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Evaluation of Chest Pain In Outpatient Clinic. Crystal Wiley Cené, MD, MPH. A Chest Pain Case. A 65 year-old man with a past medical history significant for hypertension and dyslipidemia presents to clinic after 2 episodes of chest pain in past couple days. What do you want to know and do?.

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Evaluation of chest pain in outpatient clinic

Evaluation of Chest PainIn Outpatient Clinic

Crystal Wiley Cené, MD, MPH


A chest pain case
A Chest Pain Case

A 65 year-old man with a past medical history significant for hypertension and dyslipidemia presents to clinic after 2 episodes of chest pain in past couple days. What do you want to know and do?


Clinical classification of chest pain
Clinical classification of chest pain

  • Typical angina (definite)

    • Substernal chest discomfort with a characteristic quality & duration that is 2) provoked by exertion or stress and 3) relieved by NTG or rest

  • Atypical angina (probable)

    • Meets 2 of above characteristics

  • Noncardiac chest pain

    • Meets 1 or none of typical anginal characteristics


1 goal
#1 Goal

EXCLUDE Coronary artery disease and other life-threatening conditions


So what are those
So, what are those?

  • Acute Coronary Syndrome/Myocardial infarction

  • Pulmonary embolus

  • Aortic dissection

  • Tension Pneumothorax

    *All of these could lead to sudden death*


History
History

  • “PQRST”

    • Provocative/palliative factors

    • Quality: character, duration, frequency, associated sxs

    • Radiation

    • Severity

    • Timing

  • Risk factors: age, tobacco use, family history, DM/HTN/Lipids, cocaine; other- DVT/PE, Marfans/Pregnancy, ETOH, NSAIDS

  • PMHx: prior CV w/u & Rx, GI history


Provocation and palliation

Postprandial? GI or cardiac disease

Exertion? Angina or esophageal pain

Cold, emotional stress, sexual intercourse can promote ischemic pain

Worse with swallowing? Esophageal origin

Body position, movement, deep breathing? Musculoskeletal origin

Antacids or food? Gastro-esophageal origin

Sublingual nitro? Esophageal or cardiac

“GI Cocktail” (viscous lidocaine and antacid)? GI or cardiac

Cessation of activity/rest? Ischemic origin

Sitting up and leaning forward? Pericarditis

Provocation and Palliation


Evaluation
Evaluation

  • Region or location:

    • Radiation to neck, throat, lower jaw, teeth, upper extremity, or shoulder

      • Radiation to arms is useful and stronger predictor of acute MI

      • Between scapulae think aortic dissection

    • Larger areas of discomfort more likely ischemic etiology

  • Severity: not useful predictor for presence of CAD

  • Timing:

    • Abrupt onset with greatest intensity in beginning: PTX, dissection, acute PE

    • Gradual with increasing onset over time: ischemic

    • Crescendo pattern: esophageal disease

    • Lasts for seconds or constant over weeks ≠ ischemic

    • Circadian rhythm (morning>afternoon) correlating with increase sympathetic tome- more likely myocardial ischemia


Associated symptoms
Associated Symptoms

  • Belching, bad taste in mouth, dysphagia or odynaphagia esophageal disease

  • Vomiting Transmural MI, GI problems

  • Diaphoresis MI> esphoageal disease

  • Syncope dissection, PE, critical AS, ruptured AAA

  • Presyncope myocardia ischemia

  • Palpitations in setting of new A. Fib + chest pain PE

  • Fatigue can be presenting complaint of MI esp. in elderly


Any exam findings that might help distinguish cardiac from non cardiac chest pain

General Appearance

may suggest seriousness of symptoms.

Vital signs

marked difference in blood pressure between arms suggests aortic dissection

Palpate the chest wall

Hyperesthesia may be due to herpes zoster

Complete cardiac examination

pericardial rub

signs of acute AI or AS

Ischemia may result in MI murmur, S4 or S3

Determine if breath sounds are symmetric and if wheezes, crackles or evidence of consolidation

Any exam findings that might help distinguish cardiac from non cardiac chest pain?


Ancillary studies
Ancillary Studies

  • EKG

    • “Normal” reduces probability chest pain is due to AMI, but does NOT exclude serious cardiac etiology (i.e. Unstable Angina)

    • ST elevation, ST depression, or new Q waves- important predictor of Acute Coronary Syndrome (AMI or UA)

    • “Nonspecific” ST and T wave changes is common- may or may not indicate heart disease

  • CXR

    • Useful in acute setting to avoid missing dangerous diagnoses (e.g. PTX, Aortic dissection, Pneumomediastinum)


Likelihood ratio
“Likelihood Ratio”

  • Likelihood ratio expresses the odds that a given level of a diagnostic test result would be expected in a patient with (as opposed to without) the target disorder

Sacket, et al. Clinical Epidemiology



Features decreasing likelihood of ami
Features Decreasing Likelihood of AMI

Panju, et al. JAMA 1998;280:14:1256-1263


Ecg findings increasing likelihood of ami
ECG Findings Increasing Likelihood of AMI

Panju, et al. JAMA 1998;280:14:1256-1263


High likelihood of acs
High likelihood of ACS

  • Worsening frequency, intensity, duration, timing (e.g. nocturnal pain, rest pain) of prior angina

  • New onset SOB, nausea, sweating, extreme fatigue in patient with known h/o CVD

  • Onset of typical anginal symptoms in pt without h/o CVD

  • New murmur (or worsening of previously noted murmur), hypotension, diaphoresis, rales, pulmonary edema

  • Transient ST deviation (≥ 1mm) or TWI in multiple precordial leads


Case

  • A 57 year old male comes in to the ER with sudden onset of “tearing chest pain” that radiates to his back.

    • What is your differential?

    • What exam findings might you look for?

    • What tests could you do and why?

    • What are the treatments for the most likely diagnoses?


What exam findings might you look for
What exam findings might you look for?

  • Acute MI

  • Hypotension in one extremity

  • Aortic murmur

  • Neurologic deficits, including paraplegia, stroke, or decreased consciousness

  • Syncope, tamponade, and sudden death due to rupture of the aorta into the pericardial space

  • Shock, hemothorax, and exsanguination

  • Acute lower extremity ischemia


Wrestler with chest pain
Wrestler with Chest Pain

  • 18 yo high school wrestler develops right-sided chest pain while pinning his opponent.

  • Physical exam reveal decreased breath sounds on right


Final thoughts
Final Thoughts

  • Nitro response is not diagnostic of UA

  • Post-prandial pain may be ischemic

  • Discomfort thresholds vary

  • Patient histrionics may influence you

  • “Atypical” is typical of something

  • Value of careful history and physical


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