You are here

Article Text

Article menu

Download PDFPDF

Education in Heart
Case 3: Acute chest pain
Free
  1. Christopher S R Baker
  1. Charing Cross and Hammersmith Hospitals, London, UK

http://dx.doi.org/10.1136/heart.90.1.112

Statistics from Altmetric.com

    Request Permissions

    If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

    A 49 year old Afro-Caribbean woman presents to A&E after a 30 minute episode of severe, burning central chest pain radiating to the throat. When she had the pain she felt cold and sweaty but is now symptom-free. Episodes of a similar but less severe pain had occurred daily for the previous 10 days, predominantly at rest but also when climbing the stairs at home.

    The patient has multiple risk factors for coronary disease (including type II diabetes, hypertension, and being a smoker), but the clinical presentation is not absolutely typical for coronary artery disease and the initial ECG is normal. There is also a history from the patient of an exercise stress test one week before, which she believed to be normal.

    The significance of these signs and symptoms, the diagnosis, and the short and long term treatment of these problems are discussed in an interactive case presentation.

    Learning objectives

    When you have completed this case you should understand:

    1. Risk assessment in patients with an acute coronary syndrome (ACS)

    2. The natural history of ACS

    3. The potential pitfalls in data interpretation

    4. Choosing who needs early intervention in ACS

    5. The best combination of drug treatment and intervention in this situation

    References

    1. Cohen M, Stinnett SS, Weatherley BD, et al. Predictors of recurrent ischemic events and death in unstable coronary artery disease after treatment with combination antithrombotic therapy. Am Heart J2000;139:962–70.
      OpenUrlCrossRefPubMedWeb of Science
    2. Antman EM, Cohen M, Bernink PJLM, et al. The TIMI risk score for unstable angina/non-ST elevation MI: a method for prognostication and therapeutic decision making. JAMA2000;284:835–42.
      OpenUrlCrossRefPubMedWeb of Science
    3. Boersma E, Pieper KS, Steyerberg EW, et al. Predictors of outcome in patients with acute coronary syndromes without persistent ST-segment elevation: results from an international trial of 9461 patients. Circulation2000;101:2557–67.
      OpenUrlAbstract/FREE Full Text
    4. Theroux P, Fuster V. Acute coronary syndromes: unstable angina and non-Q-wave myocardial infarction. Circulation1998;97:1195–206.
      OpenUrlFREE Full Text
    5. Antman EM, Tanasijevic MJ, Thompson B, et al. Cardiac-specific troponin I levels to predict the risk of mortality in patients with acute coronary syndromes. N Engl J Med1996;335:1342–9.
      OpenUrlCrossRefPubMedWeb of Science
    6. Ottani F, Galvani M, Ferrini D, et al. Direct comparison of early elevations of cardiac troponin T and I in patients with clinical unstable angina. Am Heart J1999;137:284–91.
      OpenUrlCrossRefPubMedWeb of Science
    7. Savonitto S, Ardissino D, Granger CB, et al. Prognostic value of the admission electrocardiogram in acute coronary syndromes. JAMA1999;281:707–13.
      OpenUrlCrossRefPubMedWeb of Science
    8. PRISM Study Investigators. A comparison of aspirin plus tirofiban with aspirin plus heparin for unstable angina. Platelet receptor inhibition in ischemic syndrome management (PRISM) study investigators. N Engl J Med1998;338:1498–505.
      OpenUrlCrossRefPubMedWeb of Science
    9. PRISM-PLUS Study Investigators. Inhibition of the platelet glycoprotein IIb/IIIa receptor with tirofiban in unstable angina and non-Q-wave myocardial infarction. Platelet receptor inhibition in ischemic syndrome management in patients limited by unstable signs and symptoms (PRISM-PLUS) study investigators. N Engl J Med1998;338:1488–97.
      OpenUrlCrossRefPubMedWeb of Science
    10. Hultgren HN, Pfeifer JF, Angell WW, Lipton MJ, Bilisoly J. Unstable angina: comparison of medical and surgical management. Am J Cardiol1977;39:734–40.
      OpenUrlCrossRefPubMedWeb of Science
    11. Luchi RJ, Scott SM, Deupree RH. Comparison of medical and surgical treatment for unstable angina pectoris. Results of a Veterans Administration cooperative study. N Engl J Med1987;316:977–84.
      OpenUrlPubMedWeb of Science
    12. TIMI IIIB Trial Investigators. Effects of tissue plasminogen activator and a comparison of early invasive and conservative strategies in unstable angina and non-Q-wave myocardial infarction. Results of the TIMI IIIB trial. Thrombolysis in myocardial ischemia. Circulation1994;89:1545–56.
      OpenUrlAbstract/FREE Full Text
    13. Wallentin L, Lagerqvist B, Husted S, et al. Outcome at 1 year after an invasive compared with a non-invasive strategy in unstable coronary-artery disease: the FRISC II invasive randomised trial. FRISC II investigators. Fast revascularisation during instability in coronary artery disease. Lancet2000;356:9–16.
      OpenUrlCrossRefPubMedWeb of Science
    14. Cannon CP, Weintraub WS, Demopoulos LA, et al. Comparison of early invasive and conservative strategies in patients with unstable coronary syndromes treated with the glycoprotein IIb/IIIa inhibitor tirofiban. N Engl J Med2001;344:1879–87.
      OpenUrlCrossRefPubMedWeb of Science
    15. RISC Group. Risk of myocardial infarction and death during treatment with low dose aspirin and intravenous heparin in men with unstable coronary artery disease. The RISC group. Lancet1990;336:827–30.
      OpenUrlCrossRefPubMedWeb of Science
    16. Knight CJ. National Institute for Clinical Excellence guidance: too NICE to glycoprotein IIb/IIIa inhibitors? Heart2001;85:481–3.
      OpenUrlFREE Full Text
    17. The PURSUIT Trial Investigators. Inhibition of platelet glycoprotein IIb/IIIa with eptifibatide in patients with acute coronary syndromes. The PURSUIT trial investigators. Platelet glycoprotein IIb/IIIa in unstable angina: receptor suppression using Integrilin therapy. N Engl J Med1998;339:436–43.
      OpenUrlCrossRefPubMedWeb of Science
    18. Simoons ML, for the GUSTO IV-ACS Investigators. Effect of glycoprotein IIb/IIIa receptor blocker abciximab on outcome in patients with acute coronary syndromes without early coronary revascularisation: the GUSTO IV-ACS randomised trial. Lancet2001;357:1915–24.
      OpenUrlCrossRefPubMedWeb of Science
    19. CAPTURE Investigators. Randomised placebo-controlled trial of abciximab before and during coronary intervention in refractory unstable angina: the CAPTURE Study. [Erratum in: Lancet 1997;350:744] Lancet1997;349:1429–35.
      OpenUrlCrossRefPubMedWeb of Science
    20. The RESTORE Investigators. Effects of platelet glycoprotein IIb/IIIa blockade with tirofiban on adverse cardiac events in patients with unstable angina or acute myocardial infarction undergoing coronary angioplasty. The RESTORE investigators. Randomized efficacy study of tirofiban for outcomes and restenosis. Circulation1997;96:1445–53.
      OpenUrlAbstract/FREE Full Text
    21. IMPACT-II Investigators. Randomised placebo-controlled trial of effect of eptifibatide on complications of percutaneous coronary intervention: IMPACT-II. Integrilin to minimise platelet aggregation and coronary thrombosis-II. Lancet1997;349:1422–8.
      OpenUrlCrossRefPubMedWeb of Science
    22. Topol EJ, Moliterno DJ, Herrmann HC, et al. Comparison of two platelet glycoprotein IIb/IIIa inhibitors, tirofiban and abciximab, for the prevention of ischemic events with percutaneous coronary revascularization. N Engl J Med2001;344:1888–94.
      OpenUrlCrossRefPubMedWeb of Science
    23. Yusuf S, Zhao F, Mehta SR, et al. Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST-segment elevation. N Engl J Med2001;345:494–502.
      OpenUrlCrossRefPubMedWeb of Science
    24. Steinhubl SR, Berger PB, Mann JT 3rd, et al. for the CREDO Investigators. Early and sustained dual oral antiplatelet therapy following percutaneous coronary intervention: a randomized controlled trial. JAMA2002;288:2411–20.
      OpenUrlCrossRefPubMedWeb of Science
    25. Moses JW, Leon MB, Popma JJ, et al. for the SIRIUS Investigators. Sirolimus-eluting stents versus standard stents in patients with stenosis in a native coronary artery. N Engl J Med2003;349:1315–23.
      OpenUrlCrossRefPubMedWeb of Science
    26. Cohen M, Demers C, Gurfinkel EP, et al. A comparison of lower-molecular-weight heparin with unfractionated heparin for unstable coronary artery disease. N Engl J Med1997;337:447–52.
      OpenUrlCrossRefPubMedWeb of Science