Post on 14-Apr-2017
transcript
Approach to Chest Pain
Chairperson– Dr.H.S.SandhuSpeaker– Dr. Nagma Bansal
Chest Pain Definitions
• Acute Chest Pain:Acute - Sudden or recent onset (usually
within minutes to hours), presenting typically <24 hrs
Chest - Thorax midaxillary to midaxillary line, xiphoid to suprasternum notch
Pain – Noxious uncomfortable sensation Ache or discomfort
Chest Pain
• Visceral– Often referred – Aching, heaviness, discomfort– Difficult to localize pain
• Somatic– Sharp, easily localized
Categorizing Chest Pain
1. Chest Wall Pain• Sharp, Precisely localized• Reproducible: Palpation, movement
2. Pleuritic or Respiratory CP• Somatic pain, Sharp• Worse with breathing/coughing
3. Visceral CP• Poorly localized, aching, heaviness
Causes
1. Chest wall• Costosternal synd• Costochrondritis• Precordial catch synd• Slipping Rib Synd• Xiphodynia• Radicular Synd• Intercostal Nerve• Fibromyalgia
2. Pleuritic• Pulmonary Embolism• Pneumonia• Spontaneous pneumo• Pericarditis• Pleurisy
Causes cont…..
3. Visceral Pain:• Typical Exertional
Angina• Atypical Angina• Unstable Angina• Acute Myocardial
Infarction (AMI)
• Aortic Dissection• Pericarditis• Esophageal Reflux
or spasm• Esophageal
Rupture• Mitral Valve
Prolapse
Initial Approach
• History:– Character of pain– Presence of associated symptoms– Cardiopulmonary history– Pain intensity, 0-10 pain
Initial Approach
• Triage– Chest pain– Significant abnormal pulse– Abnormal blood pressure– Dyspnea– These pts need IV, O2, Monitor, ECG
Initial Approach
• Evaluation – Airway– Breathing– Circulation– Vital Signs– Focused exam
• Cardiac, pulmonary, vascular
Initial Approach
• Secondary exam:– History– pneumonic OLD CARTS
O- onset L- location D- duration C- character A- associated/ aggravating factors R- relieving factors T- timing or periodicity S- severity
– Risk factors– Physical exam– Review old records/ekg’s
Chest pain incidentals ACS
• AMI Rare under 30 y/o– except with cocaine use
• GI cocktail may cause relief even in AMI
• Nitroglycerin can cause relief of esophagus spasm, biliary colic, and AMI
• NSAIDS can be analgesic for all types of pain
Atypical Chest Pain- AHA guidelines• Sharp or knife like pain brought on by respiratory movements
or cough• Primary or sole location of discomfort in middle or lower abd
region• Pain that may be localized at tip of one finger• Pain reproduced with movement or palpation of chest wall or
arms• Constant pain that persists for many years• Very brief episodes of pain that lasts few sec• Pain that radiates into lower extremities
• Atypicals usually in– DM, females, non-white, elderly, altered MS pts
Acute Coronary Syndrome (ACS)
• ACS = AMI or Unstable Angina• Visceral chest pain pts
– AMI – 15% – UA – 25-30%
Acute Coronary Syndrome (ACS)
• ECG is the most useful test• Incidence
– Significant ST elevation = 80% are AMI– ST depression/T wave inversion = 20%
are AMI– No change <4% are AMI
Differential Dx ACS
• Myocardial Ischemia:– Retrosternal, diffuse, heaviness, or
pressure– Radiation to neck or arm– Usually persistent pain >20 min, severe– Associated Sx or anginal equivalents:
Dyspnea, Diaphoresis, Nausea, fatigue, faintness
– May even be Reproducible
Differential Dx ACS
• Exertional Angina:– Episodic pain, <10 min– Onset with exertion– Resolves with rest, sublingual NTG– Response to exertion and rest follows
same pattern
Differential Dx ACS
• Atypical Angina:– Occurs at rest– Coronary spasm– Pattern of episodes same
Differential Dx ACS
• Unstable Angina (UA):– Change in the pattern of angina
• New Onset• More frequent, severe, easily provoked• More difficult to relieve• Occurs at rest, lasting >20 min• High risk of AMI
Testing for ACS
• EKGs• Serum Markers• Imaging studies
Testing for ACS - EKG
• AHA Guidlines:– Any pt with Ischemic type pain is to have
an EKG done within 10 minutes of arrival.
– This is to be handed directly to the physician
Testing for ACS - EKG
• AMI PT EKGs:– 50% = ST elevation > 1mm in 2 contiguous
leads– 20-30% = new ST seg. changes or T wave
inversion– 10-20% = ST depression and T wave
inversions Similar to previous EKGs– 10% nonspecific changes– 1-5% will have NORMAL initial EKG
Testing for ACS - Serum Markers
• AMI on Initial EKG– Markers not required for Dx
• Marker changes may precede EKG Change
• AMI– CK-MB initially elevated in 30-50% – Serial CK-MB elevate in 6 hours in 80-
96%
Testing for ACS - Serum Markers
• CK – elevates 4-8 hours after coronary Art. Occlusion– Peaks = 12 to 24 hours– Nml = 3 to 4 days
• CK-MB– Detectable 4-8 hrs– Peak = before 24 hrs– Nml = in 48hrs
• CK-MB normally can be 5% of total CK (Rapid Index)
Testing for ACS - Serum Markers
• Common Causes of CK-MB Elevation:– UA, ACS– Inflammatory Heart Dz– Cardiomyopathies– Shock– Cardiac
Surgery/Trauma– Trauma– Dermatomyositis– Myopathic Disorders
– Muscular Dystrophy– Extreme Exercise– Malignant Hyperthermia– Reyes Syndrome– Rhabdomyolysis– Delerium Tremens– Ethanol Poisoning,
chronic
Testing for ACS - Troponins
• Main regulatory protein of thin filament of myofibrils that regulate the Ca++ dependent ATP hydrolysis of actinomysin
• 3 Subunits:– Trop I = Inhibitory Subunit
• Myocardial Specific• Elevation indicated worse prognosis
– Trop T = tropomyosin-binding subunit– Trop C = calcium-binding subunit
Testing for ACS - Troponins
• AMI:Cardiac Troponin I (cTnI) and cTnT
• Elevates in 6 hrs• peaks in 12 h• Remain elevated for 7 to 10 days• Higher specificity than CK-MB• Controversy = Troponins are found to be
elevated in Renal Failure pts without proof of ACS/AMI
Other causes of positive trop-T
• Pacing, automated implantable cardioverter-defibrillator• Tachyarrhythmias• Hypertension• Myocarditis• Myocardial contusion• Acute and chronic congestive heart failure• Cardiac surgery• Renal failure• Pulmonary embolism• Subarachnoid hemorrhage• Sepsis• Hypothyroidism• Shock
Testing for ACS - Serum Markers
• Using Myoglobin, CK-MB, and cTnI initially and at 3 hours = 90% of AMI pts diagnosed
• Emerging cardiac markers are– c-BNP– Myeloperoxidase levels– Ischemia modified albumin
Non atherosclerotic causes of angina
• Congenital coronary artery anomalies– Slit like ostia– Presence of major artery b/w wall of pulmonary
trunk and aorta– Origin of major artery from pulmonary trunk– Myocardial bridges– Single coronary artery
• Prinzmetal’s angina• Coronary artery dissection eg kawasaki
disease• Traumatic coronary artery
Vasospastic (prinzmetal’s angina)
• Also called as variant angina/ angina inversus
• Angina at rest usually at night• More in younger women• Negative treadmill test• ECG changes- ST elevation on instead of
depression as in angina• Cardiac markers may be positive• Gold standard is coronary angiogram with
injection of provocative agents
Cardiac syndrome X• Microvascular angina• Post menopausal women• Ass. With insulin resistance syndrome• Typical chest pain usually precipitated after
exercise• Positive exercise test but normal
angiography• Treatment is with nitrates, beta blockers
and CCBs• Prognosis is good
Pulmonary Embolism• History and risk factors– hypercoaguable state,
malignancy, recent immobilization, recent surgery• Clinical features- Atypical, presenting with any
combination of:• Chest Pain, Dyspnea, Syncope, Shock, Hypoxia• Fever, cough, hemoptysis
– Pain is often pleural• Reproducible with breathing, palpation
– Classic presentaion:• Sharp pain, Dyspnea• Tachypnea, tachycardia, hypoxemia
Pulm embolism contd…
• O/E- neck vein distension, signs of RV failure, hypotension, accentuated P2 on auscultation
• ECG- S1Q3T3 sign is characteristic, but most common finding T inversion in V1 to V4.
• Diag- D-dimer more sensitive for PE than DVT• ABG lack diagnostic utility• X-ray chest–westermark’s sign (focal oligemia),
hampton’s pump (wedge shaped density over diaphragm, palla’s sign (enlarged descending pulm artery)
• CT chest with contrast is diagnostic
Aortic syndromes
• Aortic rupture(aortic aneurysms)
• Aortic dissection
• Intramural hematoma
• Penetrating atherosclerotic ulcer
Aortic Dissection• History and Risk Factors – usually a middle
aged male having Atherosclerosis, HTN (uncontrolled), Coarctation of Aorta, Bicuspid Aortic Valve, Aortic Stenosis, Marfan Syn, Ehlers-Danlos Syn
• C/Fs- Pain – sudden onset,midline Substernal CP, tearing, ripping, reaching peak immediately, radiating to interscapular area and also migrates with the propagation of dissection
• Pain Above AND Below Diaphragm• Others are syncope, dyspnoea, diaphoresis,
weakness
Aortic dissection cont…• O/E- • Hypo or hypertension,• loss or irregularity of pulses, • AR, • pulm edema, • findings due to occlusion of major arteries like
stroke, AMI, bowel ischemia, hematuria or compression of adjacent structures
• ECG- no evidence of AMI provided coronary ostia are not involved
• Diagnosis- by trans esophageal echocardiography, CT, MRI
Spontaneous Pneumothorax:
Risks: • Sudden Change in barometric pressure• Smokers, COPD, Idiopathic Blebs
C/Fs: • sudden, sharp, pleuritic chest pain, and dyspnea
O/E: • Absence of breath sounds ipsilaterally• Hyper resonance to percussion
Diagnosis by chest x-ray and CT
Acute PericarditisC/Fs-
• Acute, sharp, severe, constant, substernal CP– Radiation to back, neck, shoulders– Worse with lying down and inspiration– Relief with leaning forward
O/E- FRICTION RUB( best at end of expiration and leaning forwards)
EKG: • ST seg elevation in widespread leads• PR elevation in aVR and depression in other• Q wave not produced• T inversion only after ST becomes isoelectric
Diag- by echocardiography
Pneumomediastinum• 3 main causes
– Alveolar rupture– Perforation or rupture of the esophagus( Boerhaave’s
syndrome)– Dissection of air from neck or abdomen
• Life-threatening• C/Fs- Substernal, sharp CP without radiation into neck and arms
– Dyspneic, diaphoretic, and ill-appearing• O/E-
-subcutaneous emphysema, -Hamman’s sign- crunching or clicking sound synchronous
with heartbeat• CXR: Normal, SQ air, Pleural Effusions, Pneumothorax,
pneumoperitoneum, pneumomediastinum
Musculoskeletal and chest wall disorders
– LOCALIZED, Sharp, positional CP– Reproducible– Pain usually localised at tip of fingerTypes –
• Costochondritis, Tietze Syndrome• Xiphodynia
GI Disorders: GERD/dyspepsia
– Heart burn or pyrosis burning, gnawing low CP– Ass. with Acidic taste and feeling of warm fluid
climbing up the throat– Aggravated by bending forward, straining, or
lying recumbent– Worse after meals– Relief by upright position , swallowing of saliva or
water and per antacids -CAREFUL, can also help in ACS
– Diag by barium swallow, esophagoscopy and mucosal biopsy
Esophageal Spasm:
– Achlasia acardia or diffuse– CP may acute to subacute, dull to sharp,
substernal, radiating to arms, neck,jaw– Aggravated by Hot or cold liquids and large
food bolus– Associated with dysphagia, achlasia
particularily to liquids – Responds to NTG– Diag by manometry and barium swallow (in
achlasia parrot beak, and in DES cork screw shaped)
Peptic Ulcer Disease:
– Gastric:• Postprandial, dull, boring pain• Midepigastric, may awake pt.
– Duodenal Ulcer:• Relieved after eating
– Symptomatic Tx: antacids– DDx: Pancreatitis and Biliary tract Dz
Neuropathic chest pain
• Post herpetic
• Post surgical( post mastectomy, post thoracotomy, phantom limb)
• Complex regional pain syndrome (reflex sympathetic dystrophy and causalgia)
Panic Disorder:
– Recurrent, Unexpected panic – Including at least 4 SX:
• Palpitations, diaphoresis, tremor, dyspnea, choking, CP, nausea, dizziness, derealization, or depersonalization, fear of losing control or dying, paresthesias, chills, hot flashes
– Rule out substance abuse
Testing for ACS Prognosis Categorization Strategy
1. AMI = Immediate Revascularization candidate
2. Probable acute Ischemia: High risk(Any of the following)Clinical InstabilityOngoing painPain at rest with ischemic EKG changesPositive cardiac marker(s)Positive perfusion imaging study
Testing for ACS Prognosis Categorization Strategy
3. Possible acute Ischemia: Intermed. Risk:Hx suggestive of ischemia with…
Rest pain, now resolved New onset of pain
Crescendo pattern of painIschemic pattern on EKG without
CP
Testing for ACS Prognosis Categorization Strategy
4.A. Probably NOT Ischemia: low riskRequires all of followingHx not strong for ischemiaEKG normal, unchanged from
previous,or nonspecific changesNegative markers
Testing for ACS Prognosis Categorization Strategy
4.B. Stable Angina Pectoris: low risk PxRequires all the following> 2wk unchanged Sx pattern, Longstanding Sx with only mild change in exertional pain thresholdEKG normal, unchanged, nonspecific changesNegative initial myocardial markers
Testing for ACS Prognosis Categorization Strategy
5. Definitely not ischemia: very low risk for adverse events
Requires AllClear objective evidence of nonischemic Sx etiologyECG normal, unchanged, nonspecificNegative Initial Markers
Disposition
• Safely Discharge: – Sharp, well localized, reproducible by
position, breathing, palpation and no prior diagnosis of angina or AMI
• Keepers:– Unexplained visceral pain
• Unless ancillary testing excludes ACS
• Close follow up!
TAKE HOME MESSAGE• Out of all admissions in ED with C/O chest pain,
31% are becoz of IHD and 42% due to gastric causes
• Diagnosis of AMI made on initial EKG, markers are only adjunctive
• Door to needle time determines the survival• Missed AMI rate is 2%... Serial ECGs, serial
markers and imaging help in improving this• Other life threatening causes like pulm embolism,
aortic dissection should always be kept in mind
Thanks