APPROACH TO CHEST PAIN

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• APPROACH TO CHEST PAIN
• Selim Krim, MD
• Assistant Professor
• Texas Tech Health Sciences Center

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Objectives

• Establish a differential diagnosis for chest pain
  
• Know what clues to obtain on history to rule-in
  or out MI, PE, pneumothorax and aortic dissection
  
• Identify risk factors for MI
• Know how to do a focused physical exam,
  identifying features that would distinguish
  between MI, PE, pneumothorax and aortic
  dissection.
• Identify investigations required in diagnosing MI
  
• Outline management strategy in MI

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Etiologies

• Myocardial ischemia or infarction
• Pulmonary embolus
• Pneumothorax
• Pericarditis
• Tamponade
• Pneumonia
• Aortic dissection
• Gastritis, peptic ulcer disease
• Musculo-skeletal
• Shingles

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• As a general rule any chest pain is ischemic in
  origin until proven otherwise!

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Myocardial ischemia or infarction

• Pressure-type of chest pain
• Generally involves central to left-sided pain
  with radiation to jaw or arms
• Exacerbated by activity, relieved with rest
• Relieved with nitro spray
• Associated with nausea, diaphoresis, syncope,
  shortness of breath
• Enquire about cardiac risk factors age, sex,
  smoking history, diabetes, hypertension,
  hyperlipidemia, previous myocardial infarction
  and family history

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Myocardial ischemia or infarction

• ?BP indicates cardiogenic shock
• ?JVP, pulsatile liver and peripheral edema seen
  in right-sided heart failure
• Oxygen desaturation, crackles, S3 seen in
  left-sided heart failure
• New murmurs mitral regurgitation murmur in
  papillary muscle dysfunction

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Work-up

• EKG (should be knee-jerk reflex in chest pain
  scenario!)
• CXR to look for signs of congestive heart failure
• Cardiac enzymes CK (will begin to rise 6 hours
  after infarct and remain elevated for 24-48
  hours), troponin (will begin to rise 12 hours
  after infarct and remain elevated for 2 weeks).
  Need to follow serially if first set negative.

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Management Strategy for NSTEMI

• Initial therapy
• Morphine for pain
• Oxygen if hypoxic
• Nitro spray/drip for pain
• Aspirin

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Management Strategy for NSTEMI/NST Chest Pain

• Establish risk level using the TIMI scoring
  system
• Low risk May be discharged after symptom control
• Moderate risk Admit for further evaluation add
  beta blockers , Ace inhibitors . Follow cardiac
  enzyme levels. If Mi ruled out, Exercise or
  Adenosine stress test before discharge
• High Risk Admit for cardiac catheterization

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Management Strategy for STEMI

• Morphine, oxygen, nitro, aspirin
• Beta blockers, Ace inhibitors
• Early invasive strategy with either thrombolytic
  therapy or percutaneous coronary intervention
  (preferred)

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Pulmonary Embolism

• Sudden-onset sharp chest pain
• Exacerbated by inspiratory effort
• Can be associated with hemoptysis, sycope,
  dyspnea, calf swelling/pain from DVT
• Risk factors immobilization, fracture of a limb,
  post-operative complications, hypercoagulable
  states (underlying carcinoma, high-dose exogenous
  estrogen administration, pregnancy, inherited
  deficiencies of antithrombin III, activated
  protein C, S, lupus anticoagulant, prior history
  of DVT/PE Virchows triad

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Pulmonary Embolism

• Anxious patient, sense of impending doom
• Tachycardia, tachypnea, hypoxia
• EKG sinus tachycardia most common,
  S1Q3invertedT3 with large embolus (classic, but
  rare!), look for right-axis deviation
• V/Q scan very sensitive but not specific
• Spiral CT with contrast show large, central
  emboli
• Pulmonary angiogram is gold standard but carries
  risk
• Consider Doppler U/S of legs

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Pneumothorax

• Can be asymptomatic or present with acute
  pleuritic chest pain and dyspnea
• Primary pneumothorax predominantly in healthy
  young tall males
• Due to trauma (MVA accidents associated with
  rib fractures, iatrogenic during line
  placement, thoracentesis)
• Increased alveolar pressure from asthma or
  barotraumas (BiPAP, ventilator-associated)
• Rupture of bleb in COPD patients

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Pneumothorax

• Decreased expansion of chest
• Decreased breath sounds and
• Decreased tactile/vocal fremitus on side of
  pneumothorax
• Hyperresonant percussion note
• Usually easily confirmed by CXR

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Aortic Dissection

• Abrupt onset
• The pain usually is described as ripping or
  tearing
• Tearing or ripping pain that is felt in the
  intrascapular area
• New diastolic murmur, asymmetrical pulses, and
  asymmetrical blood pressure measurements
• Risk factors HTN, Marfan syndrome, coarctation
  of aorta..
• Widened mediastinum on a portable anteroposterior
  (AP) radiograph
• TEE considered diagnostic test of choice

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Case 1

• A 64-year-old woman is evaluated in the
  emergency department 6 hours after the onset of
  severe crushing chest pain associated with
  diaphoresis, nausea, and vomiting. Her medical
  history is significant only for mild
  hyperlipidemia. Her medications include
  atorvastatin and aspirin. Her blood pressure is
  150/88 mm Hg, and her pulse rate is 88/min. The
  lungs are clear she has no murmurs examination
  of the abdomen and extremities is normal. What is
  the best next step in the management of this
  patient?
• CXR
• EKG
• Cardiac enzymes
• CBC

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Case 1

• Electrocardiogram shows a 3-mm ST-segment
  elevation in leads II, III, and aVF, with
  occasional premature ventricular contractions.
  Cardiac enzymes are elevated. What is the next
  step in the management of this patient?
• Thrombolytic therapy
• Coronary angiogram
• Beta blockers
• Amiodarone

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Case 2

• A 72-year-old man is evaluated in the emergency
  department for the sudden onset of severe sharp
  anterior chest pain radiating into the back. He
  is a former smoker with a long history of type 2
  diabetes mellitus, chronic renal insufficiency
  (creatinine 2.0 mg/dL 176.84 µmol/L), sick
  sinus syndrome with a DDD pacemaker implanted in
  1995, and hypertension. His medications include
  insulin, furosemide, ramipril, and aspirin.

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Case 2

• On examination, the blood pressure is 185/85 mm
  Hg bilaterally, and the pulse rate is 90/min and
  regular. A grade 2/6 systolic murmur and a soft
  decrescendo diastolic murmur are heard at the
  second right intercostal space. There are
  abdominal and bilateral femoral bruits, with
  absent distal pulses. His EKG shows no ST, T
  wave changes. CXR is normal. Which of the
  following is the most appropriate initial imaging
  study?
• Non-contrast chest CT
• Chest MRI
• Transesophageal echocardiography
• Transthoracic echocardiography

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Case 3

• A 64-year-old man is evaluated in the emergency
  department for epigastric chest discomfort and
  episodes of dyspnea with moderate activity. The
  discomfort started 2 days ago and has been
  intermittent, occurring mostly at rest. He works
  in an office and is relatively inactive. He had
  been using antacids for several months with
  variable response. He has no significant medical
  history and takes no other medications.

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Case 3

• Blood pressure is 150/85 mm Hg and heart rate is
  81/min there is no jugular vein distention or
  carotid bruits cardiac examination reveals a
  normal S1 and S2, with no murmur, gallop, or
  clicks. Examination of the abdomen and
  extremities is normal. Electrocardiogram shows
  flattened T waves. What is your next step in the
  management of this patient?
• Discharge him home with follow up with his
  physician
• Admit to rule out Myocardial infarction
• Emergent coronary angiogram
• Thrombolytic therapy

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Key Points

• Not every chest pain is MI, however every chest
  pain should be considered as ischemic until
  proven otherwise
• A good history and physical exam may help with
  the diagnosis
• EKG is the best single diagnostic test to help
  rule out MI
• Use the TIMI scoring system to help for the
  diagnosis and prognosis of MI

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• Thank You