Chest Pain/ACS/Acute MI

1. Background/Cultural Points:

   Coronary artery disease and acute coronary syndromes are increasingly common in Cambodia due to uncontrolled and untreated hypertension, diabetes, dyslipidemia, smoking, worsening diets and increasing obesity. Patients often present late because of lack of an appropriate EMS syndrome and lack of access to intensive hospital care.

2. Diagnosis, Lab and Monitoring:

   1. Consider diagnosis in patients with chest pain/tightness and associated symptoms including exertional pain, radiating pain to arm/jaw, SOB, Nausea, Diaphoresis.
   2. Consider patient risk factors: Age, Sex, FHx, HTN, DM, Dyslipidemia, Smoking
   3. 12 Lead EKG – Look for ST/T wave changes, Q Waves
   4. If suspect acute coronary syndrome, place patient on continual cardiac monitor Troponin initially and then in 12 hours
   5. CBC, creatinine, electrolytes. Consider AST/ALT, UA, etc. for end organ evaluation.
   6. CXR – Look for cardiomegaly and signs of congestive heart failure
   7. Consider Echocardiograpy – Evaluate EF, IVC respiratory variation, wall motion, heart valves, etc.

3. Management/Education/Treatment:

   1. Education
      1. consistent life-long treatment significantly reduces risk of worsening disease
      2. good management requires the patient’s willingness to adjust his/her lifestyle and use medication as prescribed.
   2. Lifestyle Points:
      1. Reduce sodium intake. Avoid too much salty fish.
      2. Change from white-rice-only diet to minimum 20% brown rice
      3. Weight loss if obese; Exercise if sedentary
      4. Smoking cessation, abstinence or moderation of alcohol use
   3. Medication
      1. Acute management
         1. Interventional Treatment for patients with financial resources:
            1.1) STEMI – Consider referral to Heart Hospital for PCI* or Fibrinolysis
            
            1.2) NSTEMI – Consider referral to Heart Hospital for PCI*
            
            *PCI = Percutaneous Coronary Intervention
            
            
      2. Medical Treatment for all patients (“BANS”):
         1. Beta-Blocker – All patients unless contraindicated (CHF, Cardiogenic Shock, Bradycardia, Heart Block, etc.). Start low and titrate. Metoprolol 25mg BID or Carvedilol 3.125mg BID. Don’t use Atenolol.
         2. Antiplatelet/Anticoagulation – Aspirin 162-325mg. Clopidogrel 300mg loading dose if under 75 years old then 75mg QD. LMWH 1mg/kg/dose BID until stable/hospital discharge (if available).
         3. Nitroglycerin - 0.4mg SL Q5 minutes x 3. May repeat 30-60 minutes after last dose for recurrent chest pain if blood pressure stable.
         4. Statin – All patients even if low LDL. High dose atorvastatin 80mg QD is best but any statin is better than none.
         5. NOTE – Recent studies have shown oxygen can be harmful in acute coronary syndromes. Only give if saturation less than 90%. Morphine can also worsen outcome so only give if very severe pain.
      3. Chronic Management
         1. Continue acute medications except LMWH. Aspirin 81mg QD. Titrate Beta-Blocker to higher dose as tolerated. Consider stopping Clopidogrel after 1 year.
         2. Add ACE-Inhibitor at discharge if adequate blood pressure.
      4. Referral:
         1. Jeremiah’s Hope or Visiting Cardiology Team List.
         2. Heart Hospital, especially for patients with STEMI who can afford it.
      5. Follow-Up:
         1. Initial follow-up at 1-2 weeks, then q3-6 mos.
         2. Monitor for signs and symptoms of CHF and start medications for this if needed (see CHF protocol)
         3. Monitor labs appropriately, based on medication chosen (ECG if new symptoms).
         4. Remember that when starting many of these medications, they can cause abnormalities in potassium. If this is the case, patient should return to clinic soon after starting medication for monitoring.