Trainee Advanced Clinical Practitioner Diary- Day 12

Treat chest pain as ischeamic heart disease until proven otherwise. Try to discover features of the chest pain which might lead you to a different conclusion.

Differentials might include:

MSK

Pulmonary Embolism

Pleurisy

Infection

Trauma

SOCRATES

Has the patient had the pain before?

How long did they have the pain for?

What brought the pain on- do they get it at rest or with exertion?

Does the patient have any of the risk factors?

e.g.

• Age >= 65- Aspirin use in the last 7 days (patient experiences chest pain despite ASA use in past 7 days)- At least 2 angina episodes within the last 24hrs- ST changes of at least 0.5mm on admission EKG- Elevated serum cardiac biomarkers- Known Coronary Artery Disease (CAD) (coronary stenosis >= 50%)

  – At least 3 risk factors for CAD, such as:

 

Hypertension -> 140/90 or on antihypertensives,

current cigarette smoker,

low HDL cholesterol (< 40 mg/dL),

diabetes mellitus,

Family history of premature CAD (CAD in male first-degree relative, or father less than 55, or female first-degree relative or mother less than 65).

The TIMI Risk Score for Unstable Angina/Non–ST Elevation MIA Method for Prognostication and Therapeutic Decision Making- JAMA. 2000;284(7)

Risk factors for myocardial infarction in women and men: insights from the INTERHEART study- European Heart Journal 2008.

Cardiovascular risk factors and clinical presentation in acute coronary syndromes- Heart 2005;91:1141–1147

GRACE ACS Risk and Mortality Calculator