Chest pain.

Surgical treatment of Acute coronary syndrome (ACS)

Chest pain
May be a symptom of a number of serious conditions and is generally considered a medical emergency. Even though it may be determined that the pain is non-cardiac in origin, this is often a diagnosis of exclusion made after ruling out more serious causes of the pain.

 Deciding the cause of chest pain is sometimes very difficult and may require blood tests, Xrays, CT scans and other tests to sort out the diagnosis. Often though, a careful history taken by the health care professional may be all that is needed to find the answer. Causes of chest pain range from non-serious to serious to life threatening

causes of chest pain

Pain can be caused by almost every structure in the chest. Different organs can produce different types of pain but unfortunately the pain is not specific to each cause

Potential causes
Broken or bruised ribs Pleuritis or pleurisy Pneumothorax Shingles Pneumonia Pulmonary embolus Angina Heart attack (myocardial infarction) Pericarditis The aorta and aortic dissection The esophagus and reflux esophagitis Referred abdominal pain

diagnose
typical approach to chest pain involves ruling out the most dangerous causes: heart attack, pulmonary embolism, thoracic aortic dissection, esophageal rupture, tension pneumothorax and cardiac tamponade.

Acute coronary syndrome (ACS)

any group of symptoms attributed to obstruction of the coronary arteries. The most common symptom chest pain often radiating of the left arm or angle of the jaw pressure-like in character associated with nausea and sweating.

 Acute coronary syndrome usually occurs as a result of one of three problems: ST elevation myocardial infarction (30%) non ST elevation myocardial infarction (25%) unstable angina (38%)

 ACS should be distinguished from stable angina, which develops during exertion and resolves at rest. In contrast with stable angina, unstable angina occurs suddenly, often at rest or with minimal exertion, or at lesser degrees of exertion than the individual's previous angina ("crescendo angina"). New onset angina is also considered unstable angina, since it suggests a new problem in a coronary artery

Diagnosis
Electrocardiogram electrocardiogram is the investigation that most reliably distinguishes between various causes. If this indicates acute heart damage (elevation in the ST segment, new left bundle branch block), treatment for a heart attack in the form of angioplasty or thrombolysis is indicated immediately. In the absence of such changes, it is not possible to immediately distinguish between unstable angina and NSTEMI.

Imaging and blood tests As it is only one of the many potential causes of chest pain, the patient usually has a number of tests in the emergency department, such as a chest X-ray, blood tests (including myocardial markers such as troponin I or T, and H-FABP and/or a D-dimer if a pulmonary embolism is suspected), telemetry (monitoring of the heart rhythm).

Treatment
STEMI If the ECG confirms changes suggestive of myocardial infarction (ST elevations in specific leads, a new left bundle branch block or a true posterior MI pattern), thrombolytics may be administered or primary coronary angioplasty may be performed.

NSTEMI and NSTE-ACS If the ECG does not show typical changes, the term "non-ST segment elevation ACS" is applied. The patient may still have suffered a "non-ST elevation MI" (NSTEMI). The accepted management of unstable angina and acute coronary syndrome is therefore empirical treatment with aspirin, a second platelet inhibitor such as clopidogrel, prasugrel or ticagrelor, and heparin (usually a low-molecular weight heparin such as enoxaparin), with intravenous glyceryl trinitrate and opioids if the pain persists.

 A blood test is generally performed for cardiac troponins twelve hours after onset of the pain. If this is positive, coronary angiography is typically performed on an urgent basis, as this is highly predictive of a heart attack in the near-future. If the troponin is negative, a treadmill exercise test or a thallium scintigram may be requested. If there is no evidence of ST segment elevation on the electrocardiogram, delaying urgent angioplasty until the next morning is not inferior to doing so immediately.

Percutaneous coronary intervention (PCI). Angioplasty

Angioplasty is the technique of mechanically widening narrowed or obstructed arteries, the latter typically being a result of atherosclerosis. An empty and collapsed balloon on a guide wire, known as a balloon catheter, is passed into the narrowed locations and then inflated to a fixed size using water pressures some 75 to 500 times normal blood pressure (6 to 20 atmospheres). The balloon crushes the fatty deposits, opening up the blood vessel for improved flow, and the balloon is then deflated and withdrawn. A stent may or may not be inserted at the time of ballooning to ensure the vessel remains open

Coronary artery bypass surgery

Coronary artery bypass surgery, also coronary artery bypass graft (CABG, "cabbage") surgery, and colloquially heart bypass or bypass surgery is a surgical procedure performed to relieve angina and reduce the risk of death from coronary artery disease. Arteries or veins from elsewhere in the patient's body are grafted to the coronary arteries to bypass atherosclerotic narrowings and improve the blood supply to the coronary circulation supplying the myocardium (heart muscle). This surgery is usually performed with the heart stopped, necessitating the usage of cardiopulmonary bypass; techniques are available to perform CABG on a beating heart, so-called "off-pump" surgery

Procedure
The patient is brought to the operating room and moved on to the operating table. An anaesthetist places a variety of intravenous lines and injects a painkilling agent (usually fentanyl) followed within minutes by an induction agent (usually propofol) to render the patient unconscious. An endotracheal tube is inserted and secured by the anaesthetist and mechanical ventilation is started. General anaesthesia is maintained by a continuous very slow injection of Propofol.

 The chest is opened via a median sternotomy and the heart is examined by the surgeon. The bypass grafts are harvested frequent conduits are the internal thoracic arteries, radial arteries and saphenous veins. When harvesting is done, the patient is given heparin to prevent the blood from clotting. In the case of "off-pump" surgery, the surgeon places devices to stabilize the heart. If the case is "on-pump", the surgeon sutures cannulae into the heart and instructs the perfusionist to start cardiopulmonary bypass (CPB). Once CPB is established, the surgeon places the aortic cross-clamp across the aorta and instructs the perfusionist to deliver cardioplegia (a special potassium-mixture, cooled) to stop the heart and slow its metabolism. Usually the patient's machinecirculated blood is cooled to around 84 F (29 C)

 One end of each graft is sewn on to the coronary arteries beyond the blockages and the other end is attached to the aorta. The heart is restarted; or in "off-pump" surgery, the stabilizing devices are removed. In cases where the aorta is partially occluded by a C-shaped clamp, the heart is restarted and suturing of the grafts to the aorta is done in this partially occluded section of the aorta while the heart is beating. Protamine is given to reverse the effects of heparin. Chest tubes are placed in the mediastinal and pleural space to drain blood from around the heart and lungs.

 The sternum is wired together and the incisions are sutured closed. The patient is moved to the intensive care unit (ICU) to recover. Nurses in the ICU focus on recovering the patient by monitoring blood pressure, urine output and respiratory status as the patient is monitored for bleeding through the chest tubes. If there is chest tube clogging, complications such as cardiac tamponade, pneumothorax or death can ensue. Thus nurses closely monitor the chest tubes and under take methods to prevent clogging so bleeding can be monitored and complications can be prevented. After awakening and stabilizing in the ICU (approximately one day), the person is transferred to the cardiac surgery ward until ready to go home (approximately four days).