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APPROACH TO CHEST PAIN

EPIDEMIOLOGY

DIAGNOSIS PRIMARY CARE EMERGENCY DEPTMusculoskeletal 36 % 7 %GIT 19 % 3 %Cardiovascular Disease 16 % 54 %Psychosocial 8 % 9 %Pulmonary 5 % 12 %Nonspecific chest pain 16 % 15 % USA Statistics (Adopted from AAFP)

STEPWISE APPROACH TO CHEST PAIN

Brainstorm for differentials of chest pain Focused history.Look for Risk factors for MI /PE/AORTIC DISSECTION/PNEUMOTHORAX.Focused physical examLabs/InvestigationsManagement strategy

Establish DifferentialsA good way to brainstorm for the differentials is to visualise the chest and think what could be wrong.Hence the pain could be due to pathology of the heart, aorta,lungs,pulmonary vessels,oesophagus,thoracic nerves,bones and muscles, and finally from subdiaphragmatic structures such as liver/gall bladder and pancreas with the pain radiating to chest.

CAUSES OF CHEST PAINMyocardial ischemia or infarction /Coronary spasm secondary to cocainePericarditis /Myopericarditis(post infarction)/ Aortic aneurysm/dissection,Aortic stenosisPulmonary embolus Pneumothorax Pneumonia/Pleurisy Esophageal spasmEsophagitis due to GERD or Hiatus Hernia (in the elderly)Boerhaaves esophageal perforation.Gastritis, peptic ulcer disease Musculo-skeletal Shingles Liver abscess(subdiaphragmatic abscess)CholecystitisPancreatitisAnxiety

CAUSES WHICH NEED TO BE RULED OUT & REQUIRE IMMEDIATE MxAcute Coronary syndromeAortic dissectionPneumothoraxPulmonary embolismBoerhaaves perforation

KEY HISTORY CLUESCharacterise the pain .Use SOCRATES approach to painPast history to look for relevant risk factorsReview of Systems : especially symptoms of CVS, RS ,GITMedications(OCP),Allergies,Family History,Travel history,Occupational & Social History

PHYSICAL EXAMINATIONGeneral AppearanceVital SignsCVSRSAbdomen

KEY LABSECGBlood tests: Cardiac Enzymes, CBC,ESR,D-dimer,RFT,Clotting studies.Imaging: CXR,CT Thorax,Spiral CT with contrast,U/S Doppler Venous system legs

Acute Coronary SyndromeHistory of sudden onset central crushing pain radiating to either/both arms and jaw especially in some one with previous history of angina on exertion or MI and /or cardiac risk factors.Associated with nausea, diaphoresis, syncope, shortness of breath Cardiac risk factors: age, sex, smoking history, diabetes, hypertension, hyperlipidemia, and family history

LIKELIHOOD OF MI

Acute Coronary SyndromeBP indicates cardiogenic shock JVP, pulsatile liver and peripheral edema seen in right-sided heart failure Oxygen desaturation, crackles, S3 seen in left-sided heart failure New murmurs: mitral regurgitation murmur in papillary muscle dysfunction Signs of systemic atherosclerotic vascular disease ;weak pulses,peripheral cyanosis,atrophic skin,ulcers,bruits on auscultation of carotid.Signs of Anaemia : as anaemia can exacerbate ischaemic heart diseaseSigns of Hypercholesterolemia: Xanthelesma,Xanthomata and ArcusSigns of Arrythmia :Arrythmia can cause ischemia in an already poorly perfused heart due to an underlying ischeamic heart disease .There may be a irregularly irregular pulse(atrial fibrillation,atrial flutter with variable heart block or frequent ectopics), a slow pulse(heart block) or a very fast pulse (atrial fibrillation/flutter induced tachycardia,reentrant tachycardia,ventricular tachycardia)

Work-upEKG

CXR to look for signs of congestive heart failure Cardiac enzymes: CK (will begin to rise 6 hours after infarct and remain elevated for 24-48 hours), troponin (will begin to rise 12 hours after infarct and remain elevated for 2 weeks). Need to follow serially if first set negative. Others for risk factors and baseline function.

Management Strategy for NSTEMI

Initial therapyMorphine for pain Oxygen if hypoxic Nitro spray/drip for pain Aspirin

Management Strategy for NSTEMIStratify/Establish risk level using the TIMI scoring system(Other risk scores are GRACE,CRUSADE and CHADS2) :

Low risk(1-2): May be discharged after symptom control

Moderate risk(3-4): Admit for further evaluation; add beta blockers , Ace inhibitors . Follow cardiac enzyme levels. If MI ruled out, Exercise or Adenosine stress test before discharge

High Risk: Admit for cardiac catheterization/thrombolysis(TIMI Score > 5)

TIMI SCORETIMI score MnemonicAMERICA: Age > 65 Markers (increased serum cardiac markers) EKG (ST depression) Risk factors (3 or more CAD risk factors: patient age (>45 M, > 55 F), family history [CAD in first degree relatives,

Management Strategy for STEMIMorphine, oxygen, nitro, aspirin

Beta blockers, Ace inhibitors

Early invasive strategy with either thrombolytic therapy or percutaneous coronary intervention (preferred)

Pulmonary EmbolismSudden-onset sharp chest pain Exacerbated by inspiratory effort Can be associated with hemoptysis, syncope, dyspnea, calf swelling/pain from DVT Risk factors: immobilization, fracture of a limb, post-operative complications, hypercoagulable states (underlying carcinoma, high-dose exogenous estrogen administration, pregnancy, inherited deficiencies of antithrombin III, activated protein C, S, lupus anticoagulant, prior history of DVT/PE [Virchows triad]

Pulmonary EmbolismAnxious patient, sense of impending doom Tachycardia, tachypnea, hypoxia EKG: sinus tachycardia most common, S1Q3invertedT3 with large embolus (classic, but rare!), look for right-axis deviation V/Q scan very sensitive but not specific Spiral CT with contrast show large, central emboli Pulmonary angiogram is gold standard but carries risk Consider Doppler U/S of legs

Wells Criteria. The Wells Score correlates with the probability that a given patient has a pulmonary embolism. The mnemonic is:Dont die, tell the team to calculatecriteria!Dont(DVT symptoms) 3 points Die(Diagnosis most likely PE) 3 points Tell (Tachycardia) 1.5 points TheTeam(Three days [at least] of immobilization, or surgery in the pastThirty days) 1.5 points To (Thromboembolism in the past [DVT or PE]) 1.5 points Calculate (Coughing up blood [hemoptysis]) 1 point Criteria (Cancer) 1 pointThis is what the scores mean: > 6Highprobability of PE 2-6Moderateprobability of PE < 2Lowprobability of PEThe modified Wells Criteria is a bit simpler: > 4 PE islikely Consider diagnostic imaging. 4 PE isunlikely ConsiderD-dimerto rule out PE.

PneumothoraxCan be asymptomatic or present with acute pleuritic chest pain and dyspnea Primary pneumothorax predominantly in healthy young tall males Due to trauma (MVA accidents associated with rib fractures, iatrogenic during line placement, thoracentesis) Increased alveolar pressure from asthma or barotraumas (BiPAP, ventilator-associated) Rupture of bleb in COPD patients

PneumothoraxDecreased expansion of chest Decreased breath sounds and Decreased tactile/vocal fremitus on side of pneumothoraxHyperresonant percussion note Usually easily confirmed by CXR

Aortic DissectionAbrupt onsetThe pain usually is described as ripping or tearingTearing or ripping pain that is felt in the intrascapular areaNew diastolic murmur, asymmetrical pulses, and asymmetrical blood pressure measurementsRisk factors: HTN, Marfan syndrome, coarctation of aorta..Widened mediastinum on a portable anteroposterior (AP) radiographTEE considered diagnostic test of choice

Boerhaaves PerforationThis is very rare but is associated with a high mortality.There is a history of sudden onset severe chest pain immediately after an episode of vomittingSymptoms may include shortness of breath and pleuritic type of chest pain (due to subsequent pleurisy and effusion).Signs of pleural effusion after some hours- dullness to percussion,absent breath sounds,decreased vocal resonance.Subcutaneous emphysema in a minority of casesAbdominal rigidity,sweating,fever,tachycardia and hypotension may be present as the fever progresses but are non specific.The way to rule it out if you strongly suspect is to perform a chest radiograph after swallowing a water soluble contrast (gastrograffin)

Thank You

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