Chest Pain Epidemiology

1
Chest PainEpidemiology

• 6 million ED visits/year
• 5-7 ED patients
• 3.3 AIS evacuations 2002, 3.5 in 2003,
  3.6 in 2004, 3.2 in 2005
• 3 million patients admitted/year
• 70 found not to have acute coronary event
• 0.4 - 4.0 acute MI are sent home

2
Chest PainPathophysiology

• Chest pain syndromes difficult to diagnose
• Multiple organ systems of the chest
• Share afferent (nerve) pathways
• Pathology in any of these systems have similar
  pattern of complaints
• Most patients have CP with acute coronary
  syndrome(ACS), others may present with only SOB,
  N/V, arm or jaw pain

3
Differential Diagnosisof Chest Pain

• Life-threatening causes
• Acute coronary syndrome(ACS)
• Aortic dissection
• Pulmonary embolism
• Tension pneumothorax
• Esophageal rupture (Boerhaaves syndrome)
• Pericarditis myocarditis
• Acute chest syndrome(in sickle cell disease)

4
Differential Diagnosisof Chest Pain

• Non-life-threatening causes
• Gastrointestinal
• Biliary colic (cholelithiasis,
  cholecystitis)
• Gastroesophageal reflux disease
• Peptic ulcer disease
• Pulmonary
• Pneumonia
• Pleurisy

5
Differential Diagnosisof Chest Pain

• Non-life-threatening causes
• Chest wall syndromes
• Musculoskeletal pain
• Costochondritis
• Thoracic radiculopathy
• Psychiatric
• Anxiety
• Shingles

6
Chest Pain Evaluation

• Problems
• History
• Risk factors
• Physical exam
• Rhythm strip, 9 lead ECG, 12 lead ECG
• Risk stratification based on above factors

7
The Initial Clinical Examination

• ECG can only help if it shows acute MI
• Initial ECG sensitivity 20 - 60 AMI
• Sensitivity of plasma CK-MB low first 4 hrs
• Cant detect unstable angina
• Therefore evaluation based on history, physical
  exam and ECG

8
History

• The most important difference between a good
  and indifferent clinician lies in the amount of
  attention paid to the story of the
  patient---Farquhar Buzzard

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History

• Helpful to group questions to target the three
  most common life threats
• Consider ACS questions
• Pulmonary embolism(PE) questions
• Aortic dissection questions

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HistoryCardiac Questions

• 2 most important historical information
• age, gender
• Advancing age, prevalence and severity of CAD
  increases
• Can estimate pretest probability of CAD based on
  age and gender
• Further refine pretest probability by classifying
  the chest pain as typical, atypical, or
  non-anginal

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Pretest likelihood of CAD based on age, sex, and
symptoms

• Asymptomatic non-anginal CP
• Age Men Women Men Women
• 30-39 1.9 0.3 5.2
  0.8
• 40-49 5.5 1.0 14.1 2.8
• 50-59 9.7 3.2 21.5 8.4
• 60-69 12.3 7.5 28.1 18.6

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Pretest likelihood of CAD based on age, sex, and
symptoms

• Atypical angina Typical
  angina
• Age Men Women Men Women
• 30-39 21.8 4.2 69.7 25.8
  
• 40-49 46.1 13.3 87.3 55.2
• 50-59 58.9 32.4 92.0 79.4
• 60-69 67.1 54.4 94.3 90.6

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Cardiac Questions

• Example 35y/o male with non-anginal CP has 5
  pretest probability of CAD(1 in 20)
• same 35y/o with atypical angina 22 of CAD or
  (1in 5)
• same 35y/o with typical angina 70(7in10)
• If patient has known previous CAD/MI raises risk
  of subsequent coronary event 5 times
• If patient has cardiac history ask about prior
  stress tests, cardiac caths, bypass surgery,
  stents

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Cardiac Questions

• Character of Pain
• Many patients have atypical symptoms
• Ask questions in regard to nature (quality),
  severity(1-10), duration, modifying factors of
  the pain, and associated symptoms
• 40 patients with AMI have atypical CP
• 35 patients without AMI have typical CP

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Cardiac Questions

• In one study of 721 patients who were diagnosed
  with AMI, almost ½ presented without CP
• SOB, weakness, dizziness, syncope, abdominal pain
• Typical angina is a deep, poorly localized chest
  or arm discomfort that is classically exertional
  and relieved with rest or nitrates

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Analysis of Clinical Predictors of AMI

• Clinical features AMI
• chest pain radiation Odds ratio
• left arm 1.5
• right arm 3.2
• both arms 7.7
• nausea, vomiting 1.8
• diaphoresis 1.4
• exertional CP 3.1
  

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Analysis of Clinical Predictors of AMI

• Clinical features AMI
• 
  Odds ratio
• burning/indigestion pain 4.0
• crushing/squeezing pain 2.1
• relief with nitroglycerin 0.9
• pleuritic pain
  0.5
• tender chest wall
  0.2
• sharp/stabbing pain 0.5

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Cardiac Questions

• Another study of 251 patients with cardiac CP
  showed 88 respond to NTG, also 92 of noncardiac
  CP responded to NTG
• Can you give GI cocktail to R/O cardiac CP?
• a study of 97 patients who received GI
  cocktail showed 8 of 11 patients admitted with
  possible cardiac ischemia had complete or partial
  relief of CP

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Cardiac Questions

• Risk Factors
• Diabetes, hypertension, smoking, high
  cholesterol, and family history
• Most CAD patients have at least one
• The absence of risk factors does not exclude
  acute cardiac ischemia

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Aortic DissectionHistory

• Male (75)
• Seventh decade
• History of hypertension (70)
• Other risk factors
• Marfans syndrome, atherosclerosis, prior
  dissection, or known aortic aneurysm

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Aortic DissectionHistory

• Pain is sudden onset (83)
• Severe or worse ever (90)
• Sharp (64) or tearing (50)
• Location anterior chest (60), back (53)
• Migratory (16), radiating (28)
• Suspect dissection in patients with clinical
  changing picture

22
Aortic Dissection History

• Should address 3 basic concerns regarding a
  patients pain
• quality (sudden and severe)
• radiation (especially to the back)
• intensity at onset (maximal)
• Aortic dissection and MI can coexist
• 8 dissection involves coronary arteries

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Pulmonary EmbolismHistory

• Clinical diagnosis of PE is difficult
• Symptoms are variable and nonspecific
• Can range from dyspnea and fatigue to severe
  pleuritic CP and syncope
• Classic description of pleuritic pain, dyspnea,
  and hemoptysis represents embolic pulmonary
  infarction and is seen most commonly in
  hospitalized patients

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Pulmonary EmbolismHistory

• Ambulatory patients often present with painless
  dyspnea
• Can have several weeks of intermittent symptoms
• Physical exam is rarely diagnostic
• Reproducible chest wall pain does not exclude
  diagnosis

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Pulmonary EmbolismHistory

• Wide spectrum of pain quality and location
• Pain that is peripheral, increases with deep
  breath, and not reproducible- suspect PE
• Isolated substernal, pleuritic CP less likely PE
• Substernal, anginal CP occurs 4 PE
• Radiation to arm distinctly unusual
• Pleuritic CP and leg pain more commonly PE than
  other diagnosis

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Pulmonary EmbolismRisk Factors

• Inherited hypercoagulability disorders
• Acquired disorders
• immobilization, pregnancy, BCP
• malignancy, age
• prior history venous thromboembolism
• trauma, obesity
• surgery, smoking

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Pulmonary EmbolismRisk Factors

• Medical conditions
• CHF
• MI
• stroke
• hyperviscosity syndrome (polycythemia vera)
• Crohns disease
• Nephrotic syndrome

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Other Conditions

• Boerhaaves syndrome presents as spontaneous
  esophageal rupture after vomiting
• Pain on swallowing
• Significant number are recently, or acutely
  intoxicated
• Pericarditis refers pain to neck, shoulder and
  worsens with inspiration, swallowing, and lying
  supine

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Physical Examination

• Stable patients with AMI rarely have physical
  findings on exam
• Vital Signs
• Chest pain and hypotension-not good
• 8 PE and 15 aortic dissection are hypotensive
  on presentation
• Patients with CP and hypotension are 3 times more
  likely to have AMI than normotensive pts

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Physical Examination

• Vital Signs
• Fever, consider noncardiac cause, pneumonia,
  mediastinitis
• Low grade fever occurs 14 PE, only 2 PE
  pts had fevergt 102F
• Tachypnea is most common sign in PE, 15 PE pts
  had respiratory rate lt20/min

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Physical Examination

• Vital Signs
• Tachycardia is nonspecific sign
• May be only clue to early pericarditis,
  myocarditis
• Bradycardia, esp. due to conduction defects, may
  be seen in right coronary occlusions

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Physical Examination

• Vital Signs
• Fifth vital sign, pulse oximetry
• Hypoxia can occur in many conditions
• Patient with low O2 saturations require
  supplemental oxygen
• O2 saturation is normal in ¼ of pts with PE

33
Physical ExaminationHead and Neck

• Check neck for Kussmauls sign
  (a paradoxical increase in jugular venous
  distension with inspiration)
• Seen in pericardial tamponade, right heart
  failure or infarction, PE, or tension
  pneumothorax)
• Subcutaneous air at the root of the neck suggests
  pneumothorax, or pneumomediastinitis
• Carotids bruits increase likelihood of CAD

34
Physical ExaminationPulmonary Exam

• Look for respiratory distress
• nasal flaring, intercostal retractions, and
  accessory muscle use
• Listen for unilateral absence of breath sounds
  consider pneumothorax, or massive pleural
  effusion
• Percuss the chest for infiltrates, effusions, and
  pneumothorax

35
Physical ExaminationPulmonary Exam

• Wheezing and rales are important findings but are
  not specific for certain diseases
• Asthma, foreign body, CHF, PE all may cause
  wheezing
• Rales are rare in pts with AMI, but their
  presence with left heart failure, raises the
  likelihood of MI by twofold

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Physical ExaminationCardiac Exam

• A new murmur may signal papillary muscle rupture
• Murmur of aortic insufficiency is an important
  finding associated with aortic dissection
• S3 gallop secondary to CHF raises likelihood of
  MI 3 times

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Physical ExaminationCardiac Exam

• Hammans crunch- crunching sound of heart beating
  against mediastinal air
• Pericardial rub(creaking of new leather) seen in
  pericarditis
• Becks triad(distant heart sounds, distended neck
  veins, and hypotension) seen in pericardial
  tamponade from proximal aortic dissection

38
Physical ExaminationChest Wall Exam

• Even with chest wall tenderness, still have to
  consider life-threatening causes
• Reproducible CP frequently seen in pts with PE
  and ACS
• Costochondritis is inflammation of the costal
  cartilages, may result in sharp, dull, or
  pleuritic CP, rarely has swelling of soft tissues

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Physical ExaminationChest Wall Exam

• Tietzes syndrome- fusiform swelling and pain of
  only one upper costal cartilage
• Compression of cervical or thoracic nerve may
  produce dull chest pain mimickings angina
  (cervico-precordial angina)
• Pain worsens with neck movement, coughing,
  sneezing, or axial loading of the vertebrae
• Check skin for herpes zoster (shingles) causes
  unilateral pain over 1-2 dermatones

40
Physical ExaminationExam of the Extremities

• Look for edema, thrombosis, or pulse deficits
• Peripheral edema frequently seen in right-sided
  and biventricular failure
• Usually absent in acute left heart failure
• Unilateral edema or palpable venous
  thrombus(cord) suggest DVT or PE
• But most pts with PE have normal ext. exams

41
Physical ExaminationExamination of Pulses

• Exam for symmetry and quality
• Pulse deficit is defined as asymmetrical
  amplitude between the right and left sides
• Pulse deficits most common in type A
  dissections(ascending aorta)
• Measured BP difference occurs 15
• Differences gt 20mmHg between arms was an
  independent predictor of dissection

42
Physical ExaminationNeurologic Exam

• Altered mental status nonspecific finding
• Associated with any cause of CP that leads to BP
  instability and cerebral hypoperfusion
• 17 aortic dissection have focal neurologic
  deficits due to occlusion of carotid or spinal
  arteries
• Distal aortic dissections can cause spinal cord
  ischemia

43
Diagnostic Studies

• The ECG is the most important test in the
  evaluation of CP
• The initial ECG is insensitive in identifying
  acute coronary syndrome
• Only 20-60 pts presenting with acute MI have
  diagnostic changes on initial ECG

44
Diagnostic StudiesECG

• What diagnostic changes?
• at least 1 mm elevation in one or more
  inferior/lateral leads
• or at least 2mm of elevation in one or more
  anterioseptal leads
• 10 pts with AMI have LVH with repolarization
  changes
• Tall peaked T waves may be earliest sign of AMI

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Acute Anterior MI
46
Acute Inferior MI
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Offshore Case Presentation 1

• Chief Complaint
• chest and arm pain
• History of Present Illness
• 38 y/o male c/o burning right sided chest and
  arm pain which began after he stood up from the
  supper table.

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Case Presentation 1History of Present Illness

• Pain is burning in quality
• Location is substernal and in the right arm
• 5 on (1-10 scale) initially, now 2
• No radiation, duration gt 2 hours
• No associated nausea, vomiting, SOB, or
  diaphoresis
• Pain increased after climbing 3 flights stairs

49
Case Presentation 1

• Past History
• 2 weeks ago dx with acid reflux, had
  substernal chest pain. PMD stated ECG was normal,
  blood test normal, but cholesterol and BP were
  elevated
• Began Nexium, cholesterol, and BP meds, but
  quit taking them
• No other past medical problems

50
Case Presentation 1

• Medications- none
• NKA
• Risk Factors
• HTN, cholesterol, Family hx heart disease,
  smoker
• - diabetes

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Case Presentation 1

• Physical Examination
• Vital signs BP-140/88, P-76, RR-20, T-97.9, O2
  sat.-98 ECG- no acute changes
• Alert WM in NAD
• skin warm, and dry
• Ht -RRR Lungs- clear Chest wall- nontender
  Abd- soft, nontender Ext- equal pulses

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Case Presentation 1

• What should we do now?

53
Case Presentation 1Treatment Plan, Physician
Orders

• 4 baby ASA chew and swallow
• O2
• IV NS TKO
• NTG SL q3-5min up to 3
• Nitrol paste 1 if BP stable
• MS if needed
• Send in emergently

54
Case Presentation 1

• Final diagnosis ACS
• Angiogram revealed two 95 blockages, 2 stents
  placed

55
Case Presentation 2

• Chief Complaint
• chest pain
• History of Present Illness
• 32y/o male with squeezing, substernal chest
  pain that began while sitting in chair. Pain is
  worse with deep breathing and not relieved by
  drinking carbonated soda.

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Case Presentation 2HPI

• Quality- squeezing
• Location- substernal
• No radiation, duration gt1 hour
• Intensity- 5 (1-10) scale
• No associated nausea, vomiting, SOB, diaphoresis

57
Case 2

• Past History
• Hx of 2 previous episodes of chest pain while on
  rig. 1st workup was neg. 2nd revealed aortic
  valve problem and coronary blockage with stent
  placement 1998
• Hx of HTN
• Medicines- Toprol, Avapro, and ASA qd
• NKA

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Case 2

• Risk Factors
• HTN, smoker, Past Hx of CAD, Family Hx of
  MI- GF (both sides)
• - DM, elevated cholesterol

59
Case 2

• Physical Exam
• Vital signs- BP 160/80, P-94, RR-16, O2 sat 98
  ECG- no acute changes
• Alert WM in NAD
• skin warm and dry
• heart- RRR Lungs- clear Chest wall
  nontender Abd- soft, nontender Ext- equal
  pulses

60
Case 2

• What should we do now?

61
Case 2Treatment Plan, Physician Orders

• O2
• IV NS TKO
• NTG SL q3-5min up to 3
• Nitrol paste 1 if BP stable
• MS if needed
• Send in emergently

62
Case 2

• Final diagnosis
• Work up revealed an ascending aortic aneurysm
• Emergent surgical repair, resection

63
Case 3

• Chief complaint
• Shortness of breath
• History of Present Illness
• 53y/o awoke from sleep with SOB. Patient
  denies CP, nausea, vomiting, or diaphoresis. No
  hx of previous episodes in past. Denies cold, but
  did have coughing episode prior to SOB.

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Case 3

• Past Medical History
• negative
• Medicine- none
• NKA
• Risk Factors
• smoker
• - HTN, DM, cholesterol, Family Hx CAD

65
Case 3

• Physical Exam
• Vital signs- BP-130/90, P-104, RR-30, T-97.4, O2
  sat- 95 ECG- sinus tach, no acute changes
• Alert WM in mild distress, not SOB now
• skin warm and dry
• Heart- RRR lungs- clear, no wheezes Abd-
  nontender Ext- no swelling, equal pulses

66
Case 3

• What should we do now?

67
Case 3Treatment Plan, Physician Orders

• O2
• IV NS TKO
• Cardiac Monitor
• Emergent evacuation

68
Case 3

• Final Diagnosis
• Pulmonary Embolism

69
Questions???