By Rhia Badial and Dr Vera Lennie Learning outcomes Develop understanding of different causes of chest pain Use history and examination to construct a differential diagnosis Understanding differential diagnoses of elevated troponin ID: 1036020
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1. Acute presentation in cardiology: It is not always what it seems By Rhia Badial and Dr Vera Lennie
2. Learning outcomes Develop understanding of different causes of chest painUse history and examination to construct a differential diagnosis Understanding differential diagnoses of elevated troponin Identify relevant investigations to aid diagnosis Consider the impact of Covid19 in cardiology
3. Presenting complaint 35 year old black man referred from the GP to cardiology2 episodes of retrosternal chest pain He says he is “struggling to catch his breath” Recently he has also been experiencing dizzy spells, headaches and tiredness General weakness over the last few days
4. What other questions would you want to ask him?
5. History of presenting complaintChest pain described as a “tightness”No radiationPain lasts for around 1 minute Both episodes of chest pain occurred on restIbuprofen improves the pain slightly He has not experienced any palpitations, ankle swelling or claudication
6. No previous hospital admissionsNo cardiac family history Non-smoker, non-drinker and no illicit drug use On no medications Normally very well and sporty
7. Due to Covid19 what other information may be relevant?
8. Has none of the main Covid19 symptoms or any other infective symptoms (fever, cough or loss of taste and smell) and has tested negativeNo family members unwellHas not had either of the Covid19 vaccines Travels to London regularly for work
9. Differential Diagnosis
10. ExaminationNormal heart soundsReduced air entry in left upper zone of chest Warm and well perfused peripheriesCapillary refill time < 2 secondsNo peripheral oedemaCalves soft and non tenderNo lymphadenopathy Apyrexial
11. Initial Investigations?ECGEEGChest xrayBlood tests ECHO CT scanCardiac angiogram
12. 12 lead ECG
13. Describe the ECG?
14. ResultsECG – T wave inversion in V2 to V6 and biphasic ST-T segment elevation in V3Elevated troponin – 2021CRP < 1Normal white cell countNormal renal and liver function Normal chest xrayECHO – no left ventricular damage, no hypertrophy and no valvular abnormalities
15. Cardiac AngiogramNormal coronary arteries with no evidence of stenosis or occlusion, which could result in coronary spasm or myocardial infarction
16. Label the coronary arteries?ABC
17. What can cause elevated troponin?Myocardial infarctionArrythmiaPulmonary embolismSeptic shockAortic dissectionCholecystitis CocaineMyocarditisPercutaneous coronary intervention (PCI)
18. Causes of elevated troponinAny infection resulting in inflammation can elevate troponin levels, the troponin levels can also elevate and reduce daily due to random cytokine responses.
19. Cardiac MRI Cardiac MRI revealed inflammation around the heart muscle and patient was diagnosed with myocarditisMost likely combined with pericarditis Sometimes this is referred as myopericarditis
20. What are the typical ECG features in pericarditis?Widespread concave ST elevationDelta wave PR depressionHyperacute T wave Dynamic ST changesSinus tachycardia
21. Patients ECG 4 weeks after admission Concave ST elevation
22. Diagnostic criteria for myocarditis History Examination Initial investigations: ECG, troponin and chest xray Cardiac MRICoronary angiogramConsider endomyocardial biopsy in required
23. What can cause myocarditis?
24. Further investigations and managementEnforced restStatinsDalteparinGive 500mls Plasmalyte 148ACE inhibitorAdminister 15l Oxygen Analgesia Viral screenSerum ACE
25. Monitoring Continuous ECG monitoring during acute phase Daily troponins It is important for the patient to undergo regular ECHOs to ensure their left ventricular function is persevered – it should be > 55% however ideally should be compared to previous ones to see if it has reduced from the patient’s normalCannot discharge patient until their troponin has reduced to normal due to risk of arrhythmias
26. Long term complications of myocarditis Fibrosis leading to left ventricular impairmentVentricular arrythmias Chronic hypoxia Life threatening Angina on exertion Heart failure
27. Complications of long Covid19PneumoniaAcute respiratory distress syndromeBacterial infectionPrimary cancer Myocarditis Infertility Septic shockMulti organ failure Permanent paralysis Cognitive impairmentObesity Breathlessness
28. Summary Myocarditis can present with non-specific symptoms There can be no obvious cause for myocarditis – it was believed that this patient developed it due to a previous episode of undiagnosed Covid19 (which is now recognised as a common cause)Troponin can be elevated by many factors other than myocardial infarction ECG can have evidence of ST elevation in myocarditis The treatment for myocarditis is mainly supportiveCovid19 can cause a range of long-term complications
29. Further Reading You have now:Developed your understanding of non acute coronary causes of chest painUsed history and examination to construct a differential diagnosisLearnt to identify abnormalities on ECGsReviewed management of myocarditis Further ReadingMore detailed learning on myocarditis: European Society of Cardiology Link between myocarditis and Covid19 vaccine: BMJ