Chest Pain
Sumit Bose, MDPGY-3
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 Pain
Scenario 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 Pain
Scenario 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