Chest Pain
Chest Pain
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 PainScenario 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 PainScenario 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