Chest Pain and Shortness of Breath

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     1  Chest Pain and Shortness of Breath Brett Sheridan, M.D., F.A.C.S Assistant Professor Cardiothoracic Surgery Department of Surgery
     2  Causes of Chest Pain and SOB Myocardial Infarction Pulmonary Embolism Pneumothorax Hemopneumothorax Thoracic Aortic Dissection Esophageal Rupture Gastro-esophageal Reflux Empyema
     3  47 y/o man is jogging with his daughter when he suddenly collapses unconscious……
     4  1) Heart Disease2) Cancer3) Stroke Most common causes of death in the US…
     5  How many people in the US died from cardiovascular disease in 2001?
     6  Do more men or women die from cardiovascular disease?
     7  Acute coronary syndrome (ACS) is defined by EITHER acute myocardial infarction OR unstable angina.These patients are divided into 3 subsets: ST elevation myocardial infarction (STEMI) non-ST elevation MI Unstable angina
     8  ECG within 10 minutes Supplemental O2 IV access continuous ECG monitoring Sublingual NTG if SBP > 90 mmHG Morphine ASA (chewed) Labs If ST elevation > 1mV or LBBB then reperfusion (fibrinolysis or PTCA) Describe the initial stabilizing treatment for symptomatic ischemic heart disease presenting in the ER
     9  What is AMI management in first 24 hours? Limited activity 12 hrs and monitor 24 hrs No prophylactic antiarrythmics IV heparin if: large anterior MI, PTCA, LV thrombus or thrombolytics administered SQ heparin for all others ASA indefinitely IV NTG x 24 hrs IV beta-blocker if stable ACE inhibitor if BP permits Statin therapy
     10  Why are patients referred for CABG instead of undergoing a PCI approach to coronary artery disease?
     11  Percutaneous coronary angioplasty (PTCA, PCI,…)
     12  Percutaneous coronary angioplasty (PTCA, PCI,…)
     13  Percutaneous coronary angioplasty (PTCA, PCI,…)
     14  Natural history of percutaneous coronary angioplasty…..uh-oh!
     15  Cite 2 prospective randomized trials comparing PCI vs CABG for the treatment of multivessel CAD
     16  Inclusion Criteria Symptomatic Multivessel CAD LVEF > 30% Baseline Characteristics Class III/IV angina - 66% Previous MI - 42% 3 vessel CAD - 30% mean LVEF = 60%
     17  Comparison of Coronary-Artery Bypass Surgery and Stenting for the Treatment of Multivessel Disease(Arterial Revascularization Therapies Study Group) CABG PCI Patients (n)                                    605                                      600 Late outcome                              ---------------------1 year-----------------Death                                           2.8%                                  2.5%MI                                                4.0%                                   5.3% CVA 2.0% 1.5% Revascularization *                    4 %                               17%Event-free survival *                  88%                                74%Symptom-free *                          90%                                    79% Cost *                            $13,638                              $10,665
     18  14% benefit w/ CABG! Event –free Survival: CABG vs PCIS
     20  16 % benefit w/ CABG! Risk of Repeat Revascularization
     21  Risk of Death 3.7 % SURVIVAL benefit w/ CABG!
     22  Conclusions-SoS Trial Again, repeat revascularization remains more common after PCI (with or without a stent) in multivessel CAD. In this study, higher rate of all cause mortality with PCI
     23  Contrast the difference between “off-pump” CABG versus the typical cardiopulmonary bypass supported CABG.
     24  Traditional CABG General anesthetic Median sternotomy Conduit harvest (LITA, radial, vein) Institution of cardiopulmonary bypass (CPB) Cardiac arrest Placement of aorto-coronary grafts Seperation from CPB Close
     26  Advantages - Traditional CABG Still Heart Exposure and access Visualization The most intensely scrutinized procedure in US medicine SAFETY
     27  Disadvantages - Traditional CABG Proinflammatory response to CPB Suggestion of end-organ injury CNS Pulmonary Renal Increased fluid shifts
     28  Off-Pump Stabilizer
     29  Off-Pump- Snare
     30  Off-Pump Stabilizing Devices
     32  Off-Pump Exposure of PDA
     33  List 10 complications of CABG and there relative frequency
     34  Death 3% Stroke 1-2% Bleeding requiring re-op 3-5% Wound Problems 0.5-5% Myocardial infarction 2-30% Arrhythmias 10-60% Pneumonia 4% Pneumothorax 1-2% Cardiac Tamponade 3-6% Pericardial Inflammation 18% Renal Insufficiency 15-20%
     35  What four medications prevent MI and death following a myocardial infarction.
     36  “Class I” Indications ASA Beta-blockers ACE inhibitor Statins
     45  Risk Of Pneumothorax Pain SOB ( dyspnea) Hypoxia Hypotension (embarrassed CO) Death
     46  DDX of Underlying Pulmonary Pathology Spontaneous Primary Subpleural bleb Secondary Chronic Obstructive lung disease Bullous disease Cystic fibrosis Pneumocystis-related Idiopathic pulmonary fibrosis Pulmonary embolism Catamenial Esophageal perforation Neonatal Acquired Trauma Iatrogenic
     47  Treatment options Observation Tube thoracostomy Surgery Other “dated” options Needle aspiration Chemical pleurodesis
     48  Observation Asymptomatic Pneumothorax less than 20% ER for 4-6 hours w/ repeat CXR F/U within 48 hours and CXR Any doubts --admit
     49  Tube Thoracostomy Primary Method of Management Prompt re-expansion of lung Prevents life-threatening sequelae Allows pleural-pleural apposition –sealing injured lung Tube removed once air leak resolves for 12 hours
     50  Prognosis Usually resolves within 1-2 days 30% chance of recurrence Increases to 60-70% if second pneumothorax
     51  Surgery- Indications Recurrent pneumothorax Persistent air leak or incomplete expansion Massive air leak with incomplete expansion History of bilateral pneumothoraces Occupational hazard or lack of access Hemopneumothorax
     52  Surgery-Procedure Video-assisted thorascopic surgery (VATS) Resection of offending bleb Mechanical pleurodesis Tube thoracostomy Chemical pleurodesis Tetracycline Talc
     53  Treatment of Secondary Pneumothoraces Usually associated with significant comorbid disease and debilitated patients Individualize treatment (less is more) AIDS and Pneumocystis carinii COPD Cystic fibrosis
     54  Hemothorax - Etiologies Pulmonary Bullous emphysema Necrotizing Infections PE with lung infarction Tuberculosis AV malformation Hereditary hemorrhagic telangiectasia Pleural Neoplasm (mesothelioma) Endometriosis Pulmonary Neoplasm Primary Metastatic Melanoma Trophoblastic tumors Blood Dyscrasia Thrombocytopenia Hemophilia Complication of systemic anticoagulation Von Willebrand’s disease Abdominal Pathology Pacreatic pseudocyst Splenic artery aneurysm Hemoperitoneum Thoracic Pathology Ruptured thoracic aortic aneurysm Top Causes Trauma . . . Cancer Pulmonary embolism
     58  Hemothorax- What to do? Traumatic Tube thoracostomy- large bore IF more than 1500 mL or more than 200 mL/hour x 3 hours THEN surgical exploration Non-Traumatic Needle aspiration Cytology Tube thoracostomy if HCT > 50%
     59  Aortic Dissection…What is it? A bad problem to have A sudden (usually) intimal tear of the aorta creating a true lumen and a false lumen Consequences of this tear are variable depending on location and progression of the dissection
     60  Classification-DeBakey
     65  Histology and Structure Normal aorta- 3 layers intima tunic media adventitia
     66  Histology and Structure Media- strongest usually 1.2 mm most affected by dissection elastic collagen fibers 20-30 % of aortic wall smooth muscle cells 5 % Microfibrils contain the glycoprotein “fibrillin.” These act as scaffolding for deposition of elastin to produce concentric rings of tunica media.
     68  more….Histology and Structure Aortic dissection denotes one or more tears b/w the the aortic lumen and a medial cleavage plane May be localized to the point of “primary tear” but often extends. Rarely circumferential Re-entry tears occur often… providing communication b/w true and false channels.
     70  even more….Histology and Structure The dissection usually splits the outer layers of the media and weakens the external coat. The false channel may dilate or rupture. The false channel eventually develops an endothelial lining but may contain extensive thrombus. Acute stage –14 days Subacute - 2 months Chronic - after 2 months
     71  Incidence Annual estimated @ 2-5 cases per million Pathology series the prevalence ranged from 0.2 to 0.8% in Chicago and Boston Males > Females 2:1 Type A - 50-55 years Type B - 65 years
     72  Risk Factors pregnancy Marfan’s hypertension aortic coarctation congenital aortic valve anomalies
     73  Presentation- acute dissection Sudden severe chest pain (90%) worst at onset not previously experienced …adjectives such as “ripping” and “tearing”
     74  Presentation- acute dissection Sudden severe chest pain (90%) worst at onset not previously experienced …adjectives such as “ripping” and “tearing” History of hypertension Type A- pain? mid-sternal Type B-pain ?inter-scapular If extension… neurologic deficit, abdominal pain, or peripheral extremity ischemia
     75  Differential Dx- acute dissection Coronary ischemia/ myocardial infarction Aortic aneurysm w/o dissection Musculoskeletal Pericarditis Biliary colic Pulmonary embolism
     76  Physical exam- acute dissection Blood pressure usually elevated Hypotension associated w/ pericardial tamponade, rupture, aortic insufficiency, or massive MI New pulse deficit- 60% Diastolic decrescendo murmur @ LSB- aortic regurgitation Diminished left-sided breath sounds- hemothorax Neurologic exam mental status, focality --peripheral vs central
     77  Diagnostic studies- acute dissection CXR deformity of Aortic knob, widened mediastinum, left pleural effusion, etc. EKG- chest pain w/ normal EKG sine qua non
     78  Diagnostic studies- acute dissection Echocardiography currently thought to be the preferred diagnostic test –rapid and accurate. Evaluates aortic valve, segmental wall function, pericardial effusion. Unfortunately operator dependent.
     79  Diagnostic studies- acute dissection CT- expeditious w/ reasonable sensitivity and specificity
     80  Diagnostic studies- acute dissection MRA-excellent sensitivity and specificity but slow
     84  Diagnostic studies- acute dissection Aortography - lacks sensitivity as imaging requires blood flow which may not occur in false lumen. Indication for coronary angiogram remains controversial.
     85  DeBakey, Surgery, 1982
     86  Medical Treatment Type A 24 hrs 72% 2 wks 43% 5 yrs 34% 10 yrs 28% Type B 100% 92% 76% 56% Masuda, Circulation, 1991
     87  Medical Treatment- Aortic Dissection Masuda, Circulation, 1991
     88  Medical vs Surgical - Type B Ao Dissection Glower, Ann Surg, 1991
     89  Conclusion Aortic dissection is a bad problem to have High index of suspicion Control heart rate and blood pressure URGENTLY Type A requires immediate surgery Type B - best served w/ medical treatment If ischemic complications, the patient faces a grim prognosis with (or without) surgery therefore a surgical approach may be advocated.
     90  Esophageal Rupture- Causes Iatrogenic Esophageal endoscopy /dilation Paraesophageal surgery Boerhaave syndrome Trauma Foreign Body Caustic
     93  Proximal to the upper esophageal sphincter Gastric cardia Esophageal stricture Esophageal Rupture- Most common sites of iatrogenic perforation
     94  Untreated perforation Medianstinitis Death
     95  Nonoperative Management of Esophageal perforation Criteria Disruption contained within the mediastinum Free drainage back into the esophagus Minimal symptoms Minimal signs of sepsis Nasogastric decompression Percutaneous drainage IV antibiotics (oral flora) Parenteral nutrition
     96  Esophageal Rupture-Principles of surgical treatment Debridement Treat the underlying problem Cancer Stenosis Reflux Repair of perforation Drainage
     97  Gastroesophageal Reflux Disease 50% of asthma patients have objective evidence of esophageal reflux Pathophysiology: Reflux vs Reflex Anti-reflux surgery improves asthma symptoms 90% of children 70% of adults
     98  GERD – Diagnostic evaluation History and Physical Exam Tests 24 hour ambulatory pH Monitoring Manometry Barium swallow Upper endoscopy
     99  GERD- Complications Stricture 4-20% Barrett’s esophagus 10-15% Esophageal ulcer 2-7% Hemorrhage 2%
     100  GERD- Pathophysiology More frequent and prolonged relaxations of the lower esophageal sphincter Increased exposure of esophageal mucosa to acid, pepsin and bile salts Hiatal hernia ???
     104  GERD- Goals of treatment Heal the injured mucosa Eliminate symptoms Prevent or treat complications of GERD
     105  GERD – Treatment Options Lifestyle modifications H2 Blockers Proton Pump Inhibitors Surveillance for persistent symptoms Endoscopy Anti-reflux surgery
     107  Empyema Infection of the pleural space Usually a complication of a bacterial pneumonia or lung abscess
     109  Empyema- Common organisms Staphylococcus aureus (most common) Streptococcus Pseudomonas Klebsiella pneumoniae E. Coli Proteus Bacteroides
     110  Empyema - Diagnosis History and Physical Exam Chest radiograph Chest CT scan Needle aspiration
     111  Empyema- Treatment Goals Resolve sepsis Complete expansion of lung Antibiotics Drain the space (abscess) – Chest tube Child vs Adult Decortication VATS Thoracotomy