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DR NAZIR AHMED MEMON. FRCP (LONDON) FACC (USA) FACVS (CANADA) FCPS (PAK). EVALUATION OF CHEST PAIN. PROF: OF CARDIOLOGY LUMHS. Objectives. To be able to rapidly and accurately assess a patient complaining of acute chest pain

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slide1

DR NAZIR AHMED MEMON

FRCP (LONDON) FACC (USA) FACVS (CANADA) FCPS (PAK)

EVALUATION OF CHEST PAIN

PROF: OF

CARDIOLOGY

LUMHS

objectives
Objectives
  • To be able to rapidly and accurately assess a patient complaining of acute chest pain
  • To be able to formulate an accurate differential diagnosis for acute chest pain
  • To understand and be able to initiate basic initial therapy for a patient in acute chest pain
the background
The background:
  • Chest pain is one of the most common chief complaints of patients presenting to EDs annually.
  • 8-10% of the 119 million annual ED visits are for chest pain and related symptoms
    • Accurate diagnosis remains a challenge
chest pain
CHEST PAIN
  • there are a lot of importment data of the pain:
    • localisation
    • radiation
    • onset of the pain
    • the type (press, smart,cutting)
    • dinamic of the pain (continouosly, ongoing, undulaiting)
    • answer to the medical therapy
the challenges
The challenges:
  • Patients presenting with chest pain who have life threatening underlying disease often look well on initial presentation
  • It is estimated that 8-10% of patients presenting with ACS are discharged mistakenly from the ED
  • These patients have 30 day mortality of 2%
challenges cont
Challenges cont:
  • Missed MI is the most common cause for litigation stemming from ED treatment
  • Higher awards are recovered in medical malpractice lawsuits for missed MI than for any other condition
  • Internists are second only to family practitioners as the most likely group to be sued for missed MI
chest pain1
Chest Pain
  • Visceral
    • Often referred
    • Aching, heaviness, discomfort
    • Difficult to localize pain
  • Somatic
    • Sharp, easily localized
chest pain definitions
Chest Pain Definitions
  • Acute Chest Pain:
    • Acute - sudden or recent onset (usually within minutes to hours), presenting typically <24 hrs
    • Chest - thorax midaxillary to midaxillary line, xiphoid to suprasternum notch
    • Pain– noxious uncomfortable sensation
      • Ache or discomfort
initial approach
Initial Approach
  • Triage
    • Chest pain
    • Significant abnormal pulse
    • Abnormal blood pressure
    • Dyspnoea
    • These pts need IV, O2, Monitor, ECG
initial approach1
Initial Approach
  • Evaluation:
    • Airway
    • Breathing
    • Circulation
    • Vital Signs
    • Focused exam
      • Cardiac, pulmonary, vascular
initial approach2
Initial Approach
  • History:
    • Character of pain
    • Presence of associated symptoms
    • Cardiopulmonary history
    • Pain intensity, 0-10 pain
initial approach3
Initial Approach
  • Secondary exam:
    • History
      • Quality, radiation/migration, severity, onset, duration, frequency, progression and provoking or relieving factors of pain
    • Risk factors
    • Physical exam
    • Review old records/ekg’s
categorizing chest pain
Categorizing Chest Pain
  • Chest Wall Pain
    • Sharp, Precisely localized
    • Reproducible: Palpation, movement
  • Pleuritic or Respiratory CP
    • Somatic pain, Sharp
    • Worse with breathing/coughing
  • Visceral CP
    • Poorly localized, aching, heaviness
slide14
Chest wall

Costosternal synd

Costochrondritis

Precordial catch synd

Slipping Rib Synd

Xiphodynia

Radicular Synd

Intercostal Nerve

Fibromyalgia

Pleuritic

Pulmonary Embolism

Pneumonia

Spontaneous pneumo

Pericarditis

Pleurisy

slide15
3. Visceral Pain:

Typical Exertional Angina

Atypical Angina

Unstable Angina

Acute Myocardial Infarction (AMI)

Aortic Dissection

Pericarditis

Esophageal Reflux or spasm

Esophageal Rupture

Mitral Valve Prolapse

categorizing chest pain assessment of risk factors
Categorizing Chest Pain Assessment of Risk Factors
  • CAD:
    • Cigarette Smoking
    • Diabetes
    • Hypertension
    • Hypercholesterolemia
    • Family History
non cardiac chest pain
Pulmonary

Pneumonia

Pleuritis

Pneumothorax

Pulmonary Embolism

Tumor

Gastrointestinal

GERD

Esophageal spasm

Mallory-Weiss Tear

Peptic Ulcer disease

Biliary/Gallbladder Disease

Pancreatitis

Musculoskeletal

Costochondritis

Cervical Disk Disease

Rib Fracture

Intercostal Muscle Cramp

Other

Herpes Zoster

Disorders of the Breast

Splenic Infarct

Panic Attacks/Anxiety Disorder

Fibromyalgia

DKA

Non Cardiac Chest Pain
cardiac chest pain
Aortic Dissection

Pulmonary Embolism

Pulmonary Hypertension

Pericardial Diseases

Aortic Stenosis

Heart Failure

Cocaine Abuse

Acute Coronary Syndromes

Stable Angina

Unstable Angina

Myocardial Infarction

Cardiogenic Shock

Cardiac Chest Pain
slide21

PE

Non Cardiac

PTX

Oesophageal disaster

Chest Pain

Coronary spasm

Aortic disease

Obstructive CAD

Cardiac

Myo/pericardium

Stable angina

Coronary disease

ACS

pe presentation
PE: Presentation
  • Presentation variable
  • Suspect in any patient c/o new or worsening dyspnoea, chest pain or prolonged hypotension without obvious etiology
    • Symptoms: dyspnoea (sec. to min) > pleuritic chest pain > cough
    • Signs: tachypnoea > tachycardia > rales > loud P2
pe anticoagulation
PE: Anticoagulation
  • Enoxaparin 1mg/kg Q12H
  • UFH: 80IU/kg then 18IU/hr (5000IU max)
  • Fondaparinux
    • 5mg daily if <50kg
    • 7.5mg daily if 50-100kg
    • 10mg daily if >100kg
  • If clinical suspicion high, initiate anticoagulation prior to confirming diagnosis
long term management
Long term management:
  • V-K antagonists
  • LMWH preferred in patients with malignancy or pregnancy
  • Duration:
    • 1st provoked: 3mo
    • 1st unprovoked, malignancy or recurrent, consider indefinite tx
slide30

PE

Non Cardiac

PTX

Oesophageal disaster

Chest Pain

Coronary spasm

Aortic disease

Obstructive CAD

Cardiac

Myo/pericardium

Stable angina

Coronary disease

ACS

pneumothorax presentation
Pneumothorax: Presentation
  • Primary Spontaneous PTX:
    • Seen in patinets without underlying lung disease
    • Smoking, FH and Marfans predispose
    • Usually 20s-40s, present with sudden onset dyspnea and pleuritic CP at rest
    • Physical findings include decreased chest excursion, decreased breath sounds, hyperresonance
    • Hypoxeima common, hypercapnea uncommon 2/2 perfusion of PTX but adequate ventilation with contralateral lung
pneumothorax presentation1
Pneumothorax: Presentation
  • Secondary Spontaneous PTX
    • Seen in patients with underlying lung disease
    • Any lung disease predisposes however COPD most common
    • PCP, CF and TB also common causes
    • Similar physical presentation to PSP
    • ABG typically abnormal 2/2 underlying lung disease
pneumothorax diagnosis
Pneumothorax: Diagnosis
  • CXR: Look for pleural line
  • Can be difficult in patients with COPD
  • CT scan can overestimate size of PTX
pneumothorax treatment
Pneumothorax: Treatment
  • ABCD
  • Assess haemodynamic stability
    • If < 2cm and stable, can observe
    • If > 2cm, chest tube

If haemodynamically unstable, chest tube

slide37

PE

Non Cardiac

PTX

Oesophageal disaster

Chest Pain

Coronary spasm

Aortic disease

Obstructive CAD

Cardiac

Myo/pericardium

Stable angina

Coronary disease

ACS

oesophageal rupture
Oesophageal rupture:
  • Hospitalized: >50% 2/2 instrumentation of esophagus
  • Traumatic: MVA, chest wall trauma
  • Spontaneous: (transmural perforation)
    • Vomiting (Boerhaave’s Syndrome): retching followed by severe chest and epigastric pain, tachypnoea, dyspnoea, fever, cyanosis, shock
    • Caustic ingestion, pill esophagitis, Barrett’s, oesophageal ulcers in HIV patients
oesophageal rupture diagnosis
Oesophageal rupture: Diagnosis
  • CXR: early shows mediastinal or free peritoneal air
    • Hours to days later: widening of mediastinum, pleural effusion
oesophageal rupture1
Oesophageal rupture:
  • CT scan: Oesophageal oedema, extra oesophageal air, perioesophageal fluid
  • Oesophagram: Extravasation of contrast
  • NO role for endoscopy which introduces more air into mediastinum
oesophageal rupture treatment
Oesophageal rupture: Treatment
  • Management variable and depends on size, location, rapidity of diagnosis and underlying disease
  • Treatment surgical
  • Complications: mediastinitis , sepsis, shock, death
slide42

PE

Non Cardiac

PTX

Oesophageal disaster

Chest Pain

Coronary spasm

Aortic disease

Obstructive CAD

Cardiac

Myo/pericardium

Stable angina

Coronary disease

ACS

aortic dissection presentation
Aortic dissection: Presentation
  • Sharp, “tearing” anterior or posterior chest and back pain.
  • Typically sudden onset and severe
  • Chest pain more common with type A dissections
  • Complicated by CVA, syncope, MI (RCA) or HF
aortic dissection diagnosis
Aortic dissection: Diagnosis
  • Generally suspected by history/physical
  • Variations in pulses or blood pressure (>20 mmHG difference between R and L arm)
  • ECG: variable depending on complications
  • Imaging when stable
    • CXR: mediastinal widening
    • CT chest, TEE, MRI other options and all superior to TTE
aortic dissection
Aortic Dissection:
  • Predisposing factors:
    • Aortic aneurysm
    • HTN
    • Vasculitis
    • Marfan’s or other collagen diseases
    • CABG/cardiac catheterizaion
    • Drugs (crack cocaine)
    • Trauma
aortic dissection management
Aortic Dissection: Management
  • Type A: Surgical
  • Type B and uncomplicated: Medical
  • Type B and complicated (major branch involved, continued expansion or aortic rupture
  • Long term management includes B blocker, serial imaging at 3, 6 and 12 months and reoperation if indicated
acute management
Acute Management
  • ICU admission
  • Pain control: Morphine
  • Reduction of SBP to 100-120 or lowest tolerated, HR <60, intubate if unstable
    • IV B blocker 1st line (labetolol, propranolol, esmolol)
    • If HR <60 and SBP >100 with good mentation and renal function nitroprusside
    • If hypotensive, look for blood loss, tamponade or HF prior to giving volume
slide51

PE

Non Cardiac

PTX

Oesophageal disaster

Chest Pain

Coronary spasm

Aortic disease

Obstructive CAD

Cardiac

Myo/pericardium

Stable angina

Coronary disease

ACS

pericarditis
Pericarditis
  • Chest pain (anterior chest, sharp, pleuritic, exacerbated by inspiration, can decrease with leaning forward, radiation to trapezius)
  • Often first sign of other systemic disease
  • Multiple possible etiologies, viral and autoimmune most common in US
  • Consider TB outside US
pericarditis diagnosis
Pericarditis: Diagnosis
  • Typically need 2/4:
    • Chest pain
    • Friction rub
    • ECG changes (wide spread ST elevation with PR depression)
    • Pericardial effusion
  • Consider tamponade (sinus tachycardia, JVD, pulsus paradoxus, Kussmaul’s sign)
pericarditis treatment
Pericarditis: Treatment
  • NSAIDs are mainstay of therapy (IBU or high dose ASA
  • Can also use colchicine or glucocorticoids
  • Tamponade: conservative management with monitoring, serial echo, volume expansion and treatment of underlying cause vs. pericardiocentesis
myocarditis
Myocarditis
  • Presentation variable
  • Viral most common etiology in developed countries
  • Presents with HF, chest pain, sudden cardiac death or arrhythmias
  • Workup with biomarkers, ECG, CXR, TTE, cardiac MR and endomyocardial biopsy
  • Consider in young male with new onset HF
slide59

PE

Non Cardiac

PTX

Oesophageal disaster

Chest Pain

Coronary spasm

Aortic disease

Obstructive CAD

Cardiac

Myo/pericardium

Stable angina

Coronary disease

ACS

slide64

Acute Coronary Syndrome

Definition

“… any constellation of clinical symptoms that are compatible with acute myocardial ischemia..."

ACC/AHA 2007 Guidelines for the Management of Patients with Unstable Angina/Non-ST Elevation Myocardial Infarction

pathophysiology
Pathophysiology:

Acute coronary perfusion deficit

  • Mechanism:
    • coronary plaque rupture (95%) lead to partial or total coronary occlusion
    • coronary spasm
      • Prinzmetal angina (transient ST elevation)
      • myocardial infarction (if the ischemic period is to long)
    • coronary embolisation
acute coronary syndrome diagnosis
Acute coronary syndrome: diagnosis
  • current complaint:
    • pain
      • there are a lot of importment data of the pain:
        • localisation
        • radiation
        • onset of the pain
        • the type (press, smart,cutting)
        • dinamic of the pain (continouosly, ongoing, undulaiting)
        • answer to the medical therapy
slide67

Unstable Angina / NSTEMI

Definition

“… ST-segment depression or prominent T-wave inversion and/or positive biomarkers of necrosis… in the absence of ST-segment elevation and in an appropriate clinical setting..."

ACC/AHA 2007 Guidelines for the Management of Patients with Unstable Angina/Non-ST Elevation Myocardial Infarction

slide68

(Unstable Angina)

Unstable Angina / NSTEMI

ACC/AHA 2007 Guidelines for the Management of Patients with Unstable Angina/Non-ST Elevation Myocardial Infarction

physical exam
Physical Exam

T 36oC, P 85, BP 140/80, R 15, Pain 2/10

General – no distress

Neuro - A&O

CVS - normal inspection, PMI normal and nondiplaced, no heave, regular rhythm with normal sounds, no murmers or rubs, JVP 7 cm, radial and pedal pulses normal

Pulmonary - clear

Abdomen – nontender without hepatomegaly

Extremities – no edema

chest x ray
Chest X-Ray

Quality – exposure and rotation

Bony structures

Mediastinum

Heart

Costophrenic angles

Lung fields

slide76

HISTORICAL

POINTS

RISK OF CARDIAC EVENTS (%)

BY 14 DAYS IN TIMI 11B*

Age  65

1

 3 CAD risk factors

(FHx, HTN,  chol, DM, active smoker)

RISK

SCORE

DEATH

OR MI

DEATH, MI OR

URGENT REVASC

1

0/1

2

3

4

5

6/7

3

3

5

7

12

19

5

8

13

20

26

41

Known CAD (stenosis  50%)

1

ASA use in past 7 days

1

PRESENTATION

Recent (24H) severe angina

1

 cardiac markers

1

ST deviation  0.5 mm

1

*Entry criteria:UA or NSTEMII defined as ischemic pain

at rest within past 24H, with evidence of CAD (ST segment

deviation or +marker)

RISK SCORE = Total Points (0 - 7)

TIMI Risk Score

www.timi.org

Antman et al JAMA 2000; 284: 835 - 842

a chest pain case1

HISTORICAL

POINTS

Age  65

1

 3 CAD risk factors

(FHx, HTN,  chol, DM, active smoker)

1

Known CAD (stenosis  50%)

1

ASA use in past 7 days

1

PRESENTATION

Recent (24H) severe angina

1

 cardiac markers

1

ST deviation  0.5 mm

1

RISK SCORE = Total Points (0 - 7)

A Chest Pain Case

CAD risk factors

- + Family history

- HTN

- Dyslipidemia

Home meds

- ASA 81 mg po daily

- HCTZ 25 mg po daily

Biomarkers

- CK 413

- MB 7 with index of 2

- Troponin I 6.8

TIMI Risk Score

- 5

a chest pain case2

RISK OF CARDIAC EVENTS (%)

BY 14 DAYS IN TIMI 11B*

RISK

SCORE

DEATH

OR MI

DEATH, MI OR

URGENT REVASC

0/1

2

3

4

5

6/7

3

3

5

7

12

19

5

8

13

20

26

41

*Entry criteria:UA or NSTEMII defined as ischemic pain

at rest within past 24H, with evidence of CAD (ST segment

deviation or +marker)

A Chest Pain Case

CAD risk factors

- + Family history

- HTN

- Dyslipidemia

Home meds

- ASA 81 mg po daily

- HCTZ 25 mg po daily

Biomarkers

- CK 413

- MB 7 with index of 2

- Troponin I 6.8

TIMI Risk Score

- 5

slide80

Other reasons for  Troponins

Heart failure

Pulmonary embolus

Renal failure

Thygensen, et al JACC 50: 2173, 2007

slide81

ACS

STEMI

NSTE-ACS

STEMI ≤ 12 h

STEMI >12 h

risk stratification

cardiogenic shock ≤ 36 h

  • high risk
  • early high risk
  • late high risk

Primary PCI ((CABG))

Open artery theory

Thrombolysis

rescue PCI ((CABG))

PCI ((CABG))

med. th.

non-inv.im. (echo, stress-test etc.

PCI ((CABG))

slide82

24-hour organised primary PCI in Budapest since 01.01.2003.

First primary PCI in 1993

First primary PCI program in 1999

in hospital mortality stemi
In-hospital mortality (STEMI)

In-hospital mortality dramatically decreased under the last 30 years:

CCU + defibrillator

thrombolysis

primary PCI

stemi
STEMI
  • Quick diagnosis (Typical chest pain and ECG )
  • Time window?
  • Prehospital therapy
    • aspirin 250 mg
    • morphine
    • nitroglycerin
      • again the pain, hypertensive state, left ventricular failure
      • Attention! Right ventricular infarction can cause sever hypotension!
    • O2
  • Send the patient to the hospital
slide85

ACS

STEMI

UA/NSTEMI

STEMI ≤ 12 h

STEMI >12 h

risk stratification

cardiogenic shock ≤ 36 h

  • high risk
  • early high risk
  • late high risk

Primary PCI ((CABG))

Open artery theory

Thrombolysis

rescue PCI ((CABG))

PCI ((CABG))

med. th.

non-inv.im. (echo, stress-test etc.

PCI ((CABG))

inferior stemi
Inferior STEMI

RCA PCI

RCA occlusion

After stenting ►

complication of myocardial infarction
Complication of myocardial infarction
  • Arrhythmias
    • Life-threating:
      • Ventricular tachycardia / ventricular fibrillation – sudden death (I. symptom?)
      • II-III degree AV block – asystolie
  • Ventricular failure (LV mass loss >40%)
    • pulmonal oedem
    • cardiogenic shock
    • right ventricular failure – impared filling pressure (CAVE: NITRO!)
  • Mechanical complication
    • mitral papillar rupture – acute mitral regurgitation
    • ventricular septal rupture
    • free wall rupture – pericardial Tamponade
cardiac rupture syndromes complicating stemi
Cardiac rupture syndromes complicating STEMI

Rupture of the ventricular septum

Anterior myocardial rupture

Complete rupture of a necrotic papillary muscle

conclusion
Conclusion
  • The acutecoronarysyncrome is an acute, life-threatingcoronaryevent
  • Need an urgenthospitalisation
  • Short anamnesis (mostlythepain!!), physicalexamination
  • rapidlyperfom an ECG
  • accordingtothe ECG: NSTE-ACS or STEMI
  • Incase of NSTE-ACS: riskstratification
  • Incase of STEMI:
    • Ifthepatient has typicalchestpain + typical ECG with acut STEMI – it is enoughtodiagnose!
    • Ifthetime-window is <12 hours: reperfusiontherapy (primary PCI orifpPCI is notfeasiblethrombolytictherapy)
acs general principles
ACS: General principles
  • Unstable Angina
    • Rest angina: Usually >20 minutes duration
    • New onset severe angina
    • Increasing angina
  • NSTEMI
  • STEMI
acs management
ACS: Management
  • Initial therapy: Oxygen, nitro, ASA, ECG
  • HR control
  • Antiplatelets: Clopidogrel, Prasugrel
  • Anticoagulation:
  • Pain control:
  • Conservative vs. Invasive management
acs cautions
ACS: Cautions
  • B blockers
  • Morphine
  • Inferior MI (RV infarct)
  • Compare ECGs
  • UH vs. LMWH
  • Repeat ECGs
  • Always consider chief complaint
acs a word about troponin
Just because there is no troponin, doesn’t mean it’s not ACS

Just because there is troponin, doesn’t mean it’s ACS

Troponin is prognostic more than diagnostic

ACS: A word about troponin
practical application
Practical application:
  • Called by nursing to evaluate patient with chest pain
  • Ask for vitals over phone, stability of the patient and brief details
  • ECG
  • Go see the patient
practical application1
Practical application
  • Focused history and physical exam
    • Focused history and chart review
    • Vitals: BP in both arms, pulsus paradoxus
    • GEN: Distress
    • Neck: JVD, carotid bruits
    • Lungs: Crackles, wheezing, effusions
    • Precordium: Heaves, reproducible pain
    • CVS: Regular/irregular, new murmurs, rubs or gallops, muffled heart sounds
    • Abd: Pulsatile masses, renal bruits
    • Ext: LE edema, peripheral pulses
practical application2
Practical application
  • ECG: compare to old, repeat frequently
  • Other imaging studies as indicated by presentation: CXR, stat TTE, CT scan
  • Biomarkers if applicable
  • KEY: Commit to a diagnosis
  • Begin initial therapy
  • Call for help at any point you are not comfortable
conclusions
Chest pain is one of the most frequently encountered complaints in both the inpatient and outpatient settings and is a significant financial burden on our health care system

Clinicians must be able to rapidly and accurately assess a patient with chest pain to maximize patient outcomes and minimize unnecessary workup

The evaluation of chest pain requires good history and physical exam skills, ECG, CXR and few other diagnostic tests

Conclusions:
ad