moreover, his AF treatment, that being Verapamil, despite it being very effective at rate control, it can also worsen heart failure.

Treatment of Acute Coronary Syndrome

  • Sit the patient up unless hypotensive
  • Give oxygen by mask
  • Give 300mg Aspirin immediately and then 75 mg daily thereafter or ADD Clopidogrel 300mg immediately and then 75mg daily thereafter if the patient is already taking aspirin. If patient has allergy to aspirin, then load with clopidogrel.
  • Give sublingual nitrate spray / tablet
  • If pain continues give morphine and anti-emetic
  • Commence intravenous unfractionated heparin or low molecular weight heparin for ACS dosing until cardiac markers are found to be negative. If positive, continue the heparin until 48 hours after last episode of chest pain.
  • If pain continues give intravenous nitrate infusion
  • Patient should have a 12 lead ECG and placed on a cardiac monitor
  • CK and Troponin T should be examined
  • If pain continues then cardiologist should be contacted with the aim of emergency PCI.
  • Patients should also be commenced on long term anti-anginal therapy if conservative therapy is to be continued including
- Isosorbide Monoitrate / Nitrate dermal patch
- Beta Blocker (not in severe CHF)
- Nicorandil
- Calcium channel blocker e.g. nifedipine / amlodipine

Patients should also be commenced on statin therapy even if the cholesterol level is normal as the benefits of having low cholesterol reduce cardiovascular events.

In this case, asking about chest pain revealed a major cardiovascular history and altered the emphasis on the patient's care.

Please consider....

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