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Epigastric Pain: Think about the Heart! - VA NR 7/23/19 - Alluri

Updated: Aug 6, 2019

Dr. Alluri presented a case of a 41 yo M w/ non-radiating epigastric abdominal pain x1d following ingestion of dinner. He had a hx of CAD s/p PCI and CABG years prior.

The differential consisted of GI etiologies (gastritis, PUD, pancreatitis, biliary and hepatic etiologies, colitis, motility D/O's, etc) as well as ACS and aortic dissection.


His initial troponin was negative and EKG showed an old Q wave Inferior MI w/ depressed/inverted t waves in these leads. Our pt's HEART score was 4.


He was admitted to OBS for ACS rule out and was found to have a precipitous increase in his troponin. He was diagnosed with NSTEMI, TIMI score 4.


ACS Categorization




ACS Pathophys - by entity



Angina Def'ns


Angina = pain due to insufficient of blood supply to myocardium


Angina is unstable if it presents in any of the following three ways:

●Rest angina, generally lasting longer than 20 minutes

●New onset angina that markedly limits physical activity

●Increasing angina that is more frequent, lasts longer, or occurs with less exertion than previous angina


TIMI Score: (1 point each) categorizes the risk of death and ischemic events which provides a basis for therapeutic decision making

• Age ≥ 65 y/o

• ≥3 traditional CAD risk factors

• Documented CAD w/ ≥50% diameter stenosis

• ST changes of at least 0.5mm on admission ECG

• ≥2 anginal episodes in the past 24 hours

• ASA use in past week

• Elevated cardiac biomarkers (CKMB or trop)

Risk score interpretation: % risk at 14 days of all-cause mortality, new or recurrent MI, or severe recurrent ischemia requiring urgent revascularization.

0-1 = 4.7%; 2 = 8.3%--> low risk

3 = 13.2%; 4 = 19.9%--> intermediate risk

5 = 26.2%; 6-7 = at least 40.9% risk--> high risk

**TIMI Score ≥3 are more likely to benefit from an early invasive approach

Patient’s TIMI Score: 4


UA/NSTEMI Management:

1. Medications:

-Dual Anti-Platelet Therapy: ASA plus clopidogrel

uACS, CABG : 12 mo uStable Ischemic Heart Disease uBMS: 1-3 mo uDES: 6 mo

-Nitrates

-high intensity statin

-BB

-heparin

-O2 if needed


2. Risk stratification using TIMI score


Atypical ACS Presentations:


Review of >430,000 pts w/ confirmed MI:

- 1/3 had no chest pain on presentation

- Instead had: dyspnea, weakness, nausea/vomiting, epigastric pain or discomfort, palpitations, syncope

- Epidemiology: older, diabetic, women.

Patients without chest pain Less likely to be diagnosed with a confirmed MI on admission

(22 versus 50 percent in those with chest pain)


Health Disparity in Women with MI

*Women with MI may more frequently present without chest pain.


In a prospective 1015 pt cohort (30% women) of <= 55yo evaluated for an acute coronary syndrome (ACS):

- % who presented without chest pain was higher in women (19.0 versus 13.7).


ER study in pts with ACS Sxs: women more likely to be discharged without hospitalization compared with men (3.4% v 1.4%, p = 0.05) .


Women are less likely to be treated with appropriate medical therapy and to receive thrombolytic therapy or primary PCI (25 versus 74 percent).


Women w/ MI: associated with an increase in in-hospital mortality (23.3 versus 9.3 percent)

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