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Hello, everyone. It's wonderful to have you, er, on this Sunday. For me, it's 11 o'clock. I don't know what time it is for you. Um, but it's great that you've joined us. Er, today we have, er, Doctor Hassan talking about chest pain differential diagnosis. Um, and er, what we're gonna do is we're gonna have er, his talk, you can ask questions in the chat and at the end we'll have a period of time where we can just go through other questions as well. Um As always feedback form will be emailed to you. It'll be in your inbox at 12 o'clock my time. So in an hour's time it'll be in your inbox, complete that feedback form. I will be sending a copy off to doctor Hassan afterwards and then you can get your attendance certificate on your med account. So without any further ado I am gonna hand you. Ok over to you. Thank you very much, sir. Uh Good morning and, or good evening, wherever you are, my name is Doctor Yamal. Has IE D consultant work at Queens Hospital, this is in Romford, just north uh east of London. Uh It is one of the busiest ed department in the country and maybe in Europe, uh I am very passionate about medical education and I am a mortality lead of the department. So this is involving a lot of medical education and training. I think this is very important because we learn all the time in medicine. Uh I would like to thank you and the organizers because this is really good uh opportunity for us all to learn from each other. And uh I will start today my talk with the chest pain as a differential diagnosis and you will have the the chat box. If you uh would like to put any questions, I will be happy to answer uh those as well. So why I choose chest pain differential diagnosis? Yeah. Uh you all agree. It is a very huge topic. It is very uh important topic as well and it is very difficult that we can uh you know, uh uh catch everything with regard to chest pain. So our objective today, I will go through you just about like general differential diagnosis. What are the most important thing to, to, to consider when the patient is coming with the chest pain? And I will, we will concentrate today on uh ischemic chest pain. So, uh this is all acute coronary artery syndrome. Uh In UK, there is half million visitors, patients visiting because of chest pain and 1 million visiting their GB because of chest pain in the United States, there is 42 million visiting their the Ed, 42 million visiting the ED because of chest pain every year. And this is cost like 10 billion per year. So it is, it is important topic and you will face it everywhere in your practice. Either you are in the uh primary care setting or you are in the medical uh I mean in hospital setting. So let us start. I will start with the case that I had a few years ago. And, uh, I would like at the end of our talk, please remind me, I will forgot just to give you the feedback about what happened to this patient and what are the learning point of that. So, uh, just before going on a Saturday, around six o'clock, just before going to my break, the uh triage nurse, hand it to me an E CG. And the story was a 51 years old female patient with past medical history of diabetes. Very slim lady, uh, presented with her husband with the chest pain stops in the same day of admission, uh to the emergency department. So started early morning, eight o'clock, chest pain on and off. Never had chest pain before in the past. And you know, by six o'clock husband said, you know, we need to contact a. So they drove themselves and they came to ad uh she had past medical history of type two diabetes and oral medication. As I say, and she stated that the pain was on the left side of her chest and going to the left arm uh on examination, she had a stable G CS was 15, obviously uh stable vital signs. And before uh seeing her, in fact, I was being I had the ECG in front of me. So this is her E CG. If anyone can comment on that E CG please any takers. So I don't know if you can hear me. Uh However, you can see there is an ST elevation in the septalis. So B1 start with B1 but very obvious in V two and V three. So this is the ECG of this lady. Important fact of her uh examination is that she had a historic murmur in the left Palestinian region. And at the end of my talk, I will come back and just discuss with you what are the significance of that. But just remember this histo murmur in the left P I just checked immediately her all notes because we have the axis of the electronic nodes online and never met her before. And I asked her if she had any murmur before any problem with her heart. She said absolutely no. Yeah, Susan, yes, it is ST elevation and uh this is excellent ST elevation is uh septal leads. We will come to this case later on and I will just tell you uh exactly what happened and what, how we approach this patient and what was the outcome? So what type of chest pain you are having in Ed or in general? So we have a cardiac chest pain, ST elevation MRI non stdm I stable angina pericarditis, myocarditis, uh cardio nerves is they present with major type of chest pain, short of breath, maybe heart failure. We have pulmonary causes of chest pain and life threating of that. You have pulmonary embolism. Very important not to miss. and uh pneumo cirrhosis. Obviously, pneumonia can ca can come with the chest pain and pleurisy as well. Uh gastrointestinal symptoms, muscle symptoms, and we will go through results just in a little bit more details and psychiatric causes as well. And I just would like to tell you a few sentences about psychiatric causes whenever you have a patient that is, I agree. Some of them, they come with uh anxiety, nonspecific chest pain, they come with uh psychosomatic disorder. However, always with psychiatric cause of a chest pain or abdominal pain or whatever or, or confusion or abnormal behavior. At the bottom of your differential knowledge, please. Disaster. I weakness in my life just because the patient is labeled mental health or psychosomatic and he has organic cause. So always try to rule out any organic cause of any kind of medical presentation before labeling patient has um you know, as anxiety or psychosomatic disorder. This is just very important. It is there, it is increasing in the diagnosis. However, it is in the bottom line, even if you have a patient who is uh known to have a mental health. So we go through through is a key differential diagnosis very quickly. We are not going to stop that much because uh I think my plan is to have uh maybe in the future, we can have another discussion about different lifethreatening, uh uh you know, presentation of the chest pain. Uh But as I say today, we'll have acute coronary syndrome and maybe in the future, we will choose another important causes as well. However, I will just go through them uh briefly and just remind you about what type of presentation we have of chest pain and what you need to, you know, to look at. So, obviously, acute coronary artery syndrome, we are going to discuss that today. So we'll leave that this is including stable angina pericarditis. I can see already there is a question about pericarditis uh and chronic elevation with pericarditis, we will come to that as well. So this is, you know, like uh pain sharp in nature, sometimes increased by breathing, localized, usually after type of uh you know, flu like symptoms. Uh and uh most likely young adult and we will have ST elevation, which is so specific about pericarditis about everywhere. Uh pneumonia obviously is uh you know, you will, you will be as it will be associated with cough with fever. Uh you know, patient could be septic with it could be just, uh you know, the pneumonia and you have your, uh you know, you would have that as a differential, that model of chest pain, pneumothorax, again, very important uh life threat diagnosis. Uh and not to be mystery sharp, chest pain in percussion, you will have numbness, uh you will have decreased air in outside and obviously you will to the your investigation of care is going to be a chest x-. That facility is available almost everywhere. However, here before the chest X ray, we do just lung ultrasound, which is very sensitive and specific of pneumo. Just to remind yourself, don't uh to remind everyone, don't uh you know, be uh misleaded by normal vitals are normal saturation to rule out that. So sometimes you say, OK, you know, it is just his saturation is fine, his breathing is fine. Just don't forget there is two lungs and one can compensate the other. And we saw a lot of patients with completely collapsed lung and the saturation is fine. The respiratory rate is not high and they are sitting very comfortable. Although the the the presentation usually is a chest pain and short of breath, we can have sharp chest pain. Sometimes the pain will be very, very severe. And you think what is going on here, you know, sometimes just mimicking uh renal colic really in the loin area, obviously, esophageal uh uh rupture, which is could be. So if patient come to you uh one day or two days after uh O BD intervention, you can, you know, think about is it esophagal, is it perforation uh esophagus? So this is very devastating diagno as well. And you know, you don't need to miss that peptic ulcer disease, obviously, which is irradiation of the pain from the big acidic to the chest area. Sometimes the patients themselves, they cannot differentiate. Is it chest pain or a big gastric pain Because of the abi gastric pain and the reflux is to fal spasm. This is could create uh little bit of difficulties because if the patient by ambulance, for example, uh had a GTN, he will tell you, oh my pa my pain is relief for GTN. So it's a vary spasm characteristic of this type of pain. Again, re chest pain. Uh and again, you will have type of relief by GTN if he had GTN by paramedics or, or, or for another reason, uh heartburn is another issue and a lot of patients with ischemic heart disease, the MRI they think it is just reflux and they will be having like visiting the right that and he will come and say, oh doctor, this is just my reflux, you know, and you do an E and you assist them and uh and it is not, it is uh acute colon syndrome. Obviously, biliary call it and remember every pa pain in the abdomen can radiate to the chest. So it can present with So we have biliary colic irradiation of the vein to the shoulder and, and, and they can have also some kind of chest pain. Uh the same is for uh chest pain. Can I get to the abdomen? So you will have a lot of patients coming with inferior wall M I and the presentation is, is uh is in, is epigastric pain just because of local localization of that tip of the heart going down. Her zoster. I had one patient like this with the chest pain uh because of herbal zoster. And you understand, and you remember that is just Dermatal type of pain. However, before the rashes start to her, they will not come with the pain. So the will be chest pain before the rashes started, obviously unstable angina that we are going to discuss today and pulmonary embolism and also very important uh differential diagnosis, which is I think we will have uh a discussion about it in a separate session. Hopefully uh again, chest pain, neotic in nature, short of breath with tachycardia. However, just remember it was uh it was from my own experience. Uh central uh ol is settle big uh uh uh clots uh in the in the settle of the of the bone arteries and not peripherally, they can have no chest pain. So, but we will come to this in d in different sessions. Aortic dissection. Again, important uh the life threatening diagnosis. I just submitted an a in the last European Congress with emergency medicine in Barcelona. About one of my patients, 53 years of old of age coming is uh called shock is hypertension and seizure. And uh this is one of the cases that is uh 7% of the cases they have no chest pain. Uh and he presented with no pain just incidentally when we investigating the shock and we did point of care ultrasound, we found that he had a big uh big cardial effusion and confirmed by the chest X ray. And we went direction of aortic dissection, but typically, it will be a chest pain going to the back and neurology obviously weakness. Uh sometimes they have seizures as well, stroke all those type of symptoms. But we will leave this for probably because this is one of the very commonly missed diagnosis. One in three misdiagnosis in, in uh uh in UK obviously bone ceratitis. So cardiac causes of chest pain. So we have acute myocardial elevation M I which we all know about and we will go through some of the ecgs here as well and we have non TM I which is sometimes is mystery and uh just when we are talking about non M I just to remember something from my own practice and my own observations, most of the elderly people in their seventies and eighties, they are coming with. No ami very rarely. You will have an elderly patient coming with M I ami So just keep that in mind, we will discuss about their presentation as well, which is really little bit different from the young patients and stable angina obviously, and you have also the southern cardiac arrest, the fatal M I that is we are trying all to prevent by primary care measures. But still we are receiving patients in young age, unfortunately, in their fifties and sixties and, and uh because of fatal M I and sudden death, why I am putting this Canadian Cardiovascular Society calcification. It is very important for the clinician just to understand what is the impact of this chest pain on the in the in your, on your patient. It is not a matter of just ticking the box like oh what is where is the chest pain? When did it start? Where is the what is the radiation of the pain? This any computer can do that? But you need to understand what is the implication of this chest pain on this uh patient life. So if he this pain is coming, for example, just you know, he has no angina, no chest pain with ordinary physical activities, you know, this is class one. If he has this chest pain with minimal activities, this is class two. And when this is severe iim limitation of his uh ordinary, he said he cannot go to work, he cannot, you know, he cannot do his daily activities because of this constant type of chest pain. And obviously the class four when they are really struggling of the chest pains or any kind of minimal activities, even just trying to change themselves. It is, it is uh it is an issue for them. So just try to understand and to listen to your patient, what is it, what how this pain is affecting them? You know, because at that time, you can make the the correct differential diagnosis and what is the best for those patients to do either in your primary setting or in your hospital? This is in Ed or they are admitted to the ward. So now we are going to talk about the character of the chest pain. So we all know the classical type of chest pain that is the uh left-sided chest pain with the radiation of the pain to the back, so sorry to the left shoulder. However, they found that most common is the pain, the radiation of the pain to the both shoulders, left arm and right arm. Uh obviously, when you are talking about chest pain with the radiation to the back, just try to remember that is uh this is one of differential diagnosis of aortic dissection. However, my experience m many of ischemic heart, chest pain, ischemic event of chest pain. Also they have i to the back. So, uh you know, this is important uh important point to, to remember it is also uh important point to remember that is those type of chest pain like a sharp stabbing unlikely to be is ischemic event. However, any pain, which is like a pressure type of pain. Uh The patient will tell you as if someone is sitting on my ha of on my chest, like heavy feeling. Uh you know, this is me, see, oh this is could be an is skiing event. Uh As I said, some of the patients they will come with sp of reflux chest pain, which is uh you know, he will take fizzy drinks and all this is very atypical and no specific and still we are missing diagnosis of the chest pain because of that atypical history, which is in elderly patients is more like short of breath, feeling unwell rather than the chest pain itself. So an elderly uh especially elderly female diabetic patient, they are the presentation most of the time is not chest pain rather than being unwell, having uh short of breath, uh even confusion. One of the differential of dele and confusion is may cause in because this is typical presentation in elderly patient or having uh fall, you know, in here we have in, in the UK, we have a lot of elderly patient with fall and uh it's important in those patients also despite, you know, the paramedics and the history from our family. Yeah, we found her, you know, in the floor and we, she was being there for maybe 20 minutes, do an E CG on them and uh because this is something that we need really to rule out uh as, as I say, pressure type of chest pain. But just keep in mind a typical presentation uh of, of, of those uh and atypical characters. But obviously, the classic ones are the pressure type of chest pain, uh it to the neck as well. Sometimes you have the patients that is just coming with the jaw pain, no chest pain just coming with the jaw pain. And it tend to be having acute coronary artery syndrome. What we can do here to, you know, now a patient is coming with the chest pain. You are doing your E CG, you are doing your assessment and, and in the UK here we use a half score and very popular here. That is uh you know, in UK, just to give you idea what is the risk factor for this patient that is having coronary artery disease and we are not sending them home uh having, you know, uh uh seriously. Aow. So we use the half the score here uh which you can find in me calculation. It is online everywhere and there is uh five points that you need to ask. So what is the history is this history suggestive of chest pain? Is this history? It's not suggestive of chest pain. Uh Is it very typical or mm mild, slightly suggestive or very suggestive uh CD changes as well. This is another factor that is unique to look at is is still inversion, ST evasion, ST evasion or STD or ST depression, ST depression is always, is given uh ST elevation could be pericarditis, could be, you know, pericardit aneurism could be early regularization, but always be concerned when there is ST depression because this is most of the time is due to ischemic event. Obviously, if you have hyper at wave in the ECG, this is another sign if there is ST e even with that higher rate, and you just calculate uh all those parameters, age, this is another uh factor of uh major cardiac event. So you have the age elderly obviously is uh is uh in the higher risk above age of 60 65 70 above just before because of all the acrotic changes and everything, what is happening to them. However, be very careful with young age on uh uh patient coming from the, from the uh Indian subcontinent, we observe that is in very young age, they can have premature coronary artery diseases and also a Carribean uh population as well. And of course, another important factor is the risk factors. So you have diabetes, obesity, hypertension, hyperlipidemia, family history, all those are in, you know, you need to calculate and obviously your initial troponin if you are having it in your hospital, you are including that. But by before the troponin, by all those history and ECG changes and the risk factor, you have an idea how high the risk of this patient if it is less than four in here in our department, we uh we assume this is low risk type of chest pain. However, the most important factor rather than only looking at those scores is how is the patient himself, even if his score is low, but this patient doesn't look right, you know, he's in pain, you know, something wrong with him. Just your that clinical sense also is important. This is all those tools are helping you. However, the most important is the patient himself, how you feel about him? How is his character of the chest pain or what uh during your clinical examination? How uh how uh what are your findings as well? Uh But less than four, we are uh we can investigate further. We can get a plan. Obviously, we have our initial tin and if there are less than four risk factors, we will, we will think what we need to do is that they can go to the chest pain clinic if they need to have a primary care follow up uh or you know, uh or we just need to do more investigation. However, if the patient is more than four in those heart score is uh uh you need to uh you know, most likely they need to get admitted. So you have heart score of six or five or seven sometimes. So this is high risk patient. Uh And uh and this is very important tool will help you and uh deciding who we can get home and who we can admit infarctions types. Uh I put this slide here because just to make you aware of this, you know, of different type of case of M I. So type one, we all know it is sclerotic changes, they come with stimulation M I coronary artery even forward, they know it. However, type two AMI which we are facing in the emergency department sometimes. And it's difficult on uh uh not difficult to diagnose. It is difficult to on what, how, how you are going to treat that. So those patients are coming because of high oxygen demand. So patient with anemia, we find some chronic anemia with hemoglobin of five or six or seven and tell ischemic event. You know, because of, of that lack of uh oxygenation to the heart uh patient who is aortic dissection as well, which is completely different type of treatment. You know, they have aortic dissection, the coronary arteries are involved and the secondary MRI because of aortic dissection rather than rather coronary artery pathology by itself. So this is completely different. You need to do CT uh aorto angiogram and you need to activate the pathway for that rather than uh uh rather than U PC. Uh you call uh version hypotension sepsis. We can find that secondary M I is there as well and now became very popular. That is and very important as well. That is you need to, you need to treat the cause of that. So patient is septic hypotensive with ischemic event high. You know, you need to address the sepsis, ok. Uh We had young uh female patient with uh ordinary outer dissection. Uh who are, there was no any kind of, you know, ladies in their 3835 in their early forties after giving birth coming with a severe chest pain. And there is an easy changes of uh Mr and some of the time this is coronary artery dissection rather than type one with a block and all that. So you need to see that and you need to put that in your, in your uh mind when you are assisting those patients sudden unexpected cover. This obviously types four and five is all related to the PC and C. So we have ATM I obviously in a standard lead, you know, uh inferior lead of the case lead and we have a new uh identified lead bundle branch block and we have STV in the er uh side. This is very important not to miss as well and we have high risk uh CD findings and we are going to just have a look and see how uh those E CG present we can have it in the emergency department. So uh can you tell me what type of ation that we have here in the box scale, please. So we, we can see that is, you know, it's written inferior M I any takers of where is the elevation here in this ECG, we'll give you just a few seconds. So you can see in this uh ECG there is, can you can you appreciate that is, yeah, there is an lateral uh and there is times that there is some ST elevation in the, in the uh in the V two but very specific here, we have the up ST elevation in lead two, lead three and F and you can appreciate here in lead, every which is a lateral lead, you will have ST depression. So here you have ST levation in the, in the, in the inferior lead and you have uh ST depression in one of the lateral leads. So this is an inferior wall M I yeah, lead 23 and aVF. So if you have the ST ation in lead 23 and lead VF. So this is our right. Uh sorry, this to inferior wall M I. So lead 23 and aVF is the inferior wall M I which we have it here. If you have it in lead V one V two and V three, this is anti receptor and there is reciprocal changes. Yes, I agree. Susan, there is recip changes in A L. So there is some kind of uh uh uh uh ischemia affecting the lateral wall as well. However, it is uh inferior wall M I and the ST elevation are in V two V three and VF and it is more than one millimeter in those uh inferior leads. So this is an inferior wall M I. So the specificity about the inferior wall M I is very unlikely they will come with any type of uh heart failure or hypertension. However, the risk of arrhythmia is high. We keep that in mind, you know, because the right Coron artery subline, the, the uh sinus node and the, and the they can go into arrhythmia at any time. So, yes, this is true Catherine uh T 23 and A VF and uh and we will go to another CG now. So uh where are the uh where is the ST measures that you're gonna appreciate here? Just have a look and see. Yeah, very true. Yeah. Lead. Uh you can see from lead V one there is elevation lead, uh V two as well and V three. Yeah, exactly. Yeah. Uh that is very true. Lead V two to V six. So we have uh ST elevation started from lead which is more than two millimeters in the anti receptor leads. Yeah, exactly. Mohammed. This is true. Uh Lead B1, you can see high, you know, in, in very prominent in lead V two here and Conca up and you have it also in need. Uh B3, you have very good R one and uh uh so you have from V one to V six. Elevation So this is uh anterior uh wall M I. So affecting all the septum and the left ventricular as well. This is major M I, this is patient could have really been serious uh uh uh you know, condition. So, because uh it is all, you know, all affecting all the left wall area and the septum as well. So he, he, he could have heart failure, he will be in severe pain and this is something that we need to address urgently and we will go through that on. Uh And uh the next slide when we are talking about treatment so very important not to miss such CG you know, this is significant. Yes. Uh a very good we are going to come to discuss about Well Syndrome. Uh I will, I will show you an E CG with Well Syndrome. This is very important point. Doctor Adi and uh I will just take you through and tell you what is the importance of uh of the Welling syndrome. Uh Can you tell me what are your findings here in this ec? Is there an ST elevation that you can see any ST elevation you can see here? So there is uh because I am aware of the time there is uh can you see any STD any changes that you can see here? Anteroseptal uh Nelson, Doctor Nelson and ST depression. Where is the, what can you see in the anteroseptal? Ok. Yeah, there is a depression in V two, V one, V two, V three. Yeah, there is depression in V one, V two, V three. Yeah, ST depression, yeah, ST elevation in the inferior leads. Yeah, exactly. That is true. So there is ST elevation in the inferior lead which is lead two, lead three and F EF and there is T wave uh ST depression in V one V two and V three. So uh there is inferior wall M I here associated. Exactly. Well, no, uh I, I'll tell you uh it is, there is posterior wall M I obviously uh this is just make you to see if there is ast depression. As I say, it is always ischemia, always ischemia. And this significant ST depression. Yeah, very good Deborah Christian uh ast depression in via exactly as is very true. So ST depression in V one to V three lead you to with the inferior ST elevation make you to think about posterior M I posterior M I is very rare. This is part of the posterior wall, very rare to be by itself, very rare to be by itself. So it's always associated with inferior wall M I very rarely, you will have isolated ST uh posterial wall M I. However, the sub the same important thing le lead you it is that you have this ST depression significant associated in V one V two and V three. So what we are going to do in this case, in this case, we are going to have posterior leads. So we are just moving the leads in the posterior part of the of, of the chest just to be a little bit tricky. And you will have lead seven, you will have lead E eight and you will have lead uh nine which are least are in the posterior part like like the back side. Yeah, exactly suspected uh posterior M I and now it is confirmed by having a ST elevation in lead seven, lead eight and lead nine if you can see there. So M I not to miss and uh and another trick you can do just mirror of your C if you have, you turn your E CG from the other side and look at it in the, in the light, you will have the ST elevation in that lead. OK. This is just uh a trick just to, to uh to, to find out if this is an ST elevation M I. However, the important part, most of the time they are not isolated, they are part of the, yeah, uh inferior wall M I. Uh yes, we, we went through this uh here. What do you think is happening? What is the, what are, where are the elevation here? So this is a 45 year old gentleman and Asian coming in with chest pain. He's still of hyper diabetes, hyperlipidemia and he is in severe pain, left sided, chest pain, vitally stable. What do you think about this E CG. Yeah, inferior leads, well done. Inferior leads. Yeah. Very good. Yeah, inferior leads in the one lead one you can see here, lead two, lead three and lead F there is inferior lead. Uh and yeah, exactly. They are suspected, slight involvement. Very good, well done all of you. So this is S Treva here and in this case, you will ask your nurse staff to do a right side. Yeah. Very good Suzanne. Yeah, there is uh lead 23 and A VF inferior leads and also lead V one and V two. There is uh yeah, there is elation that is very true and Catherine and here we have this is you are suspecting now, right side involvement, right? There is at invasion here but not very convincing. And there is also lateral wall involvement as well. A VL there is severe C depression, you can see and there is lead one. So lead one and lead A VL are both lateral. So uh and you ask your nurse to do a right side. So you will put the least in the right side and you can have V four and very clear ST depression, ST elevation. So this is the right ventricular wall. And the problem is the right ventricular wall M I. The presentation will be like uh type of uh heart failure as well. Yeah, this is very true. Yeah. No, does it? Uh we'll just go quickly about Wellans syndrome. One of your colleague mentioned Will syndrome. So this is a Dutch cardiologist uh who wrote about this syndrome in 1982. And you can see here what is the characteristic of this uh ECG is like ST elevation and there is T wave followed immediately by tt wave depression like so negative T wave. So STD, this is type one, there is two type type A and B. So ST elevation you can see here and you can find also T wave invasion. It is very important not to miss this diagnosis because this is a sign of critical uh left anterior descending artery, uh critical stones of left anterior descending artery. And the tricky part of this Wellans syndrome is uh they will have five type of thrombus in the left anterior descending artery. They will have a chest pain, they will come to you by the time aspirin is given, you will have either aspirin induced, you know, uh lass of the of the clot or you will have spontaneous thrombo thrombolisis of this uh of this uh clot in right uh anterior descending artery. However, uh at that point of time, you will have no chest pain. So we had a patient typical like this and 51 years old, a caribbean just three months ago. Uh initially, he was normal, it is not that much of elevated. And we had uh when he had the chest pain, when the pain subsided. He had the typical ECG syndrome and one of your colleagues mentioned about T DT wave, which is just exactly type two. So you have deep T wave here in the septal leads. OK? And the patient will be just painfree. Don't send them home, please. This is the critical of the L AD and they can have uh M I next days or weeks or catastrophic fatal uh event as well. So remember about Well Syndrome and just read about it more in your free time. Another diagno this is another do cardiologist, uh Robert De Winter who also uh uh wrote about anterior elevation equivalent syndrome. You can see here high but a few T waves again in the septal lead come into the anterior list as well. And this is like 2% of patients with M I and mostly most of the time is young, uh young patients. Uh and this syndrome was being just described in 2008, you know, and you can see hyper acute T waves and again, those patients are critical stenosis of L AD. So discuss with the cardiologist, discuss with the PC and usually they take them for BC and usually they are young male patient, unstable angina. Uh Just few words, this is Angina for the first time. Angina. That is the patient will tell you uh you know, my pain is getting worse and it is I'm just not feeling well all the time with this pain. Worse on time of intensity and the time as well. Uh stable angina, remember, stable angina is always reducable and predictable. So the patient will tell you, oh doctor, I will go to the corner shop, you know, and just before reaching there, I will have this chest pain. I need, I need to stop. So he knows that is this pain is, you know, rotating by two kilometers walk, for example. But if this has changed, like I'm getting the pain now and I'm just moving having 100 m of walk or pain in rest. So you see this is unstable angina and unstable Angina is why it is serious because this means like there is there is significant pathology going on. You can have just mildly elevated troubling and those patients are going to be at risk of having complete M I and necrosis of the, of the, of the car uh of the cardiac muscle, which is we want to prevent. Now we will take you. Now you did the the patient came with a chest pain, he's low risk, you know, according to the half the score, the ECG is normal and you and now you want to do a cardiac enzymes to rule out to rule out any no M I. So either one of two, if he had, you know, if the A CD is normal and he has high troponin. So this is going to be uh no amri uh the problem is is this gray zole when there is just mildly elevated troponin. For example, uh you have the troponin is uh uh our, our cup point here in our emergency department is 1417 for female and 14 for males. And uh this patient is coming with the chest pain. You did the initial thro it came like, OK, let us say uh 17. And what are you going to do? Not that much of chest pain, you know, and E CG is normal? Very important that you review the E CG. So serious E CG are important. So you have another E CG done as well, which is normal. He said, OK, my pain improved doctor but you know, uh still have some discomfort. So you are having the second drop after two hours, you know, and the second drop came back 25 from, from 17, it went to 25. So in this depa in our department here we use 20% if there is any 20% variation, 20% variation from the F and the second drop, we take that as significant or cardic event. Just remember uh the troponin is not a sign of MRI, it is a sign of uh of uh myocardial injury. And I will next slide, I will explain to you what are the other causes that cause the rest? So as 20% variation from your basic drop make you to see, OK, there is 20% increase or 20% decrease. So we think this is an event going on. And uh now uh there is many uh centers they use not that variation of 20% but they use just the absolute difference, absolute difference mean. So for example is for example, this is this uh normal tr is 14 and your second drop came back 16 and now it's 25. So you have like increased by nine, you know, from to the 16 to 25 9. So this nine, they take that this number of nine and just divide it and see what is the, what is the half of the, of the, of your normal baseline. So your baseline is supposed to be 14. So half of 14 is 17, which we call it the absolute difference. So uh half a for uh sorry ha a 14 is seven and you have the difference of nine. So this is significant again. So either you take 2% 20% difference from your fries on the second drop or you take, you know, the difference of the absolute difference. That is more than half uh of your uh 99 percentile, 99 percentile means that is patient are uh you know, having that baseline of 14. This is just a reference from the lab. Uh Obviously retro may cause an infarction, tachy arrhythmia, Mayardit, pulmonary embolism, uh chronic heart failure can cause chronic trouble, uh raise of tron chronic kidney injuries, myocarditis and diabetes, they can all cause chronic risk of. Now, sometimes we use base Tron as well. So if the patient is having chronic kidney injury, he has troponin come to the department 34 times in the last one year and he has troponin of 40. So, uh sometimes we use that as a baseline of this particular patient. However, the most important is the patient himself. Uh what is the treatment? Very important? The ABC approach, ABC approach in trauma ABC approach in heart failure, ABC approach. In chest pain, you need to be sure that this patient is breathing fine. His situation is fine uh and his circulation is fine. So check your pulse, check your BP, check your uh heart rate, uh check your capillary refill. Take those ta take, take this patient to cardiac area. Don't leave them in the triage, don't leave them in the waiting area because they can derate at any point of time and go and go for a cardiac arrest anti ischemic uh medication. Uh GTN, obviously, if your BP is is fine and acceptable, you give them two puffs GTN under the tongue, you can use morphine because what why you are using the morphine and we know the GTN is well dilated. But why we are using the morphine because all the catamine increase the pain, increase anxiety, increase the uh you know, uh makes it worse. So you just need to make him painfree, give him some morphine, give him the GTN which monitor area discuss with your senior. Uh If ST MRI, obviously, you need to activate your PCI uh pathway and the blood is what we use in our department. And aspirin, it is called the combination that we use. And the treatment, the gold in treatment is the reperfusion cerebellum. So, uh obviously, in Europe PC is done in 72% of the cases and 20% they use thrombotic therapy as well. So I understand uh you know, you we use more uh thrombotic therapy in uh in other parts of the world PCI may be not available everywhere. But just to remember if you are in your setting, PCI is your, is your uh uh you know, treatment of choice. Yeah, this is because what is, what we need to do is just to get this, get, get, get this oxygen and blood supply to the cardium as early as possible to prevent any necrosis, necrosis will affect that part of the, of the, of the heart, of the, of the cardiac wall. Obviously, after that, arrhythmias and heart failure and and so on and so on. Uh I remember in my early days we used to go with streptokinase. Uh you know, still maybe in some parts, we still use some streptokinase. However, we use methylase here uh whenever there is a delay in uh sending those patients to the M I to the PCI center uh before starting any, uh, thrombotic therapy, you need to go through all the contraindication as well, please. So, don't try to remember them. Just take, make a list of them in your computer or in your laptop or sorry, or in your mobile. And just if you had any COVID event, I mean, any, you know, the bleed recently, if you had any major surgery recently, if you have any reco disorder and, uh, and so on. So go through the list, you know, and uh, if you need thrombotic therapy, you can provide that with your juniors with your seniors. Can we learn from the patient? Yes, we can learn from the patient. Just ask your patient, how do you feel? Is it, is it your similar chest pains that you have? The patient will tell you this is a similar patient that similar pains that I had years ago doctor. This is look like my Angina again or he will tell you something different. So listen to them. Uh you know, and uh, and uh, and just take their view involved. Do we miss mis? Yes. Unfortunately, we still miss mis and this is mainly most likely young patient, uh female patient. Uh 50% of them of unstable angina is missed. And, and the reason is that as I say, elderly patient, they will come with nonspecific uh type of chest pain or nonspecific presentation. So they will not come with significant chest pain rather than synco attack short of breath, generally, feeling confusion fall and all those type of things, young patients we tend to be like, OK, you know, not, most likely not. We tried to booster the away from them. However, just remember young people in the Asian Afro Caribbean uh Caucasian with high risk family history important to us about this family history is hyperlipidemia. They are at high risk of uh of uh M I so uh thank you very much for attending. And if there is any questions, I think we have all 34 minutes for questions. I think we had some questions right at the start, didn't we? From uh Doctor Abby? Um Oh, my days. Are you able to see them because they're quite long? Yes. Yes. Yeah, I can, I can see uh from doctor a about uh ST elevation. So uh uh one of the causes of the resistant ST elevation even after ami is a, is a type of uh uh left ventricle aneurysm. So in this case, the patient will have uh resistant ST elevation. Exactly. So he had an inferior wall M I and he's coming again with not a specific type of chest pain and you do an E CG and uh ST elevation is there. Uh uh my advice will be uh look at previous EC GS if that is was been present for some time. And the most important Doctor Adi is your patient himself. I had one such patient like maybe one year ago, he had an M I uh in long, you know, like 23 years before his presentation. However, he was sitting there in his mobile chatting with his friends. It doesn't sound like M I. So, you know, all those ECG S and uh and, and, and cardiac enzymes and labs and, and CT scans are tools to help us but not, cannot replace clinicians. So if this patient is behaving like M I, is this be behaving like IC carditis? Is this patient behaving like just the resistant elevation? Take it serious. I don't want to say ignore it even if it is there. However, try to look at previous note is that the resistant uh elevation was of aneurysm or because of pericarditis, pericarditis. This is an autoimmune reaction after A I. Is it behaving sharp type of chest pain obviously in UK and maybe in other areas as well. Your tool is ultrasound. Please try to remember to take home from this uh from this uh session. Ultrasound is very important too. You can just go and do point of care. Ultrasound. We are not doing any depth echo, just point of care ultrasound and you can find any abnormal mm motion of the ventricle as well. So this will be my answer for this question. OK. We have a um uh question radiotherapy uh in cancer patient, long term cardiac fibrosis, ulv disease, coronary artery disease. Oh Which one are you on? Uh from, I gave it from doctor. OK. Come on. Uh does radio therapy for thoracic cancer cause long term cardiac fibrosis var disease? Yeah. Yeah. Uh uh ii it is difficult for me because I am not, I am not a cardio, I am not a oncologist. However, we uh patient the present to the emergency department is uh cardial effusion, you know, uh because of the uh of, of uh a relation with the cancer and we had few cases with uh uh with uh cardiac tamponade due to different type of cancer and they developed significant cardial infusion. Uh Obviously, you can have radio of pulmonary uh cardiac fibrosis and cardiovas as well, but very rarely to be presented to the. But uh keep in mind those uh uh uh because of cancer related there is yes. Uh this is another question from uh as well. It is uh about the troponin. You, we had SC KMB, we had a lot of novel treatment, you know, uh cardiac enzyme. However, until now, there is a lot of investigations and a lot of research going on. And uh the troponin is uh is the ones that we are using and proved to be very useful. Uh There is Professor uh Richard uh body who is in Manchester. He's an ad physician and he had a lot of research with regard to troponin and cardiac enzymes. And uh the latest things I can just update you that uh there is a big trial going in Manchester with regard to prehospital drug. So what they are going, the ambulance uh arrive to the, you know, to the patient at home. And if they think this is not card patient, we can be happy if we have negative Troon, they will, they will do a Troon on, on uh on uh of the scene. It will take eight minutes. However, this drop cannot be done while you are in the kids themselves. They need to be not, you know, during transport. So this is what we are waiting for. Uh you know that uh study to come with the results. So we can have pre hospital drug done. Now, a lot of hospital in Europe, they use one hour drop. So you don't need to wait for three hours. Uh I remember we had the CK before, you know, when I was young doctor, completely nonspecific C KMB came back and we have been very happy, came back. But uh none of them proved to be doing any good. The drug is uh is uh uh uh is the one of the one is the, is the drug, is the investigation of choice renal disease. Obviously. Yes, you know, we have that probably will be 200 with acute with chronic kidney injury. Uh In this case, you cannot interpret it on the troponin. It is all about your patient. How you think he's doing renal disease by itself is high risk of uh ischemic event. So be careful with those patients, but obviously, you cannot rely on the thin when you are talking about uh renal disease. However, uh just ii went through that the slide with regard to chronic. So diabetes, they can have heart thro chronic skin disease, they can have Hyro but you need to interpret that with your patient. How is your patient doing? You know, uh is it co alleviation in his stroke? Is it due to renal, you know, failure? As you see, the patient is important. Serial P CS are important. The history is important. 80% will diagnosed in the history. So just take careful history from the patient from relative from paramedics and interpretate your clinical examination, uh your clinical, your investigation findings accordingly. I hope that will answer your question. Ok, we have a couple more. Uh We have one from Suzanne and one from Christian. Uh What about Agosa criteria? Could you please clarify it for us? In brief? Yes. Uh It is with, with regard to left bent transport, it was being left before it is a new onset of left bundle block. That is uh uh coming to obviously, this is an indication of PCI and referral to the emergency department. I will advise it was being left behind, but now again, modified uh criteria came on and, and, and, and we can use it uh criteria. So uh uh most of the time we use it, however, uh don't, it's not going to be really like uh your decision with regard to referring patient to the BC or not. Uh Still you need to discuss with the cardiology about it. If you have left bundle branch block, just try to go quickly to the patient notes and uh and find if you have the left bundle branch, all leg bundle branch block, uh if it is old, that's fine. So you don't need to do anything unless he's really in pain. But if it is a new onset, you need to discuss with your cardiologist. Obviously, if there is negative coins, all of them, you can it help you on the one but not to rely on them completely. Still. If you see this is a left bundle branch on, this is an indication of PCR. If you see this patient is hypertensive cardiomyopathy. Uh a lot of visit to the ED, you can have his old notes uh and you can have all ECG S and you say, oh, this is an old. Uh And again, the most important if he has left on the bottom and sitting there and his mind fine and everything is fine. Chest pain is not specific. We don't need to go for that. Uh We have patients that we send PCI with the block. Uh and they, you know, and they send them back. So it is not something that is uh at the moment of uh of uh the what I can say, determined factor on what you are going to do rather than the patient itself at the form of. Uh but it still in the guidelines you need to discuss with the PCI center. Ok, Christian. Um and I think somebody else uh Mavis has uh uh said, can you please comment on the first case, a female diabetic smoker with chest pain and systolic murmur? Yes. Uh Thank you for reminding me about this. Really. I just, I had this patient about fi uh five years ago as I see it. And when I examined her, uh it she, she had the left butal murmur and uh we had no uh we had fast scan machine, but this is not an echo machine. And I went through her file. I asked her if she had a murmur or not. She said no murmur, nothing. Is there? I work in a hospital at that time during the winter time, we don't have helicopter to fly. So uh the transport period from our hospital to the BCI center during the wintertime by land, it will take about more than two hours. So that was indication for so therapy in the hospital, in our hospital and rescue BCI in you know, the BCI center. But I was very suspicious about this left uh uh left P member. So I decided, no, we are not going to vi this patient. You need to go straight to them and it was been a discussion between me and cardiology. You know, you need to, you know, uh either we will or not anyhow, we disagree. Not hard just to clarify what is going on. Uh And this lady tend to have uh septal defect induced by the Mr so she had the septal M I like I show you in the ECG and this is one in 50,000 complication of M I. So one in 50,000 M I, they can have uh interven receptor defect due to the M I itself. So when she arrived there, she had a collapse, they did a bedside echo and they found that there is a sep defect. They kept her for two days because you need two weeks to, to heal that you can go do any kind of intervention. However, her critical situation, her critical condition, uh you know, uh uh uh uh after review by the Cardiothoracic Center, she had two days of uh two days on the it and she went for surgery. So the, the message is on the learning point, your clinical examination is important. You know, we know ST elevation Mr everyone is excited about it. However, you go, you examine the patient if there is any murmur. Uh you know, you just need to uh you know, to look at that. So in this case, very rare, we had uh septal and, and uh septal defect induced by septal MRI. And I think we've got one Did you see the one from Doctor Abby? Yes. Uh left ventricle aneurysm become thromboembolic. Obviously, every type of aneurysm, it can be uh it can present, it can have uh thrombotic events. So what is going on with aneurysm? You have that uh kind of uh decreased motion, decreased motility of that area and any kind of decreased motility, you will have uh the position of thrombo embolic event in and this in af while you're in af we need to uh start the anticoagulant because the decreased motion, decreased mo mo mobility of that particular area of the ventricular wall. And that area is prone to, to formation of uh thrombus and uh and uh and obviously embolisms, strokes, uh ran and you know, pulmonary embolism and other part of mesenteric as well. So usually, I think they need to be uh you know, this is why we start patient with arterial fibrillation on anticoagulant. This is the the main reason. And now even your patient is coming with arterial fibrillation uh in the department most of the time, you know, 50% they convert by themselves or you give some kind of uh meta blocker metoprolol or whatever you are given and they are back to sinus reason. Now, the tendency of uh of some of the cardiologists, even if they revert to sinus with your, their admission to the ED is still they go with anticoagulant at home for two days. And the reason is that they think that is that part of the wall who is, who has been in atrial fibrillation, it will take time for it to completely, you know, uh uh completely regain the motion. And uh for until that time is happening, there is also position of forming uh you know, thrombus over there and causing cerebellar stroke. It is very important topic. I'm very happy that you raise this point because in a we tend not to start anticoagulation, we leave it to someone else. However, now we have many patients attending A&E because of atrial fibrillation. You know, we give them some birth control medication or, or car variant. Sometimes they go home and they go home and you know, they have stroke, which is devastating, horrible thing to have. Perfect. I think that's us. I think as you can see, you've got lots and lots of thank yous, lots and lots of er, amazing informative. Um So that's absolutely brilliant. Um To all our delegates, the feedback form will be in your inbox. Um If you can complete that, that would be great. I will be passing on the feedback er, to Doctor Hasan. So please complete that feedback form. I can pass it on and maybe we can convince him to give us another talk one day. Ok. So for now, er, Doctor Hasan and I will say goodbye to you all. So enjoy the rest of your day and we will see you at another medical education.