Acute coronary syndromes chest pain

Nitrates are required for symptomatic relief of chest pain they are not proven to improve hard outcomes such as MI or death. Nitrates should be given initially sublingually or by spray, followed by oral or transdermal routes if pain is relieved. Lack of pain relief mandates i.v. administration. Beta-blockers such as metoprolol are used and may reduce the risk of subsequent MI. Calcium channel blockers such as dilfiazem, verapamil, or long-acting di-hydropyridines can be added for symptom control if nitrates and beta-blockers do not suffice they do not improve outcomes. In fact, they may worsen outcomes in the presence of left ventricular dysfunction or CHF in acute coronary syndrome. 

Storrow AB, Gibler WB. Chest pain centers Diagnosis of acute coronary syndromes. Ann Emerg Med 2000 35 449-461. 

Based on a retrospective study of 344 patients with cocaine-associated chest pain, it has been suggested that patients who do not have evidence of ischemia or cardiovascular complications over 9-12 hours in a chest-pain observation unit have a very low risk of death or myocardial infarction during the 30 days after discharge (59). Nevertheless, patients with cocaine-associated chest pain should be evaluated for potential acute coronary syndromes those who do not have recurrent symptoms, increased concentrations of markers of myocardial necrosis, or dysrhythmias can be safely discharged after 9-12 hours of observation. A protocol of this sort should incorporate strategies for treating substance abuse, since there is an increased likelihood of non-fatal myocardial infarction in patients who continue to use cocaine. 

Cocaine use may account for up to 25% of acute myocardial infarctions among patients aged 18-45 years. The safety of a 12-hour observation period in a chest pain unit followed by discharge in individuals with cocaine-associated chest discomfort who are at low risk of cardiovascular events has been evaluated in 302 consecutive patients aged 18 years or older (66% men, 70% black, 84% tobacco users) who developed chest pain within 1 week of cocaine use or who tested positive for cocaine (59). Cocaine use was self-reported by 247 of the 302 subjects and rest had urine positive for cocaine 203 had used crack cocaine, 51 reported snorting, and 10 had used it intravenously. Of the 247 who reported cocaine use, 237 (96%) said they had used it in the week before presentation and 169 (68%) within 24 hours before presentation. Follow-up information was obtained for 300 subjects. There were no deaths from cardiovascular causes. Four patients had a non-fatal myocardial infarction during the 30-day period all four had continued to use cocaine. Of the 42 who were directly admitted to hospital, 20 had acute coronary syndrome. The authors suggested that in... 

Amsterdam EA. Frequency of acute coronary syndrome in patients presenting to the emergency department with chest pain after methamphetamine use. J Emerg Med... 

Overdose is common amongst users (up to 22% of heavy users report losing consciousness). The desired euphoria and excitement turns to acute fear, with psychotic symptoms, convulsions, hypertension, haemorrhagic storke, tachycardia, arrhythmias, hyperthermia coronary vasospasm (sufficient to present as the acute coronary syndrome with chest pain and myocardial infarction) may occur, and acute left ventricular dysfunction. Treatment is chosen according to the clinical picture (and the known mode of action), from amongst, e.g. haloperidol (rather than chlorpromazine) for mental disturbance diazepam for convulsions a vasodilator, e.g. a calcium channel blocker, for hypertension glyceryl trinitrate for myocardial ischaemia (but not a p-... 

In 7800 patients with chest pain and either ST segment depression or a positive troponin test, the addition of abciximab to unfractionated heparin or low molecular weight heparin in the treatment of acute coronary syndrome was not associated with any significant... 

The term acute coronary syndrome (ACS) encompasses all the clinical situations with acute myocardial ischaemia expressed by chest pain, discomfort or equivalent, which appears suddenly at rest (de novo) or has increased with regard to prior anginal (in crescendo angina). All this leads the patient to seek urgent medical care. However, occasionally the patient may underestimate the symptoms or the physician may not interpret them properly. In addition, the ACS may occur with no anginal pain, or the pain may be atypical or may present other... 

Adverse reactions to ultrasound contrast agents (SonoVue 46% and Luminity 54%) have been assessed in 3704 patients, of whom 1150 underwent stress echocardic -raphy with exercise or dobutamine [SS ]. There was no excess of adverse events in those with stable chest pain or suspected acute coronary syndrome. 

Cardiovascular A 64-year-old woman treated for macular degeneration with intraocular injections of bevacizumab presented with chest pain, nausea and vomiting. After an initial diagnosis of acute coronary syndrome and anticoagulation treatment with intravenous heparin, she remained stable without chest pain or shortness of breath and with no evidence of arrhythmias. This may be the first report of an association between intraocular bevacizumab and reversible myocardial dysfunction with a pattern similar to stress-induced cardiomyopathy (also called Takotsubo cardiomyopathy or apical ballooning), although clear evidence for a causal relationship is lacking [97 ]. 

Vascular emergencies play an important role amongst the various differential diagnoses for acute chest pain. Pulmonary embolism, acute aortic syndromes as well as acute coronary artery disease have to be considered.The latest scanner technology available (> 64-slice multi-detector-row spiral CT platforms) allows for a straight-forward work-up in the emergency situation. A dedicated triage based on a sophisticated clinical assessment, however, ist required. 

Acute chest pain is one of the major clinical emergency conditions. Various differential diagnoses have to be considered, some of them are potentially life-threatening. CT assessment for vascular pathologies of the chest can be split up into three major categories. Pulmonary embolism, acute aortic syndromes and coronary artery disease (CAD) require a rapid, reliable and effective diagnostic pathway allowing for an immediate therapeutic decision thereafter. A simple and objective cross-sectional modality should ideally be available on a 24/7 basis. 

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