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Chest Pain

Darrell Rubin, MD PhD

Department of Medicine

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Objectives

• Presentation of chest pain

• Evaluation of chest pain

• Acute coronary syndrome (ACS)

• Initial treatment

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A Chest Pain Case

A 65 year-old man with apast medical historysignificant for hypertensionand dyslipidemia presentsto the emergencydepartment after 2

episodes of chest pain.What do you want to knowabout the symptoms?

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A Chest Pain Case

Provocative/palliative factors

Quality 

- character

- duration

- frequency

- associated symptoms

RadiationSeverity

Timing

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A Chest Pain Case

First episode  – 6/10 exertional chest pain relievedwith rest

Second episode - occurred at rest and did notimprove until EMS was activated.

Associated symptoms - dyspnea and diaphoresis

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Perspectives

Resident’s perspective 

• Admission

• Serial AMI panels• MONA

• Plavix, Heparin

• Statin, β- blocker,ACEI

• NPO

• Echo, stress, ± angio

Patient’s perspective 

• Heart attack

• Heart attack

• Heart attack

• Heart attack

• Heart attack

• Heart attack

• Heart attack

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Glossary

Chest pain

Angina

Ischemia

ACS

Unstable AnginaNSTEMI

STEMI

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Angina

Definition

“… a discomfort in the chest or 

adjacent areas caused bymyocardial ischemia, usuallybrought on by exertion and

associated with disturbance ofmyocardial function, butwithout myocardial necrosis."

Akbar et al JAMA 280(14): 1256, 1998

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Myocardial Ischemia

Definition

“… an imbalance between

myocardial oxygen supply andmyocardial oxygen demand..."

“Hurst’s The Heart” 12th edition

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Grading Angina

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http://slidepdf.com/reader/full/04-chest-pain 11/33ACC/AHA 2002 Guideline Update for the Management of Patients with Chronic Stable Angina

Differential Diagnosis

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http://slidepdf.com/reader/full/04-chest-pain 12/33Clifford, et al JAMA 294(20):2623, 2005

Valuable History

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Acute Coronary Syndrome

Unstable Angina

NSTEMI

STEMI

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Definition

“… any constellation of clinical

symptoms that are compatiblewith acute myocardial

ischemia..."

Acute Coronary Syndrome

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Unstable Angina / NSTEMI

Definition

“… ST-segment depression or

prominent T-wave inversionand/or positive biomarkers ofnecrosis… in the absence of 

ST-segment elevation and inan appropriate clinicalsetting..."

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Unstable Angina / NSTEMI(Unstable Angina)

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Unstable Angina / NSTEMI

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STEMI

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LBBB

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Physical Exam

T 36oC, P 85, BP 140/80, R 15, Pain 2/10

General – no distress

Neuro - A&O

CVS - normal inspection, PMI normal andnondiplaced, no heave, regular rhythm withnormal sounds, no murmers or rubs, JVP 7cm, radial and pedal pulses normal

Pulmonary - clear

Abdomen – nontender withouthepatomegaly

Extremities – no edema

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Chest X-Ray

Quality – exposure and rotation

Bony structures

Mediastinum

Heart

Costophrenic angles

Lung fields

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TIMI Risk Score

Antman et al JAMA 2000; 284: 835 - 842 www.timi.org 

Age 65 

3 CAD risk factors(FHx, HTN, chol, DM, active smoker) 

ST deviation 0.5 mm 

cardiac markers 

Recent (24H) severe angina 

HISTORICAL 

PRESENTATION 

RISK SCORE = Total Points (0 - 7) 

Known CAD (stenosis 50%) 

ASA use in past 7 days 

1 

1 

1 

1 

1 

1 

1 

POINTS  RISK OF CARDIAC EVENTS (%)

BY 14 DAYS IN TIMI 11B* 

0/12

3

4

5

6/7 

RISK

SCORE 

33

5

7

12

19 

DEATH

OR MI DEATH, MI OR

URGENT REVASC 

58

13

20

26

41 *Entry criteria:UA or NSTEMII defined as ischemic pain

at rest within past 24H, with evidence of CAD (ST segment

deviation or +marker)

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A Chest Pain Case

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AMI Panels

Creatine Kinase (CK) - 413 U/L (0-215)

CK-MB 7 and RI 2%CKMB <7 and RI <4% :Negative

CKMB <7 and RI >4% :Equivocal

CKMB >=7 and RI <4% :EquivocalCKMB >=7 and RI >4% :Positive

Troponin I 6.8 (0 – 0.06)

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A Chest Pain Case

CAD risk factors- + Family history- HTN- Dyslipidemia

Home meds- ASA 81 mg po daily- HCTZ 25 mg po daily

Biomarkers

- CK 413- MB 7 with index of 2- Troponin I 6.8

TIMI Risk Score- 5

Age 65 

3 CAD risk factors(FHx, HTN, chol, DM, active smoker) 

ST deviation 0.5 mm 

cardiac markers 

Recent (24H) severe angina 

HISTORICAL 

PRESENTATION 

RISK SCORE = Total Points (0 - 7) 

Known CAD (stenosis 50%) 

ASA use in past 7 days 

1 

1 

1 

1 

1 

1 

1 

POINTS 

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A Chest Pain Case

CAD risk factors- + Family history- HTN- Dyslipidemia

Home meds- ASA 81 mg po daily- HCTZ 25 mg po daily

Biomarkers

- CK 413- MB 7 with index of 2- Troponin I 6.8

TIMI Risk Score- 5

RISK OF CARDIAC EVENTS (%)

BY 14 DAYS IN TIMI 11B* 

0/12

3

4

5

6/7 

RISK

SCORE 

33

5

7

12

19 

DEATH

OR MI DEATH, MI OR

URGENT REVASC 

58

13

20

26

41 *Entry criteria:UA or NSTEMII defined as ischemic pain

at rest within past 24H, with evidence of CAD (ST segment

deviation or +marker)

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Thygensen, et al JACC 50: 2173, 2007

Other reasons for Troponins

Heart failure

Pulmonary embolus

Renal failure

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Orders

• Admit to telemetry• MONA• Serial AMI panels

• Statin,  β- blocker, ACEI

• Heparin IV or Enoxaparin• Clopidogrel and/or Eptifibatide• Echo• NPO• Stress test• Angiography

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Orders

• Admit to telemetry  – monitor for arrhythmia

• MONA

 – Morphine – Oxygen – Nitroglycerin – Aspirin

• Serial AMI panels

 – Electrolytes, Cr, CBC, coags• Statin,  β- blocker, ACEI

 – Atorvastatin 80 mg po – Metoprolol 12.5 mg po q6 – Captopril 6.25 mg po q8

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Orders

• Anticoagulation – Heparin IV

 – Enoxaparin sc

• Clopidogrel loading andmaintenance

• Eptifibatide loading and

maintenance

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Orders

• NPO after midnight

• Transthoracic echocardiogram

• Stress test – Exercise nuclear stress test

 – Chemical nuclear stress test

 – PET myocardial viability study

• Angiography ± PCI

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The Case

• NSTEMI

• Enoxaparin

• Clopidogrel load and maintenance

• TTE demonstrated EF 65% without wall motion abnormalities orvalvular dysfunction

• Coronary angiography demonstrated 95% right coronary artery

lesion

• PCI included a drug-eluting stent across the RCA lesion

• Discharged home with daily aspirin, clopidogrel, atorvastatin,

metoprolol, and lisinopril

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Summary

• Presentation of chest pain

• Evaluation of chest pain

• Acute coronary syndrome (ACS)

• Initial treatment