Many Faces of Chest PainIan McLeod, MS, MEd, PA-C, ATC

Northern Arizona University

ASAPA Spring Conference 2019

Disclosures

• I have no financial disclosures to report

Objectives

• Following the presentation attendees will be able to:• Develop a concise differential diagnosis for patients with chest pain including

cardiac and non-cardiac causes.

• Describe key clinical characteristics and management of the following chest pain etiologies: angina, embolism, gastroesophageal reflux, costochondritis, costochondral dysfunction, anxiety and pneumonia.

• Discuss appropriate use of diagnostic studies utilized in the evaluation of patients presenting with chest pain.

Chest Pain – Primary Care Setting

• ~1.5% of all visits are for chest pain

• Musculoskeletal 35-50%

• Gastrointestinal 10-20%

• Cardiac 10-15%

• Pulmonary 5-10%

• Psychogenic 1-2%

Chest Pain Differentials

• Cardiac• Stable angina• Acute coronary syndrome• Pericarditis• Aortic dissection

• MSK• Costochondritis• Tietze syndrome• Costovertebral joint dysfunction

• GI• Gastroesophageal reflux disease

(GERD)• Medication induced esophagitis

• Pulmonary• Pneumonia• Pulmonary embolism• Spontaneous pneumothorax

• Psych• Panic disorder

Setting the stage

• Non-traumatic

• Acute chest pain

• Primary care setting• H&P

• ECG

• CXR

Myocardial Ischemia Risk Factors

• Increasing age

• Male sex

• Chronic renal insufficiency

• Diabetes Mellitus

• Known atherosclerotic disease → coronary or peripheral

• Early family history of coronary artery disease• 1st degree male relative < 55 y/o

• 1st degree female relative < 65 y/o

• ASCVD risk calculator

Myocardial Ischemia – Pain Characteristics• Pain descriptors

• Deep (retrosternal)

• Poorly localized → center or left sided

• Oppressive

• Pressure

• Heaviness

• Tightness

• Constriction

• Radiation• Neck

• Jaw

• Shoulder

• Arms

• Uncharacteristic / unlikely• Sharp, knife-like, stabbing

• Change with respiration or body position

• Provoked / worsened with chest wall palpation

Myocardial Ischemia – Pain Characteristics

• Stable angina• Gradual onset and offset

• Precipitated by exertion and relieved by rest

• Emotional stress

• Cold

• Sublingual nitroglycerin

• Acute coronary syndrome → unstable angina or AMI• Angina at rest

• New-onset angina

• ↑ angina severity or ↑ duration

Myocardial Ischemia – Associated Symptoms

• Dyspnea

• Nausea and vomiting

• Diaphoresis

• Presyncope

• Palpitations

• Atypical presentations→ females, dementia, older patients• Absence of chest pain

• Epigastric discomfort

• Dyspnea

• Indigestion

• Nausea and vomiting

• Weakness

• Pleuritic chest pain

Barstow C, et al. 2017

Myocardial Ischemia – Diagnostic Testing

• Electrocardiogram• ST Elevation MI (STEMI)

• ST segment elevation at the J-point in 2 contiguous leads with the cut-points:

• ≥1 mm in all leads other than leads V2-V3

• Leads V2-V3:

• ≥2 mm in men ≥40 years

• ≥2.5 mm in men <40 years

• ≥1.5 mm in women regardless of age

• Non-ST Elevation MI (NSTEMI)• Horizontal or downsloping ST-depression ≥0.5 mm in two contiguous leads

and/or

• T inversion >1 mm in two contiguous leads with prominent R wave

Limb and Chest Lead “Views” of the Heart

Myocardial Injury – ST Segment Elevation

• Zone of injury does not repolarize completely so it remains more positive than surrounding tissue leading to ST segment elevation

Myocardial Ischemia – ST Segment Depression

• ST segment depression

• Area of ischemia is more negative than surrounding tissue

Myocardial Ischemia – T Wave Inversion

• T wave inversion because ischemic tissue does not repolarize normally

• ST-segment elevation myocardial infarction (STEMI)• ST elevations across the precordium (V1-V5) with reciprocal ST depressions

inferiorly (II, III, aVF) • Concerning for proximal left anterior descending (LAD) lesion causing

ischemia

• Episode of chest pain at rest in a patient with unstable angina• ST-segment depression above 1 mm is present in leads V4 to V6• Chest pain and ST-segment depression disappeared promptly after the

administration of sublingual nitroglycerin

Acute Pericarditis

• M>F

• 20 to 50 y/o MC

• Causes• Idiopathic (presumed viral)• Infectious

• Viral / Bacterial / Fungal / TB / HIV

• Non-infectious• Connective tissue disease / autoimmune disorders• Malignancy• Cardiac disorder• Renal failure (uremia)• Radiation• Medication adverse reaction• Trauma

Acute Pericarditis – History

• Sudden onset of retrosternal chest pain (>95%)• Sharp and pleuritic

• ↑ coughing, inspiration and / or swallowing

• ↑ lying supine

• ↓ sitting and leaning forward

• +/- radiating pain → similar to MI

• Prolonged duration

• +/- Preceding viral syndrome (URI or GI)

• +/- Fever

• +/- Dyspnea

Pericarditis – Physical Exam

• Pericardial friction rub• Scratching or grating sound

• Highly specific

• Loudest left sternal border

• Increases with leaning forward

• +/- Fever (>100.4°F)

• +/- Tachypnea

• +/- Tachycardia

Yelland, MJ. Outpatient evaluation of the adult with chest pain. In: UpToDate, Aronson, MD (Ed), UpToDate, Waltham, MA, 2018.

Acute Pericarditis – Diagnostic Studies

• ECG• Diffuse concave ST elevation

• PR depression

• Blood work• CBC → leukocytosis if infectious

• ESR / CRP → elevated

• Cardiac troponin → elevation indicates myopericarditis

• Additional bloodwork based upon suspected causes

• CXR → typically normal

Acute Pericarditis – Electrocardiogram

Imazio, M. Acute pericarditis: Clinical presentation and diagnostic evaluation. In: UpToDate, LeWinter, M (Ed), UpToDate, Waltham, MA, 2017.

Acute Pericarditis – Treatment

• High-risk features that necessitate hospital admission• Fever > 100.4°F

• Subacute course

• Hemodynamic compromise (cardiac tamponade)

• Large pericardial effusion

• Immunocompromised

• Current anticoagulant therapy

• Elevated cardiac biomarkers

• Failure to clinically improve with 7 days of appropriate NSAID therapy

Acute Pericarditis – Treatment

• Idiopathic (presumed viral)• Ibuprofen 600 to 800 mg TID or• Aspirin 650 to 1000 mg TID or• Indomethacin 25 to 50 mg TID• Plus colchicine 0.5 mg QD if < 70 kg or BID if >70 kg x 3 months

• Bacterial• Vancomysin 30 mg/kg/day and• Ceftriaxone 3 mg/kg/day• Pericardiocentesis

• Restrict from exertional activities until symptoms resolve and labs normalize

Taper when symptom free & CRP normalizes

Aortic Dissection

• Acute severe / sharp chest and back pain• +/- ripping or tearing quality• UE peripheral pulses and blood pressures may be diminished or unequal• Surgical emergency

Costochondritis

• MC cause of MSK anterior chest pain

• F=M

• > 40 y/o

• Idiopathic – hx of preceding illness with coughing or recent strenuous exercise is common

• Inflammation of costochondral or chondrosternal junction• Unilateral

• 90% > 1 level

• 2nd – 5th ribs most common Mayo Clinic

Costochondritis – History & Physical Exam

• Sharp, aching or pressure like pain• Anterior

• May radiate laterally

• ↑ deep breathing, coughing, sneezing and laughing

• ↑ upper body movements

• Reproduction of pain with palpation

• No overlying discoloration or swelling

• ROM restriction uncommon

Mayo Clinic

Tietze Syndrome

• Rare

• F=M

• < 40 y/o

• Idiopathic – hx of preceding illness with coughing

• Inflammation of costochondral or costosternal junction• Unilateral

• 70% 1 level only

• 2nd – 3rd ribs most common

Tietze Syndrome – History & Physical Exam

• Sharp, aching or pressure like pain• Anterior

• May radiate laterally

• ↑ deep breathing, coughing, sneezing and laughing

• ↑ upper body movements

• Reproduction of pain with palpation

• Swelling overlying the involved joints

• ROM restriction uncommon

Costochondritis & Tietze Syndrome – Treatment

• Analgesics• NSAIDs

• APAP

• Activity modification

• Variable course• Weeks to months

• Rare to exceed a year

• Chest wall tenderness has a tendency to linger

• Refractory cases → lidocaine/corticosteroid injection

Costovertebral Dysfunction

• F>M

• Recent history of restricted chest posture

• Rib hypomobility / “subluxation”• Functional disruption of the

costovertebral and costosternal articulations

• Alteration of rib mechanics with inspiration and expiration

Costovertebral Dysfunction – History

• Sharp stabbing pain• Present upon waking

• Unilateral

• Anterior and posterior → “feels like a knife is being stabbed through my chest”

• May radiate laterally along dermatomal distribution

• ↑ deep breathing → subconscious alteration of inspiratory effort

• ↑ coughing, sneezing and laughing

• ↑ trunk movements

Costovertebral Dysfunction – Physical Exam

• Reproduction of pain with palpation

• PA mobilization of adjacent vertebra• ↑ pain

• Hypomobility

• Protective muscle spasm

• Restricted trunk range of motion• Extension, ipsilateral rotation and ipsilateral flexion

→ limited by pain

• Opposite movements → limited by tightness

• Sudden reduction in pain with physical exam → rib relocation

Costovertebral Dysfunction – Management

• Pharmacologic• Analgesics

• NSAIDs or

• APAP

• Muscle relaxants

• Manual therapy• Physical therapy

• Chiropractic therapy

• Massage therapy

GERD

• Reflux esophagitis• Abnormal LES function

• Reflux of stomach contents into esophagus

• Prolonged exposure to gastric acid

• Contributing factors• Hiatal hernia

• Obesity

• Pregnancy (30 to 50%) and exogenous estrogen

• Diet and medications

Mayo Clinic

GERD – History & Physical Exam

• Heartburn• Retrosternal burning or squeezing• ↑ lying down, bending over• MC postprandial• +/- nocturnal pain• +/- exacerbation due to emotional

stress• Pain may last minutes to hours• Some relief with antacids

• Regurgitation• Dysphagia• Chest pain → may mimic angina• Nausea / vomiting (rare)• Nonspecific physical exam findings

• Alarm symptoms• Anemia

• Loss of weight

• Anorexia

• Recent onset of progressive symptoms

• Melena or hematemesis

• Swallowing difficulties (dysphagia or odynophagia)

GERD – Treatment

• No alarm symptoms• Lifestyle and dietary modifications combined with 4-8 week trial of PPIs

• Alarm symptoms• GI consult (urgent or emergent)

Medication Induced Esophagitis• F>M

• Mean age 41.5 y/o

• Indirect mechanism• Adverse reactions → weakening LES

• Disrupting protective barrier → NSAIDs

• Medication induced infection → Antibiotics

• Direct mechanism• Medication lodged at area of esophageal narrowing → aortic

arch

• Local caustic injury to adjacent mucosa

• Antibiotics: tetracycline, doxycycline and clindamycin

• Bisphosphonates

• Potassium chloride, quinidine preparations, iron compounds

Medication Induced Esophagitis – History & Physical Exam• Sharp retrosternal pain or heartburn

• Odynophagia

• Dysphagia

• Infrequent but alarming symptoms• Inability to swallow saliva

• Hematemesis

• Abdominal pain

• Weight loss

• Nonspecific physical exam findings

Medication Induced Esophagitis – Treatment

• Discontinue medication or switch to liquid form

• +/- acid suppression agents

• Endoscopy indications:• Alarm symptoms

• Severe pain

• Persistent symptoms >1 week after discontinuing medication

Pneumonia

• Infection of the lung parenchyma• Bacterial

• S. Pneumoniae ~60% of all CAP• Viral• Fungal

• Risk factors• Immunocompromised• <2 y/o or > 65 y/o• Alcohol abuse• Tobacco use• Asthma• Lung disease• Heart disease• Institutionalization

Pneumonia

• Alveolar inflammation

• Accumulation of WBCs, fluid and proteins in the alveolar space

• Impairment of gas exchange

Ramirez, JA. Overview of community-acquired pneumonia in adults. In: UpToDate, File, TM (Ed), UpToDate, Waltham, MA, 2018.

Pneumonia – History

• Specific (more common)• Cough

• +/- sputum

• +/- hemoptysis

• Pleuritic pain

• Dyspnea

• Non-specific• Sweats, chills, rigors

• Fatigue, myalgias

• Headache

• Chest discomfort

• Abdominal pain

• N/V

• Anorexia

• Mental status changes

Pneumonia – Physical Exam

• Asymmetric breath sounds

• Rales

• Egophony

• ↑ tactile fremitus

• Local dullness to percussion

• Fever > 100.4° F

• Tachypnea

• Tachycardia

• ↓ O2 saturation

Pneumonia – Diagnostic Studies

Radiology Masterclass

Pneumonia – Treatment (CURB-65)

• CRB-65 (remove BUN)• 0 → outpatient• 1-2 → consider hospitalization• 3-4 → urgent hospitalization

Pneumonia – Treatment

• CAP outpatient empiric treatment• Healthy with no antibiotic use in past 3 months

• Macrolide or doxycycline

• Potential for macrolide resistance or antibiotic use in past 3 months• Respiratory fluoroquinolone or high dose amoxicillin* (or Augmentin*) + macrolide

* Ceftin (cefuroxime) alternative option

Pulmonary Embolism

Pulmonary Embolism

Pulmonary Embolism – History & Physical ExamSymptoms• Dyspnea 73%

• Rapid onset within seconds or minutes

• Pleuritic chest pain 66%

• Cough 37%

• Orthopnea 28%

• Calf or thigh pain and/or swelling 44%

• Wheezing 21%

• Hemoptysis 13%

• Pre(syncope) <10%

Signs• Tachypnea 54%

• LE signs of DVT 47%

• Tachycardia 24%

• Rales 18%

• Decreased breath sounds 17%

• Fever, mimicking pneumonia 3%

• ↓ O2 saturation

Pulmonary Embolism – Wells Criteria

• Scoring< 2 low probability (3.4%)

2-6 moderate probability (27.8%)

> 6 high probability (78.4%)

Pulmonary Embolism – Diagnostic Studies

• Electrocardiogram → common but non-specific abnormalities• Sinus tachycardia and non-specific T wave changes → 70%

• Classic S1Q3T3 pattern <10%• S wave in lead I, Q wave in lead III and inverted T wave in lead III

• CXR• 50% are normal / non-diagnostic → useful in ruling out other conditions

• PE specific abnormalities• Hampton's hump (pulmonary infarction) → wedge shaped consolidation in the periphery

w/ base against pleural surface

• Westermark’s sign (vasculature collapse) → sharp cut-off of pulmonary vessels with distal hypoperfusion (oligemia)

Thompson, BT, et al. Acute pericarditis: Clinical presentation, evaluation, and diagnosis of the nonpregnantadult with suspected acute pulmonary embolism. In: UpToDate, Mandel, J (Ed), UpToDate, Waltham, MA, 2018.

Thompson, BT, et al. Acute pericarditis: Clinical presentation, evaluation, and diagnosis of the nonpregnantadult with suspected acute pulmonary embolism. In: UpToDate, Mandel, J (Ed), UpToDate, Waltham, MA, 2018.

Spontaneous Pneumothorax

• Primary• M:F 6:1• Tall, thin young men (20-40 y/o)• Rupture of small blebs, usually

located near the apex of the upper lobes

• Secondary• Most common: COPD• Other: pneumonia, bronchogenic

carcinoma, mesothelioma, sarcoidosis, tuberculosis, cystic fibrosis, iatrogenic

Spontaneous Pneumothorax – History

• Pleuritic chest pain (90%)• Sudden onset of sharp pain → progresses to becoming dull after a few hours

• Unilateral

• Dyspnea (80%)

• Cough (10%)

• Symptom severity is related to the size of the pneumothorax

Spontaneous Pneumothorax – Physical Exam

• Tachycardia

• Tachypnea

• ↓ O2 saturation

• Diminished breath sounds

• Hyperresonance to percussion

• Decreased tactile fremitus

• Subcutaneous emphysema

Spontaneous Pneumothorax – Diagnostic Studies

Radiology Masterclass

Spontaneous Pneumothorax – Diagnostic Studies

Radiology Masterclass

Spontaneous Pneumothorax – Diagnostic Studies

Radiology Masterclass

Panic Disorder

• F>M

• Median age 24 y/o

• Risk factors• Neuroticism→ proneness to experiencing negative emotions• Anxiety sensitivity → disposition to believe that anxiety symptoms are

harmful• Childhood sexual and physical abuse• Smoking• Life stress

• Anticipate catastrophic outcome from a mild physical symptom• Chest pain → heart attack

Panic Disorder – DSM V Criteria

• Recurrent unexpected panic attacks

• Abrupt surge of intense fear or discomfort → peaks within several minutes

• 4 or more associated symptoms

• Inquire about previous workup

• Palpitations, pounding heart, or accelerated heart rate

• Sweating

• Trembling or shaking

• Sensations of shortness of breath or smothering

• Feelings of choking

• Chest pain or discomfort

• Nausea or abdominal distress

• Feeling dizzy, unsteady, light-headed, or faint

• Chills or heat sensations

• Paresthesias (numbness or tingling sensations)

• Derealization (feelings of unreality) or depersonalization (being detached from oneself)

• Fear of losing control or “going crazy”

• Fear of dying

Panic Disorder – Treatment

• Cognitive behavioral therapy (CBT)

• SSRI or SNRI → considering tapering after ~1 year• Sertraline (Zoloft) – 50mg/day – increase dosage after 6 weeks

• Venlafaxine (Effexor) – 37.5 mg/day – increase dosage after 6 weeks

• Partial response after 8 – 12 week trial consider adding clonazepam (Klonopin)

Thank YouIan.mcleod@nau.edu

References

• UpToDate

• Radiology Masterclass (https://www.radiologymasterclass.co.uk/)

• Barstow, C, et al. Acute Coronary Syndrome: Diagnostic Evaluation. Am Fam Physician. 2017; 95(3): 170-177.

• McConaghty, JR and Oza, RS. Outpatient Diagnosis of Acute Chest Pain in Adults. Am Fam Physician. 2013; 87(3): 177-182.

• Proulx, AM and Zryd, TW. Costochondritis: Diagnosis and Treatment. Am Fam Physician. 2009; 80(6): 617-620.

• Jameson J, et al. Harrison's Principles of Internal Medicine: Chest Discomfort, 20e; 2018. https://accessmedicine.mhmedical.com/ViewLarge.aspx?figid=192010949