A 60 year old male known case of COPD on pMDI as well as a known case of old ACS done PCI last on October 2016 presented to the OPD with complaints of left sided chest pain/heaviness radiating to left arm. He is already on atorvastatin 10mg, Aspirin 75mg, metoprolol 25mg XL along with other medications for COPD. His ECG was done and it was WNL. His BP is 150/90mmHg. Kindly comment on the line of management for this case? Can we tackle it by adding trimetazidine and ACEI? How about nitrolong 2.6 twice daily?




Past h/o COPD ACS undergone PCI on rx C/o pain chest suggest unstable angina which reflects underlying CARDIAC MYOPATHY Hence needs 2decho and stress test As well as repeat cardiac enzymes Yes he may be on nikoran 10mg 1bd or tds

Thanx dr Vipin Bihari Jain

Pt is a k/ c/o /COPD as u mentioned ECG is normal in that case second step is to take a chest x-ray to look for pneumatic, pleural effusion pleural pain, Third pt is on aspirin so it may cause oesophagitis,gastritis, GERD which causes the referal pain from the remote area to chest and back, some times pancreatitis, cholecystitis ,for that USG whole abd, endoscopy, Fourth h/o CAD to rule out anginal pain and to r/o ischemia/mi sr ECG,cardiac enzymes, ECHO,

Left sided chest pain in known case of past acute coronary syndrome Current ECG is normal Serial ECG can be done - some times there is delayed manifestation of ECG changes in ACS 2 D ECHO and stress test may be done to actively look for new ACS Revascularization is first choice of treatment in any New onset Acute coronary syndrome

Do, CXR P/A, Do Cardiac Profile & Enzymes, CBC & ESR. Give Tab. Pansac DSR -OD, Tab. Amlodipine 5Mg OD, NTG patch are Placed .

Thanx@Dr. Vipin Bihari Jain Sir Ji

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DD Since patient is k/c of COPD , consider Left pneumonitis ,with pleural pain . Need to have Xray chest GERD ,with lower oesophageal erosions, common with COPD and chronic Aspirin use .can also produce chest pain with left arm radiation. Needs abdominal ultrasound and upper GI endoscopy Considering history of CAD, suggest keep patient on observation, serial ECGS, and troponin

Ideal is to diagnose angina When there is pain take ecg or stress test or stress echo Bp150/90 amlodipine 5 mg with nitrolog2 point6 bd if diagnosed add ppi