Chest Pain On The Acute Medical Take

Acute Block UHCWSeptember 25th 2014

Dr. Adam IqbalClinical Teaching Fellow

UHCW NHS Trust

ObjectivesBy the end of this session you should be able to:

• List the common and serious causes of chest pain presenting to the acute medical take

• Recognise the clinical features of (interactive discussion):

– Acute coronary syndrome, aortic dissection, pericarditis

– Pulmonary embolism, pneumothorax

– Exacerbation of COPD & acute asthma

• Recognise radiological features of:

– Pericardial effusion

– Pneumothorax

– Pulmonary embolism

• Discuss management of acute coronary syndromes (didactic teaching)

Clinical Assessment

A

B

C

D

E

1. IDENTIFY problem

2. CORRECT abnormalities

…then PROCEED

• History:

– SQITAS

– Problem solving

– PMHx

– DA

– SHx, FHx

Which system?

Cardiac

Respiratory Musculoskeletal

Gastrointestinal Neurological

Clinical Features of ACS …HISTORY CLINICAL EXAMINATION

Clinical Features of ACS …HISTORY

Sudden onset central chest pain

“Squeezing, tight, crushing, pressure, dull ache”

Radiation – neck, jaw, arms

Typically severe (subjective!)

Precipitated by exertion, relieved by rest (but beware unstable disease)

Sweaty, nauseous, collapse

DM, smoker, IHD, male, age, FHx, alcohol, HTN, PVD, renal failure

(Beware atypical presentation in women, DM, elderly)

CLINICAL EXAMINATION

Usually normal unless complications

May be some evidence of risk factors: PVD (i.e. bypasses, tissue loss), DM (fingerprick), tar staining, hypertensive changes (retinal, bruits), arcus

Clinical Features of Aortic Dissection

HISTORY CLINICAL EXAMINATION

Clinical Features of Aortic Dissection

HISTORY

Sudden onset severe central chest pain

“Tearing”

Radiation – arms, back

May ‘migrate’

Neurological symptoms

Autoimmune rheumatic disorders, Ehlers-Danlos, Marfan’s, HTN, trauma, recent instrumentation of aorta

CLINICAL EXAMINATION

Tachycardic, raised BP

Brachial pulse discrepancy

Proximal extension:

murmur (AR), cardiac tamponade/ischaemia

Distal extension:

renal failure, visceral, limb, or spinal ischaemia

Clinical Features of Pericarditis

HISTORY CLINICAL EXAMINATION

Clinical Features of Pericarditis

HISTORY

Sharp central chest pain

Worsened by movement, breathing, and lying down (relieved by sitting forwards)

Hx of recent cardiothoracic insult (surgery, radiotx, trauma) or MI (AMI, Dressler’s)

Recent viral, bacterial, tuberculous illness

CLINICAL EXAMINATION

Pericardial rub

Features of pericardial effusion

Haemodynamic compromise

Features of acute heart failure (myocarditis or constrictive pericarditis)

Clinical Features of Pulmonary Embolism

HISTORY CLINICAL EXAMINATION

PEs can be small, massive, or multiple

Clinical Features of Pulmonary Embolism

HISTORY

Dyspnoea (chronic or sudden onset)

Chest pain (+/- pleuritic)

Cough (+/- haemoptysis)

Risk factors: prev VTE, smoker, pregnancy, immobility, recent surgery, dehydrated, FHx VTE, drugs, OCP

CLINICAL EXAMINATION

Tachypnoea, tachycardia

Raised JVP, hypotension

Features of pulm HTN

Minimal chest signs

Peripheral DVT

PEs can be small, massive, or multiple

Clinical Features of Pneumothorax

HISTORY CLINICAL EXAMINATION

Clinical Features of Pneumothorax

HISTORY

Sudden onset unilateral pleuritic chest pain or progressively increasing breathlessness

Cough

Young male (M:F ratio 6:1), tall, COPD, asthma, ca lung, suppurative lung disease, instrumentation (!!)

CLINICAL EXAMINATION

Tachypnoea, desaturation

Haemodynamic compromise if tension

Reduced expansion, tympanic PN

Mediastinal shift

Clinical Features of COPD Exacerbation

HISTORY CLINICAL EXAMINATION

Clinical Features of COPD Exacerbation

HISTORY

Cough, Phlegm, Fever

Chest pain (tightness, sharp/pleuritic)

SOB, wheeze

Smoker, known obstructive spirometry, under resp physician, frequent exacerbations

CLINICAL EXAMINATION

Tar staining, CO2 flap, tachypnoea, tachycardia, cyanosis, hyperexpanded chest, accessory muscle use, resonant PN, crackles, bronchial sounds, wheeze, prolonged expiratory phase

Clinical Features of Acute Asthma

HISTORY CLINICAL EXAMINATION

Clinical Features of Acute Asthma

HISTORY

SOB

Cough

Wheeze

Phlegm

(Diurnal variation, triggers)

Hx of atopy

DA: beta-blockers, NSAIDs

CLINICAL EXAMINATION

Tachypnoea, tachycardia

Widespread wheeze

Accessory muscle use

Desaturation, cyanosis, see-sawing

Acute Coronary Syndrome

• Make the diagnosis !

• Manage cause / condition / complications

ACS

Angina UA NSTEMI STEMI

Pathophysiology

Angina Unstable Angina

• Exertional

• Relieved by rest

• ± ECG changes ( ST depression, T wave inversion)

• Troponin negative

• Can occur at rest

• Crescendo

• ± ECG changes ( ST depression, T wave inversion)

• Troponin negative

NSTEMI STEMI

• Troponin +ve

• ± ECG changes (ST depression/ T wave inversion)

• Troponin +ve

• ST elevation

– 2mm in 2 consecutive chest leads

– 1mm in 2 limb leads

• New onset LBBB

Acute Management of ACS• A-E assessment (ECG vital)• Identify Problem > Correct > Reassess > Proceed• Monitoring (!!)• UA / NSTEMI

– Aspirin 300mg, Clopidogrel 300mg, Clexane 1mg/kg SC BD• STEMI

– 2222 (!!)– Aspirin 300mg, Ticagrelor 180mg

• Manage symptoms / complications– Beta-blockers prevent arrhythmias (!!)– GTN (SL or infusion)– Analgesia (diamorphine 2.5-10mg IV) & Antiemetic (metoclopramide

10mg IV)– Careful clinical assessment (arrhythmias, heart failure, RVF etc)– Oxygen ONLY IF HYPOXIC

ABSOLUTE CONTRAINDICATIONS

•Active bleeding or GI bleed < 4/52

•Suspected aortic dissection

•Surgery/Trauma/Head injury < 2/52

•Recent non-embolic stroke <6/12

RELATIVE CONTRAINDICATIONS

•HTN

•Prolonged CPR (>5min)

•Pregnancy

•Therapeutic anticoagulation

•Retinopathy

Investigations• Electrocardiogram – serial

• Blood tests– Full Blood Count / U&E

– Lipid Profile / BMs

– Clotting screen

– Troponin (in this trust 3hrs & 6hrs)

• Chest radiograph

• Echocardiogram (LV function)

• Coronary angiogram > PCI

• Myocardial perfusion scan

Post Event management• Lifestyle & risk factor modification

– Smoking cessation– Dietary changes– Exercise– Diabetes & dyslipidaemia– HTN

• Secondary prevention– ACE-I– Beta-Blocker– Statins– Dual anti-platelet therapy for 1yr, aspirin for life

• Cardiac rehabilitation• Clinic follow up & repeat echocardiography

Summary

• Chest pain is the single most common presenting complaint on the acute take

• Know how to recognise the serious (& rare!)

• Reassure the patient

• Bear in mind causes not discussed here i.e. GI

• Apply your clinical reasoning (as opposed to questioning by rote) & you will recognise what you have never seen

• Be thorough, systematic, logical and … keep an open mind!