Chest Pain

Objectives Overview of chest pain Differential diagnosis of chest pain Typical vs. atypical chest pain Evaluation of chest pain Review patient cases

Overview Chest pain accounts for 6 million annual

visits to the EDs in the United States Chest pain is the second most common

ED complaint Patients with chest pain present with a

wide spectrum of signs and symptoms It is up to the clinician to recognize the

life-threatening causes of chest pain

Overview

Cayley 2005

Pearl 1

CHEST PAIN ≠ ACSPOSITIVE TROPONIN ≠ ACS

Life-threatening causes of chest pain Acute coronary syndrome (unstable

angina, NSTEMI, STEMI) Aortic dissection Pulmonary embolism Pneumothorax Tension pneumothorax Pericardial tamponade Mediastinitis (e.g. esophageal rupture)

Differential diagnosis

UpToDate 2012

Typical vs. Atypical Chest Pain

Typical

Characterized as discomfort/pressure rather than pain

Time duration >2 mins Provoked by activity/exercise Radiation (i.e. arms, jaw) Does not change with

respiration/position Associated with

diaphoresis/nausea Relieved by rest/nitroglycerin

Atypical Pain that can be localized

with one finger Constant pain lasting for

days Fleeting pains lasting for a

few seconds Pain reproduced by

movement/palpation

Typical vs. Atypical Chest Pain

UpToDate 2012

Typical vs. Atypical Chest Pain

Cayley 2005

Evaluation of Chest Pain Scenario 1 - It’s 2:00 AM and you are

the VA NF intern. The nurse pages you and tells you that Mr. S, a 67 yro M with known hx of CAD, who is admitted for ARF is having chest pain after he walked back from the bathroom. What would you do next?

Evaluation of Chest PainScenario 1: Ask nurse for most current set of

vital signs Ask nurse to get an EKG Ask nurse to have the admission

EKG at bedside if available Go see the patient!

Evaluation of Chest Pain Once at bedside, determine if

patient is stable or unstable Read and interpret the EKG.

Compare EKG to old EKG if available

If patient looks unstable or has concerning EKG findings, call your senior resident for help

Evaluation of Chest Pain If patient is stable:

Perform a focused history Does patient have known CAD or other cardiac risk factors? Is the pain typical/atypical? Is the pain similar to prior MI?

Perform a focused physical exam Look for tachycardia, hypertension/hypotension or hypoxia on vital

signs General: Sick appearing, actively having chest pain HEENT: JVD, carotid bruits Chest: Rales, wheezes or decreased breath sounds CVS: New murmurs, reproducible chest pain, s3 gallop Abd: Abdominal tenderness, pulsatile mass Ext: Edema, peripheral pulses Skin: Rash on chest wall

Evaluation of Chest Pain Labs/imaging/disposition

CXR Cardiac biomarkers ABG? Telemetry/ICU

Write a clinical event note!

Evaluation of Chest Pain Scenario 2 - You are the orphan

intern and you get a page from 67121 and the DACR informs you that you have a 45 yro female in the ED who is being admitted to the Hellerstein service for r/o ACS. How would you approach this patient?

Evaluation of Chest PainScenario 2: Get report from ED physician about

the patient Ask ED physician about patient’s

initial presentation Get last set of vital signs Ask ED physician to order EKG and

CXR

Evaluation of Chest Pain Go to UH Portal and print out an old

EKG for comparison Review prior discharge summaries Quickly review prior cardiac work up

–echo, stress tests and cath reports Review any labs/imaging from

current ED visit

CASES

Case 1 You are on the Wearn team and

the nurse calls you and tells you that Ms. Z suddenly started having chest pain and her O2 sat went from 94% on room air to 88% on 2L via NC

Case 1 Ms. Z is a 62 yro F with PMHx of CAD s/p remote PCI to the LAD, COPD and right

THA 3 weeks ago who was admitted for a COPD exacerbation EKG on admission:

Case 1 You go see the patient. The patient tells you that she was feeling

better after getting duonebs during this admission, but suddenly developed chest pain that is L-sided, 8/10 and worse with breathing. She has never experienced pain like this in the past

Vital signs: Afebrile, HR 120, BP 110/70, RR 28, O2 sat 89% on 2L Physical exam

Gen – in distress, using accessory muscles of respiration Lungs – CTAB, no rales/wheezes Heart – tachycardic, nl s1, loud s2, no mumurs Abd – soft, NT/ND, active BS Ext – b/l LEs warm and well perfused

Labs: CBC wnl, RFP wnl, BNP = 520, D-dimer = positive, Troponin = 0.12

Case 1

Case 1

Case 1

Case 1 - Pulmonary Embolism

Cayley 2005

Case 1 - Pulmonary Embolism Diagnostic testing

Pulmonary angiography (Gold standard) Spiral CT (CT-PE protocol) V/Q scan (helpful for detecting chronic

VTE) D-dimer (<500ng/ml helps exclude PE in

patient with low/moderate pre-test probability)

Case 1 - Pulmonary Embolism Treatment of PE

Anticoagulant therapy is primary therapy for PE

Unfractionated heparin LMWH

For unstable patients, catheter embolectomy or surgical embolectomy are options

For patients at risk for bleeding, IVC filter is an alternative

Case 2 24 yro M is being admitted to you from the

ED for chest pain and EKG abnormalities PMHx:

SLE Asthma

You go see the patient and he tells you that he has had this chest pain for ~2 days, but it has progressively gotten worse. His chest pain is worse with breathing. He does report getting over a recent URI few days ago

Case 2 VS: T 38.1 HR 104 BP 140/76 RR 20 O2 sat 95% on

RA Physical exam:

Gen – in mild distress due to chest pain, leaning forward while in bed

Lungs – CTAB Chest wall – no visible rash, chest wall NT to palpation Heart – tachycardic, nl s1/s2, no rub Rest of physical exam benign

Labs: WBC = 14, RFP wnl, AMI panel x 1 = negative

CXR = negative

Case 2 EKG on admission:

Case 2 - Pericarditis Refers to inflammation of pericardial sac

Preceded by viral prodrome, i.e. flu-like symptoms

Typically, patients have sharp, pleuritic chest pain relieved by sitting up or leaning forward

Case 2 - Pericarditis

Goyle 2002

Case 2 - Pericarditis

Goyle 2002

Case 2 - Pericarditis Diagnostic criteria

UpToDate 2012

Case 2 - Pericarditis Treatment

UpToDate 2012

Case 3 You are evaluating a patient on the Carpenter

team with chest pain

Patient is a 67 yro M with PMHx of HTN, HLD, DM-2 and CAD s/p PCI to the LCx in 2007 who is admitted for L leg cellulitis. He develops new onset chest pain that is retrosternal, 7/10, associated with nausea and diaphoresis. Says pain is radiating to his L jaw and is similar to the chest pain he had during his last MI

Case 3 VS: T 37 HR 108 BP 105/60 RR 20 O2 sat 93%

on RA Physical exam:

Gen – actively having chest pain, diaphoretic Lungs – rales at bilateral bases Heart – tachycardic, nl s1/s2, no mumurs or rub Rest of the exam benign

Labs: CBC wnl, RFP wnl, Troponin = 3.2, CKMB = 9, CK = 345

Case 3

Case 3 - NSTEMI Risk stratification?

Case 3 - NSTEMI Management of UA/NSTEMI

Aspirin Inhibits platelet aggregation

HR control with beta-blocker Titrate to goal HR ~ 60 beats/min

Statin Nitroglycerin SL

Use if patient having active chest pain DO NOT USE if patient is hypotensive and concern

for RV infarct

Case 3 - NSTEMI Management of UA/NSTEMI

Plavix P2Y12 receptor blocker Inhibits platelet aggregation

Anticoagulation Heparin/LMWH

Inhibits thrombus formation Oxygen

For O2 sat <90% Morphine

For refractory chest pain, unrelieved by NTG SL

Pearl 2

USE THE CHEST PAIN ORDER SET!

Order Set

QUICK CASES

Case 4

Case 4 You find out the patient is having

crushing chest pain radiating to the back. His BP in the R arm = 193/112 and in the L arm = 160/99

What diagnosis is on top of your differential?

Case 4 - Aortic Dissection Stanford Classification

Type A – Involves ascending aorta Type B – Involves any other part of aorta

Diagnostic Imaging CXR CT chest with contrast MRI chest TEE

Case 4 - Aortic Dissection Management of Aortic Dissection

Type A dissection – Surgical Type B dissection – Medical

Mainstay of medical therapy Pain control HR and BP control

Goal HR = 60 beats/min, goal SBP = 100-120 mmHg Use IV beta-blockers (i.e. Labetalol, Esmolol) Can also use Nitroprusside for BP control AVOID Hydralazine

Case 5 This is a 45 yro M with PMHx of

rheumatoid arthritis who presented with progressive sob. He was found to have a R-sided pleural effusion and underwent an US guided thoracentesis with removal of 1.5 liters of pleural fluid. Two hours after his procedure, he develops new onset R-sided chest pain

Case 5

Case 5 - Pneumothorax Management of Pneumothorax

Supplemental O2 and observation in stable patients for PTX < 3 cm in size

Needle aspiration in stable patients for PTX >3 cm

Chest tube placement if PTX >3 cm and if needle aspiration fails

Chest tube placement in unstable patients

Pearl 3

ECG Wave-Mavenhttp://ecg.bidmc.harvard.edu/maven/mavenmain.asp

Summary Chest pain is a very common complaint but has

a broad differential Always try to rule out the life-threatening causes

of chest pain It is important to remember that troponin

elevation DOES NOT always mean ACS Use the history, physical exam, labs, EKG and

imaging to commit to a diagnosis Whenever you are stuck, ask for help. Your

seniors are here to help you!

References Cayley, W.E. Diagnosing the cause of chest pain. (2005). American Family Physician, Vol 72 (10),

2012-21. Goyle, K.K. and Walling, A.D. Diagnosing pericarditis. (2002). American Family Physician, Vol 66

(9), 1695-1702. Diagnostic approach to chest pain in adults. (2012). UpToDate.

http://www.uptodate.com/contents/diagnostic-approach-to-chest-pain-in-adults?source=search_result&search=chest+pain&selectedTitle=1%7E150

Differential diagnosis of chest pain in adults. (2012). UpToDate. http://www.uptodate.com/contents/differential-diagnosis-of-chest-pain-in-adults?source=search_result&search=chest+pain&selectedTitle=3%7E150

Evaluation of chest pain in the emergency department. (2012). UpToDate. http://www.uptodate.com/contents/evaluation-of-chest-pain-in-the-emergency-department?source=search_result&search=chest+pain&selectedTitle=5%7E150

Clinical presentation and diagnostic evaluation of acute pericarditis. (2012). UpToDate. http://www.uptodate.com/contents/clinical-presentation-and-diagnostic-evaluation-of-acute-pericarditis?source=search_result&search=pericarditis&selectedTitle=1%7E150

Treatment of acute pericarditis. (2012). UpToDate. http://www.uptodate.com/contents/treatment-of-acute-pericarditis?source=search_result&search=pericarditis&selectedTitle=2%7E150