Approach to the Patient With Chest Pain Diagnostic Workout

Approach to the PatientApproach to the PatientWith Chest PainWith Chest Pain

Diagnostic WorkoutDiagnostic Workout

5% of ER admissions5% of ER admissions

Much larger proportion in internal medicine-ER section (about 10-20%)

Since people are concerned with chest pain

5% of ER admissions5% of ER admissions

Minority: Immediate life-threatening conditions (MI, dissection, PE)

Majority: Minor causes or non-urgent significant disorders

Among Hospitalized Patients:Among Hospitalized Patients:Inversed ProportionInversed Proportion

Chest PainChest PainTriage

Diagnosis

ER Ward

Home SweetHome

Chest PainUnit

Chest PainDiagnostic Challenge

UPS…


r/o life threatening conditions: MI, PE, dissection, tension pneumothorax

Multiple Potential Origins of Chest pain

Superficial (skin and appendices)

Musculo-skeketal: chest wall (muscles, ribs)

Pleuritic: (parietal pleura, pericardium)

Myocardial ischemia

Esophageal

Aortic

Other mediastinal

TracheaVertebral / nerve compression

First step: Characterization of painDefining its origin

Skin and appendices

Abscess / cellulitis - obviousMastitis / mastopatia fibrosa cystica – obviousVaricella Zoster – tricky at initial phase

(S) Burning pain“superficial” sensitivity affected by dressing(O) Hyperalgesia / disesthesia

Chest wallSensorium by intercostal nervesSensory fibers in perichondrium andIntercostal musclesShoulder girdle muscles

http://www.ajronline.org/content/vol184/issue3/images/large/00_04_0554_01a.jpeg

Chest wall

TraumaTumorTietze syndromeMyositis / myalgia

(strain, immune disease, infection)

Rosaries in rickets

Infection: most common – viral-influenza peculiar - trichinella

“Siertze balit”

Chest wall

(S) localized, stab-like, aggravated by breathing(O) Appearance with hand over nipple Local tenderness

Pectoralis M. strain

Chest wall

(S) Pain while doing push-ups(O) Trigger points pain intensified while contracting / stretching muscle

Pleuritic pain (pleura, pericardium)Inflammation>>Sensorial input from parietal baso-lateral aspects of serosaPhrenic N, Intercostal N.

Pleuro-pericartitisInfections (bacterial, viral)TraumaTumorPEPneumothoraxImmune (SLE, RA, sceroderma)Miscell. (FMF, Dressler’s syndrome)

Pleuritic pain (pleura, pericardium)Inflammation>>Sensorial input from parietal baso-lateral aspects of serosaNo inflammation – no pain

(S) Less localized, stab-like, aggravated by breathing Positional effect ; Effect of swallowing Radiation – shoulder (phrenic), localized (intercostal) Other related complains Pericarditis-some components of anginal pain(O) No local tenderness (unlike musculo-skeletal) Other related physical findings Other related objective indices

Gallop+

Epidemic Pleurodynia

Coxsackie B

FeverGI symptomsRespiratory symptomsExanthemaHeadache, aseptic meningitisPeri-myocarditisChest pain – pleurisy (Bornholm’s disease)

pleuro-pericarditisintercostal myocarditisperichondritis, periosteitis

Anginal painSensorium – symathetic nerves along coronary adventitia (sub-epicardial)Reflects Interstitial lactic acidosis?

Coronary heart diseaseStable AP < - > UAPNarrowing< - > ruptured plaque

Lt ventricular strain (subendocardial ischemia)ASHOCMSevere HTN – chronicSevere HTN – acute (pheochromocytoma, sympatomimetic toxidrome)

Rt. ventricular strainPEHypoxia >>>chronic PHTNAcute mountain sickness

OthersCO poisoning, methemoglobinemia, cyanide poisoning, nitrate withdrawalTachyarrythmia of any cause, alone or superimposed on CAD

(↓diastole, ↓ BP, LVEDP↑)

Anginal painSensorium – symathetic inflow along coronary adventitia (sub-epicardial)Reflects Interstitial lactic acidosis?

(S) Pain type: pressure-like \ heaviness \ burning Acute < - > chronic intermittent Pain radiation Effort-related (differ from enhanced respiration-related musculo-skeletal/pleuritic) Relived by rest (time!), by nitrates Herald symptoms before AMI – milder episodes of pain Associated complains (SOB, orthopnea, cold perspiration, nausea, doom) In chronic pain – specify functional capacity (NYHA) Risk factors (O) …..

Esophageal pain

Muscular pain (motility disprders) Diffuse esophageal spasm Nutcracker esophagus

Mucosal pain Reflux esophagitis (GERD) Infection (candida, cytomegalovirus etc) Post chemotherapy / irradiation Thermal/acid/alkali burns FB: fishbone

(S) Much like anginal pain: pressure like, radiation No relation to exrcise Some association with eating/swallowing Relieved by nitrates and CCB

(S) heartburn, regurgitation associated with swallowing, aggravated by recumbent position acid taste, night cough, “asthma”, appears after special food or wine, relief by anti-acids

Esophageal pain

Mixed muscular / mucosal painForeign bodiesAchalesia

(S) Mixed symptoms drooling non-acid reflux

Vascular - Aortic pain

Aortic dissection

)S (Excruciating pain Radiation between scapulae

Doom)O (Sympathetic overactivity

Unequel pulses / BP AR

Bruits Features of “collagen” disease

Aortitis / inflammation of major vessels

Inflammatory (Takayasu)Infective

(S) Less defined, subacute / chronic(O) carotidenia, epigastric tenderness Bruits

Other mediastinal pain

Infection esophageal rupture (Borhave) post surgicalTumor

(S) Ill-defined retrosternal dull / severe pain Many other symptoms

Pain originating from airwaysSensorium by vagal inflow down to the carina

Tracheitis-mucositis Infection Chemical Thermal Irradiation, chemotherapy Post - intubation

(S) Retrosternal sharp pain, associated with breathing / cough “as if something is torn from within” aggravated by dry air, improved by humidified air

Chest pain - miscellaneous

Acute chest syndrome in sickle cell disease

(S) Chest pain: pleuritic + anginal type Cough, fever, dyspnea(O) Tachypnea, hypoxia, lobar infiltrate>>> diffuse infiltrates, respiratory failure cardiovascular failure

Pain related to pleuritis and PHTN

Chest pain - miscellaneous

Prolapsed (floppy) mitral valve (barlow’s syndrome)

(S) “A-typical” stab-like chest pain, lasting seconds “like needle pricks” “Fatigue syndrome”, “neuresthenia”(O) Sometime, some musculo-skeletal components Physical hints for abnormal collagen synthesis Anxiety

Mechanism of pain ???

Origin of Chest PainNot always within the chest

Neck, shoulder girdleChest structures

Abdominal origin

Referred pain

Referred pain

spine

Referred pain

GallbladderLiverPancreasGastric/duodenalColon (splenic fl.)Spleen

(S) GIT symptoms Radiation to shoulders(O) Abdominal tenderness and findings

Radicular pain

Radicular pain

(S) Related to specific movements(O) Triggered by movements Trigger points

Supraspinatus (rotator cuff) Infraspinatus (rotator cuff)

Subscapularis (rotator cuff) Teres minor

Trapezius

Scalenus anterior & posterior) thoracic outlet(

Rotator cuff injuryFrozen shoulder

Chronic shoulder dislocation

Radiated shoulder pain

Referred pain in the other direction

Chest >>>abdomen

Basal pneumoniaAMI (diaphragmatic wall)

Chest>>>neck

UL pneumoniaPancoast syndrome

Chest Pain Evaluation

Medical historyPhysical examinationInitial diagnostic testsProvocative/therapeutic testsObservation period in ER – dynamicsHospitalization

Chest Pain: Evaluation

Type of pain, duration, location and radiationAssociated acute complains: SOB, nausea perspiration, doom perceptionAssociation with: exercise, breathing, peculiar movement, swallowing, coughAssociated additional symptoms: fever, weight loss…Risk stratification

r/o life threatening conditions: MI, PE, dissection acute chest syndrome in a black patient

Most important

Medical historyPhysical examinationInitial diagnostic testsProvocative/therapeutic testsObservation period in ER – dynamicsIn-hospital final diagnosis and treatment

Vital signs, compare pulsesGeneral appearance Hyperalgesia / disesthesiaLocal tendernessProvocation of painSigns of DVT

r/o life threatening conditions: MI, PE, dissection


Medical historyPhysical examinationAssessment: define type of painInitial diagnostic testsProvocative/therapeutic testsObservation period in ER – dynamicsIn-hospital final diagnosis and treatment



SkinChest wall (musculo-skeletal)Pleural/pericardial (serositis)Anginal/esophageal-muscular (m. ischemia)Esophageal – mucositisRadicularOther referred pain



ECG (is it in the presence of pain?)±CXR±Basic lab tests, cardiac enzymes, D-dimer, blood gases, surgery protocol, etc.±echo / spiral CT


Properties of individual markers

Marker Initial Rise Peak Persistence Heart Specificity

CK 4 - 6 h 18 - 24 h 24 - 36 h +

CK MB 4 - 6 h 16 - 20 h 18 - 30 h ++

Myoglobin 1 - 2 h 4 - 6 h 8 - 12 h +

Troponin I 4 - 6 h 18 - 24 h 5 - 7 d ++++

Troponin T 3 - 5 h 18 - 24 h 5 - 7 d ++++

GOT

LDH

8-12

12-24

12-24

24-36

24-36

36-48

-

-

Figure 1. Plot of the appearance of cardiac markers in blood vs. time after onset of symptoms. Peak A, early release of myoglobin or CK-MB isoforms after AMI; peak B, cardiac troponin after AMI; peak C, CK-MB after AMI; peak D, cardiac troponin after unstable angina. Data are plotted on a relative scale, where 1.0 is set at the AMI cutoff concentration.




Diagnostic maneuversChanging positionDeep breathManipulation of neck, shoulder girdleLocal pressureExercise




Therapeutic trialsNitrate test

Nitrate Test

Pain relief(clinical response)

Shorttime

PositionPharmacologic

response

Test responsesClinical (+), pharmacologic (+) = positive testClinical (-), pharmacologic (+) = negative testClinical (+), pharmacologic (-) = placebo effectClinical (-), pharmacologic (-) = ineffective drug

Be there




Therapeutic trialsNitrate test (how performed!)Anti-acid with immediate effect (Maalox)Local anesteticsInhalation of humidified air / lidocaine




Provocative testsExercise testBernstein test

Medical historyPhysical examinationAssessment: define type of painInitial diagnostic testsProvocative/therapeutic testsComplementary testsObservation period in ER – dynamicsIn-hospital final diagnosis and treatment



Cardiac echoSpiral CTV/Q scanRibs X raysChest X rays on expiriumAbdominal US/CT

Medical historyPhysical examinationAssessment: define type of painInitial diagnostic testsProvocative/therapeutic testsComplementary testsObservation period in ER – dynamicsIn-hospital final diagnosis and treatment



The time effect – repeated re-evaluationChange in symptomsChange in objective findingsRepeated blood tests (cardiac enzymes) and ECGExercise test

Chest pain units

Medical historyPhysical examinationInitial diagnostic testsProvocative/therapeutic testsComplementary testsObservation period in ER – dynamicsIn-hospital final diagnosis and treatment orAmbulatory final evaluation and treatment



Exercise testThalium scanCardiac catheterizationEndoscopy, esophageal manometryBone scan

Treatment Options

Diagnostic Scenarios

Outpatient clinic

Low risk, atypical chest pain, no findingsNegative ECG (if available)

Ambulatory evaluationHome Sweet Home

Otherwise

ER

Low risk, atypical chest pain, no findingsNegative basic diagnostics (ECG, ± CXR)

Otherwise

Diagnosed cause requiring hospitalizationHigh index of suspicion, even if ECG normal (without pain)

Intermediate Chest Pain Unit

Hospitalization

Take Home Massages

Numerous causes

SkinChest wall (musculo-skeletal)SerositisAnginalEsophagealVascularRadicularReferred pain

Take Home Massages

Diagnostic steps

Definition of chest pain typeConsider/exclude threatening conditionsReach final diagnosis

Medical historyPhysical examinationInitial diagnostic testsProvocative/therapeutic testsObservation period in ER – dynamicsHospitalization

Medical interview

Physical Examination

Diagnostic tests

70-80%

Contribution toDiagnosis

Take Home Massages

Most important

Take Home Massages (cont.)

In the seventies – Undiagnosed AMI discharged - 8% of patientsNeed for assessment by experienced physiciansPlay safe whenever in doubt – admit for hospitalization“White appendix” phenomenon better than missed diagnosis and discharge

Dynamics in clinical presentationSome indices require time for appearance (enzymes, ECG)Time for patient to adjust – shift of medical history

Observation periodRepeated medical history, PE, and diagnostic maneuvers (ECG, enzymes etc.)Repeated assessment

Patients asymptomatic on arrival and without findings may crush later onKeep high index of suspicionStrongly consider hospitalization unless evidently “clear”

Patients may simultaneously have lice and fleas (i.e. musculo-skeletal + anginal pain)Make sure pain induced by maneuvers is exactly as the one they complain ofPlay safe whenever in doubt - hospitalize

Treatment Options

Documents

Approach to the Patient With Chest Pain Diagnostic Workout