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A 57-year-old male presents to his local A&E department complaining of chest pain.1. What questions would be helpful?He gives you the following history:“The pain is in the middle of my chest and came on suddenly an hour ago whilst I was watching TV. It feels like I’ve got an elephant sat on my chest doctor, it’s awful. I had a bit of tingling in my neck and jaw, but that’s gone now. I feel really nauseated, I vomited once at home before the ambulance arrived. I do feel a little short of breath, which is weird, I’ve never had that before, maybe I’m just anxious. The pain isn’t affected by my position or by taking in a deep breath, it’s just always there. The pain has improved but it’s still aching and feels heavy, I’d say it was 8/10 at the start and it’s now about 5/10.”What further history would be helpful?More history“I’ve never had chest pain like this before, maybe a few niggles every few months, over the last few years, but nothing like this! I didn’t bother going to the doctor about the niggles, as they always settled on their own and I’ve never been diagnosed as having any heart trouble.”“I’ve got high blood pressure and cholesterol, I’m on tablets for those though.”“I do smoke, about 20 a day and have done for the last 30 years”“I’m not a drinker doctor, I like to stay healthy so I stay away from it”“I don’t really do much exercise, but I get from the shops and back without any trouble”What examination would you do?Examination findings:The patient has a regular pulsetachycardic at 105 bpmhypertensive with a BP of 160/110He has some?xanthelasma?around his eyes and also has corneal?arcus.Heart sounds are normal and his chest is clear.There is no?evidence of peripheral oedema.The abdomen is soft and non-tender. There is no organomegaly. There is no expansile mass on palpation of the aorta.What is your differential diagnosis?What investigations would you do?You take the following ECG?(show them an ECG)What is the diagnosis?which blood vessel is most likely affected?What is the immediate management?What is the definitive treatment?What is the long-term management?ANSWERS1. Use SOCRATES to gather further information about the chest pain:Site – where exactly is the pain?Onset – sudden or gradual?Character – sharp / dull / crushing?Radiation – does it move anywhere?Associated symptoms – shortness of breath / pre-syncope / syncopeTiming – duration of chest pain?Exacerbating & Relieving factors – what makes it worse or better?Severity – on a scale of 1-10 – useful when later assessing impact of treatment2. Past medical historyHas the patient had chest pain in the past?When was the first episode?How frequently do the episodes occur?Is there an obvious trigger –?e.g. exertion?Have they been investigated for the chest pain?Do they have a diagnosis of any cardiac problems??Any other medical problems??(specifically cardiac risk factors)DiabetesHypertensionHypercholesterolaemiaIschaemic heart diseaseFamily history of cardiac issues?Social historySmoker?Exercise tolerance?Alcohol intake?4. DifferentialsAcute coronary syndromePulmonary embolismPericarditisDissecting aortic aneurysmOesophageal spasm7. Anterior ST-elevation myocardial infarction (STEMI).The ECG demonstrates significant ST elevation in the anterior leads.This suggests the presence of full-thickness myocardial infarction in the anterior portion of the heart.8. Left coronary arteryThe left coronary artery provides the blood supply to the anterior?portion?of the heart.Therefore, in this circumstance, it is likely that this vessel in the one affected.Below is a guide to which vessels are most likely affected in each type of myocardial infarction.Anterior –?Left coronary arteryPosterior –?Left circumflex artery (usually) / Right coronary arteryInferior –?Right coronary arteryLateral –?Left circumflex arteryAntero-septal –?Left anterior descending (LAD)Initially, an ABCDE approach should be adopted to ensure any immediate threats to life are?recognised?and treated.Next steps in immediate management?Morphine – 5-10mg IV?(can also give anti-emetic to reduce nausea)Oxygen –?if saturation less than 94%Glyceryl trinitrate (GTN)?– avoid if hypotensiveAspirin 300mg + Clopidogrel 300mg?(or other antiplatelet e.g. Ticagrelor)Fondaparinux 2.5mg?subcutaneousThe on-call interventional cardiologist should be contacted as soon as possible, in this scenario time is muscle, so the longer the delay to definitive treatment, the worse the outcome.Primary percutaneous coronary intervention (PCI)This is the best choice of treatment for recent onset STEMIIdeally should be done within 90 minutes of chest pain onsetInvolves widening of affected coronary arteries by a?balloon?catheterA stent is then put in place to keep the vessel patentThis allows restoration of blood flow to the myocardial tissueAntiplatelets :Dual antiplatelet therapy is often continued for 12-24 months after PCIA single antiplatelet agent is then continued long-term?Address other cardiac risk factors:Hyperlipidaemia –?give a long term statin (e.g. Atorvastatin)Hypertension –?initiate appropriate antihypertensive medicationBeta blocker ?Smoking cessation?Lifestyle advice:Regular exerciseLow-fat diet.Cardiac?rehabilitation ................
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