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Acute Management of Chest Pain and Hypertension Intern

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Title: Acute Management of Chest Pain and Hypertension Intern


1
Acute Management of Chest Pain and Hypertension
  • Intern Lecture Series
  • Scott Pawlikowski, M.D.
  • ACLS Guidelines updated 2004
  • ACC/AHA Guidelines
  • JNC VII
  • NEJM 2000 342(16) 1187-1195

2
Chest Pain Opening Stats
  • Most common Gen Med admit at HVA, and probably
    LUMC as well
  • Why?
  • Biggest fear amongst E.R. staff is sending
    patient home mistakenly while AMI is going on
    (big OOPS!)
  • Short-term mortality rates
  • AMI, mistakenly sent home 25
  • AMI, admitted to hospital lt12.5

3
Chest Pain Opening Stats
  • Let the data ease your mind!
  • Prevalence of AMI given the following
  • 1mm ST-segment ? (new) 80
  • ST-segment ? or TW inversion 20 (when not
    known to be old)
  • No ischemic EKG ?s, h/o CAD 4
  • No ischemic EKG ?s, no h/o CAD 2

4
Chest Pain DDx
  • Why start here at differential diagnosis?
  • Why not History and Physical first?
  • NEED TO CONSIDER TIMELINESS OF DIAGNOSIS AND
    TREATMENT
  • NEED TO THINK ABOUT THE LIFE THREATS

5
Chest Pain Life Threats
  • Acute Myocardial Infarction(AMI) or Unstable
    Angina (USA)
  • Acute Aortic Dissection (usually thoracic)
  • Pulmonary Embolism
  • Acute Pericarditis/Pericardial Tamponade
  • Tension Pneumothorax
  • Esophageal Perforation
  • Hypertensive Emergency/Crisis

6
Chest Pain Non Life Threats (At Least Not
Immediately)
  • GERD
  • Esophageal Spasm
  • Pleurisy
  • Bronchitis/Pneumonia
  • Costochondritis
  • Muscle strain/Sprain
  • Panic Attack
  • Shingles/Zoster
  • Trauma (contusions, ecchymosis, rib/sternal Fx)
  • Lung Tumor/Cancer

7
Chest Pain Initial ApproachMultitask!!
  • Vital signs including O2 sat
  • Obtain IV access
  • 12-lead EKG
  • Done AND reviewed within 10 minutes!
  • Can get R-sided EKG in select patients (low HR,
    low BP)
  • Brief, targeted history and physical
  • Initial labs (CBC, BMP, coags, troponin)
  • Portable CXR
  • done and read within 30 minutes! (look yourself!)
  • O2 2-4L via nasal cannula
  • Aspirin 162 to 325mg PO
  • Usually 81mg x 4 chewed
  • NTG SL or spray
  • 0.4mg SL x 1 q5 min up to 3 in 15 min as
    tolerated
  • Morphine sulfate 2-4mg IV
  • If pain not relieved with NTG and pain is felt to
    be the real deal
  • Remember, MONA greets all patients

8
Chest Pain Initial History
  • Characteristics of pain
  • Location, radiation, quality, severity
  • Time of onset
  • Duration/frequency
  • Associated symptoms
  • SOB/DOE, diaphoresis, syncope, presyncope,
    anxiety/gloom n doom
  • CAD or CAD risk factors DM, HTN, dyslipidemia,
    smoking, FMHx (premature)

9
Chest Pain Initial History
  • Relationship of chest pain to
  • Exertion
  • Position
  • Breathing (i.e. is it pleuritic?)
  • PO intake
  • NTG administration at home/in E.R.
  • Note timing, other associated NTG effects
  • Illicit substance ingestion, e.g. cocaine

10
Chest Pain Initial History
  • Prior PCI or surgery?
  • Prior anginal symptoms?
  • Similarity of current CP with prior anginal Sxs?
  • Any GERD symptoms or history?
  • Bitter taste in AM, chronic heartburn?
  • Any musculoskeletal symptoms or history?
  • Heavy lifting, trauma, change with arm movement?
  • Any recent URI-type symptoms?
  • Cough, sore throat, fever/chill, nasal congestion?

11
My Thoughts on NTG
  • A favorable response in CP to NTG is NOT a
    reliable indicator for/against symptomatic CAD
  • However, try to understand what pt.s response to
    NTG is
  • How fast after taking did CP get better?
  • Did tongue fizzy, rush, and headache happen?
  • How old are the nitros at home?
  • If BP crashes after SL NTG think RV AMI, volume
    depletion, critical AS, severe CMP, vitamin V

12
Chest Pain Initial Exam
  • Note vital signs
  • Good, quick exam is the rule
  • CV focus
  • Pulmonary/lung focus
  • Abdominal/GI focus
  • DRE with stool guaiacprobably should do in all
    patients, but interpret with caution!

13
Chest Pain Initial Exam
  • Extra exam maneuvers DO NOT BE AFRAID TO DO
    THESE ON ANY PATIENT YOU THINK NEEDS IT!!!
  • BP in both arms-aortic dissection
  • Thorough peripheral pulse exam-aortic dissection
  • Pulsus paradoxus-pericarditis/tamponade
  • CP reproducibility test-MS causes

14
Chest Pain Initial Exam
  • Extra exam maneuvers DO NOT BE AFRAID TO DO
    THESE ON ANY PATIENT YOU THINK NEEDS IT!!!
  • Dynamic auscultation
  • Lean forward, end expiration
  • Brings out AI murmur-aortic dissection
  • Brings out rub-pericarditis/tamponade

15
Chest Pain Initial Exam
  • Extra exam maneuvers DO NOT BE AFRAID TO DO
    THESE ON ANY PATIENT YOU THINK NEEDS IT!!!
  • Becks triad-pericarditis/tamponade
  • Look for JVD, hypotension, muffled HS
  • Palpate trachea in sternal notch-tension
    pneumothorax
  • Thorough LE exam-DVT/PE

16
Chest Pain STEMI
  • ST elevation or new/presumably new LBBB
  • Adjunctive therapies
  • Beta blockers IV (goal is HR in 50s as BP/Sx
    tolerate)
  • NTG IV (can give SL NTGs on top for ?s in CP)
  • Heparin IV (use lower dose nomogram)
  • ACE-I after 6 hours if stable (captopril/lisinopri
    l)
  • If Sxs lt 12 hours, reperfuse!
  • Lytics door to drug within 30 minutes
  • PCI (HVA/LUMC) door to balloon within 90 minutes
  • If Sxs gt 12 hours, further stratify to CCU vs.
    reperfusionget Cards involved EARLY to help

17
Chest Pain NSTEMI/USA
  • TIMI risk score predictor variables
  • Age 65 y/o 1 point
  • 3 RFs for CAD 1 point
  • Aspirin use in past 7 days 1 point
  • 2 anginal events in last 24 hrs 1 point
  • Elevated troponin 1 point
  • ST deviation 0.5 mm 1 point
  • Prior coronary artery stenosis 50 1 point

18
Chest Pain NSTEMI/USA
  • Primary End Points death, new or recurrent
    myocardial infarction, need for urgent
    revascularization

19
Chest Pain NSTEMI/USA
  • Low risk TIMI score (0-2)
  • Admit to tele bed (if at all)
  • Rx with ASA and individualized therapy
  • 2 serial EKGs
  • 2 sets of cardiac markers
  • 2nd set 6-8 hours after onset of CP
  • Stress testing inpt versus outpt team decision
  • D/C on ASA daily with PCP f/u
  • Re-stratify if new events while in hospital
    during observation or during stress testing

20
Chest Pain NSTEMI/USA
  • Intermediate risk TIMI score (3 or 4)
  • Admit to tele vs. CCU bed
  • Use beta blockers if no contraindications
  • Add anticoagulation
  • LMWH vs. IV heparin
  • Cards/Gen Med attending specific
  • For renal insufficiency, Age gt75 y/o LMWH
    contraindicated only in STEMI
  • Add plavix if NOT at HVA (per ACLS/AHA)
  • 300mg PO load, then 75mg PO daily
  • AVOID LOAD at HVAtoo much bleeding in Hines
    population based on ITV/CV experience

21
Chest Pain NSTEMI/USA
  • Intermediate risk TIMI score (3 or 4)
  • 2 serial EKGs
  • 2 sets of cardiac markers
  • 2nd set 6-8 hours after onset of CP
  • Stress testing inpt versus outpt team decision
  • D/C on ASA /- clopidogrel, PCP /- Cards f/u
  • Re-stratify if new events while in hospital
    during observation or during stress testing

22
Chest Pain NSTEMI/USA
  • High risk TIMI score (5-7)
  • Admit to tele vs. CCU bed
  • If troponin negative and no early invasive
    strategy at your institution, consider early
    conservative strategy
  • Follow Intermediate risk pathway
  • Deviate and proceed to cardiac cath if
  • Refractory ischemic CP, recurrent/persistent ST
    deviation, sustained VTACH, hemodynamic
    instability, signs of pump failure
  • If troponin positive, then add G IIb/IIIa
    inhibitor and push for cardiac cath (should be in
    CCU at this point)

23
Chest Pain Aortic Dissection
  • Rapid/prompt diagnosis is crucial!
  • Suspect in hypertensive patients with good story
  • Use extra exam maneuvers as needed to raise/lower
    clinical suspicion
  • Always look at CXR yourself and compare to old
    ones
  • Mediastinal widening
  • Aortic knob sign

24
Chest Pain Aortic Dissection
  • Diagnostic options
  • All need good IV access (dye/sedation)
  • CT-angiogram with IV contrast
  • Relatively fast, sensitive, specific, localizing
  • Need good renal function
  • Avoid with azotemia or contrast allergy
  • MRA
  • Sensitive, specific, localizing, less dye issues
  • Takes time, dangerous place for unstable pt.

25
Chest Pain Aortic Dissection
  • Diagnostic options
  • Transesophageal ECHO (TEE)
  • Sensitive, specific, localizing for proximal
    dissections
  • Can perform in well-monitored setting
  • No dye issues at all
  • Invasive, need Cards attending around to do
  • Consent for procedure also needed

26
Chest Pain Aortic Dissection
  • Treatment
  • Get CV involved early, especially with Stanford
    type A/DeBakey type I dissections
  • Get BP controlled!!
  • A-line, ICU setting
  • IV nitroprusside or labetolol
  • Avoid anticoagulation

27
Chest Pain DVT/PE
  • Low threshold to assess for and exclude with
    fairly rigorous workup
  • Listen to the gremlin on your shoulder!
  • V/Q scan and LE doppler at HVA are usually M-F
    9AM-330PM tests, while CT scan is usually 24/7
    (UGH!)
  • Interpret D-dimer assay result with caution,
    especially at HVA!

28
Chest Pain Other Causes
  • Pericarditis/pericardial tamponade
  • Understand that tamponade physiology can happen
    at any BP, so have low threshold to get ECHO if
    you suspect it
  • Always look at CXR yourself and compare to old
    ones
  • Look for abrupt change in cardiac size
  • Look for electrical alternans or new low voltage
    on EKG
  • Get cards/CCU involved early if you suspect
    tamponade

29
Chest Pain Other Causes
  • Tension pneumothorax
  • Standard of care if you have STRONG clinical
    suspicion
  • 16 Gauge Angiocath in 2nd anterior ICS
  • IMMEDIATELY and PRIOR TO CXR!
  • Decompress, let the dust settle, then get your
    films and pulmonary consults cooking

30
Chest Pain Other Causes
  • Esophageal perforation
  • Get CV/Gen surg and GI involved early, big
    problems with mediastinitis and crashing in these
    patients
  • Hypertensive emergency
  • Need A-line and IV BP drips in ICU setting to
    control pressures (more on this later)
  • Avoid being too aggressive too quick, avoid
    anticoagulation if possible (CVA!)

31
Chest Pain Other Causes
  • Non Life Threats take your pick for Rx
  • All causes reassurance (my favorite!)
  • GERD/esophageal spasm GI cocktail/PPI/H2RA
  • MS causes NSAIDs, tylenol, muscle relaxants,
    narcotics, physical therapy
  • Psyche causes ativan, SSRIs, buspar,
    lobotomy/ECT (just kidding)
  • URI-related causes cold remedies, albuterol, ABx
  • Shingles/zoster acyclovir, gabapentin, capsaicin

32
Hypertension JNC VII ReviewShort Version
  • Classification of blood pressure
  • Normal lt120/80 mmHg
  • Prehypertension 120-139/80-89 mmHg
  • HTN Stage 1 140-159/90-99 mmHg
  • HTN Stage 2 160/100 mmHg

33
Hypertension JNC VII ReviewShort Version
  • Principles of treatment
  • Treat to BP lt140/90 mmHg in most patients
  • lt130/80 mmHg in diabetes or CKD
  • Consider lt125/75 mmHg with DM/CKD and significant
    proteinuria (1gm/day)
  • Lifestyle modification, then drugs
  • Start one drug for Stage 1 HTN, two drugs for
    stage 2 HTN

34
Hypertension JNC VII ReviewShort Version
  • First line drug usually thiazide diuretic, alone
    or in combination with beta blocker, ACE-I, ARB,
    or CCB
  • Consider changing your strategy for certain
    compelling indications

35
Hypertension JNC VII ReviewShort Version
  • Compelling indications/strategies
  • HF thiazide, BB, ACE-I, ARB, aldosterone
    antagonist (my own opinion loop diuretic)
  • Post-MI BB, ACE-I, aldosterone antagonist
  • High CVD risk thiazide, BB, ACE-I, CCB
  • DM thiazide, BB, ACE-I, ARB, CCB
  • CKD ACE-I, ARB
  • Recurrent stroke prevention thiazide, ACE-I

36
HTN Secondary Causes
  • OSA
  • Drug-induced
  • Venlafaxine
  • Sibutramine
  • Cocaine/speed
  • CKD
  • Primary hyperaldosteronism
  • Renal artery stenosis
  • Cushings syndrome or chronic steroid therapy
  • Pheochromocytoma
  • Coarctation of aorta
  • Hyperthyroidism (usually systolic HTN)
  • Hypothryroidism (usually diastolic HTN)
  • Hyperparathyroidism

37
HTN Intern on Call Stuff
  • One of the dreaded X-cover pages Doctor, Mrs.
    Wilsons BP is 180/100, what do you want me to
    give her?
  • Do we need to treat this urgently?
  • What exactly does urgent mean, anyways?
  • 1 hour, 6 hours, 1 week, 1 month?
  • In other words, do I have to deal with this
    tonight?

38
HTN Intern on Call Stuff
  • My approach take it step by step
  • STEP 1 Is this real?
  • If you need to, take BP yourself and in both arms
  • STEP 2 Why is the BP elevated?
  • Some important hospital scenarios to consider
  • Uncontrolled pain
  • ETOH/BZD withdrawal
  • Cocaine/amphetamine abuse
  • Rebound from stopping clonidine/beta blockers
  • Volume overload
  • Myocardial ischemia/infarction
  • Evolving intracranial pressure elevation (CVA,
    bleed, tumor)
  • Preeclampsia/eclampsia

39
HTN Intern on Call Stuff
  • Step 3 Is this hypertensive Emergency or
    Urgency?
  • Emergency BP gt180/120 with impending or
    progressive target orgen dysfunction
  • Hypertensive encephalopathy
  • Intracerebral hemorrhage
  • Acute myocardial infarction
  • Acute LV failure with pulmonary edema
  • Unstable angina
  • Dissecting aortic aneurysm
  • Eclampsia
  • Urgency no progressive target organ dysfunction
  • May have symptoms, though
  • SOB, severe headache, epistaxis, severe anxiety

40
HTN Intern on Call Stuff
  • STEP 4 If Im worried about emergency, how do I
    raise/lower my suspicion?
  • Physical exam clues
  • Papilledema on direct fundoscopy
  • Rales/S4 that are new/not known to be old
  • Acute delerium
  • CVA/dissection/eclampsia findings
  • Other objective clues
  • ST elevation/depression or new onset LV strain on
    EKG
  • Progressive renal dysfunction on labs, may have
    microhematuria

41
HTN Intern on Call Stuff
  • STEP 5 How do I treat?
  • Emergency admit to ICU (beware of the age-old
    MICU vs. CCU fight)
  • A-line placement
  • Parenteral administration of IV meds (usually
    drips)
  • Sodium nitroprusside, nitroglycerin, labetalol
  • Initial goal is to lower MAP by no more than 25
    over several minutes to one hour
  • Then shoot for BP 160/100-110 in next 2-6 hours
  • Then shoot for normal BP over next 24-48 hours

42
HTN Intern on Call Stuff
  • STEP 5 How do I treat?
  • Caveats to Emergency treatment
  • Ischemic stroke no clear evidence this benefits
    (unless planning to give tPA)
  • Typical drugs to use here nitro paste, IV
    labetalol, IV enalapril
  • Aortic dissection get SBP lowered to lt100mmHg
    ASAP if tolerated

43
HTN Intern on Call Stuff
  • STEP 5 How do I treat?
  • Urgency two schools of thought
  • Plan A treat with oral, short acting agent
  • Captopril 25mg PO, labetalol 100mg PO, or
    clonidine 0.1mg PO
  • Reassess within a few hours
  • Plan B conscientious neglect
  • My favorite, though the RNs hate this!!!
  • Wait until Gen Med team gets in the next day
  • Can adjust/titrate already existing
    antihypertensive therapy in the meantime if you
    like

44
HTN Intern on Call Stuff
  • STEP 5 How do I treat?
  • Caveats to Urgency treatment
  • There is NO evidence to suggest that failure to
    aggressively decrease BP over a few hours for HTN
    urgency is assiociated with ANY increased
    short-term risk for those presenting with severe
    HTN
  • Aggressive dosing with IV drugs (or even PO
    drugs) to lower BP is NOT without risk
  • Beware of cumulative effects of repeated oral
    loading dosescan lead to hypotension!

45
HTN Intern on Call Stuff
  • STEP 5 How do I treat?
  • Caveats to Urgency treatment (cont.)
  • I tend to be more willing to treat urgently if
    HTN in general complicates the management of what
    the patient is admitted for
  • e.g. CAD, HF, HTN/DM noncompliance, CKD
  • Dont forget to treat uncontrolled pain, ETOH/BZD
    withdrawal, volume overload with their
    appropriate/directed treatments
  • e.g. pain meds, BZDs, and loop
    diuretics/nitrates, respectively
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