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Approach to Chest Pain

Approach to Chest Pain. Intern Bootcamp , 2014 Nathan Stehouwer, MD PGY-4, Internal Medicine & Pediatrics. Differential. Cardiac MI Pericarditis Myocarditis Aortic Stenosis Pulmonary PE PNA Asthma/COPD Acute Chest Syndrome Pleura Pleuritis Pneumothorax Aorta Dissection

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Approach to Chest Pain

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  1. Approach to Chest Pain Intern Bootcamp, 2014 Nathan Stehouwer, MD PGY-4, Internal Medicine & Pediatrics

  2. Differential • Cardiac • MI • Pericarditis • Myocarditis • Aortic Stenosis • Pulmonary • PE • PNA • Asthma/COPD • Acute Chest Syndrome • Pleura • Pleuritis • Pneumothorax • Aorta • Dissection • Perforated ulcer • Chest wall • Costocondiritis/musculoskeletal • Esophagus • Esophageal Spasm • Eosinophilic Esophagitis • Esophageal Rupture/Perforation • GERD • Mediastinitis • RUQ pathology • Panic attack

  3. Pearl: ALWAYS have the patient point to the pain!

  4. 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 Typical vs. Atypical Chest Pain Typical 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

  5. Typical vs. Atypical Chest Pain UpToDate 2012

  6. Typical vs. Atypical Chest Pain Cayley 2005

  7. Case 1 • You are the orphan intern on Wearn team at 6PM. You are called by the nurse because Ms. Z has developed chest pain. Ms. Z is a 62 yo 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. • What would you do next?

  8. Evaluation of Chest Pain Case 1: • Ask nurse for most current set of vital signs • Ask nurse to get an EKG • Obtain the admission EKG from the paper chart • Go see the patient!

  9. Evaluation of Chest Pain • Once at bedside, determine if patient is stable or unstable • Perform focused history and physical exam • 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 • Write a clinical event note!

  10. Evaluation of Chest Pain • focused physical exam for chest pain • Vital Signs: tachycardia, hypertension/hypotension or hypoxia • 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

  11. Case 1 • You go see the patient. She had been feeling better after getting duonebs, but suddenly developed chest pain that is L-sided, 8/10 and worse with breathing. This pain is not like her prior MI. • Vital signs: Afebrile, HR 120, BP 110/70, RR 28, O2 sat 89% on 2L (was 95% on RA this morning) • 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

  12. Case 1

  13. Case 1

  14. Differential • Cardiac • MI • Pericarditis • Myocarditis • Pulmonary • PE • PNA • Asthma/COPD • Acute Chest Syndrome • Pleura • Pleuritis • Pneumothorax • Aorta • Dissection • Perforated ulcer • Chest wall • Costocondiritis/musculoskeletal • Esophagus • Esophageal Spasm • Eosinophilic Esophagitis • Esophageal Rupture/Perforation • GERD • Mediastinitis • RUQ pathology • Panic attack

  15. Modified Wells Criteria • Clinical symptoms of DVT (3 points) • Other diagnoses less likely than PE (1 point) • Heart Rate >100 (1.5 points) • Immobilization >/= 3 days or surgery within 4 weeks (1.5 points) • Previous DVT/PE (1.5 points) • Hemoptysis (1 point) • Malignancy (1 point) • Interpretation: • >6: high • 2-6: moderate • <2: low

  16. Next moves • DDIMER: 95% sensitive, VERY nonspecific • ABG – Elevated A-a gradient fairly sensitive, highly nonspecific • EKG – most commonly nonspecific changes (ST/T wave changes, etc) • V/Q scan – helpful in patients with HIGH or LOW pretest probabilities in whom a CTPE cannot be obtained (eg CKD) • LE Ultrasound: not sensitive • CTPE • Sensitivity 83% • Specificity 96% • Moderate - high clinical probability and positive CTPE: 92-96% chance of PE

  17. Pearl A CT angiogram (important for evaluating for Pulmonary Embolism or Aortic Dissection) requires EITHER: 1) At least a 20G peripheral IV OR 2) A Power injectable central line

  18. Case 1

  19. Diagnostic approach is simple if you suspect PE… • Probability low: obtain D-DIMER • If positive: obtain CTPE • If negative: PE excluded • Probability moderate or high: obtain CTPE • If positive: treat • If negative: PE excluded

  20. Acute Pulmonary Embolism Management • Stabliize patient • oxygen • Fluids if hypotensive! • Anticoagulants • Preferred: LMWH or Fondaparinux • Enoxaparin 1.5mg/kg daily or 1mg/kg BID • Fondaparinux subcutaneous once daily (weight based) • Alternative: UFH (IV or SC) – select high intensity protocol • Hemodynamically unstable patients • High risk of bleeding (reversible) • GFR < 30 • Can initiate warfarin on same day • IVC filter an alternative in patients with mod-high bleeding risk

  21. Search “heparin infusion orders”

  22. Pearl: If you have a moderate or high suspicion of PE, you can start anticoagulation while awaiting full diagnostic workup

  23. PE with hypotension • Thrombolysis • Administer over short infusion time • Catheter based thrombectomy • For failure of thrombolysis or likelihood of shock/death before thrombolysis can take effect (hours) • Surgical thrombectomy • Failure of above therapies

  24. Case 2 • You are the long call intern on Hellerstein and get a call to 67121 at 6:58PM. You have a new patient in the ER, being admitted for ACS rule out. • What’s your next move?

  25. Evaluation of Chest Pain • Get report from ED physician about the patient • Ask ED physician about patient’s initial presentation • Ask for most recent set of vital signs • Ask about EKG and CXR results • Ask what meds have been started in ER and how patient responded

  26. 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 • Go see the patient!

  27. Case 2 • Mr. M is a 67 yo man with PMHx of HTN, DLD, DMT2 and CAD s/p PCI in 2007. He presents with new onset chest pain x 2 hours that is retrosternal, 7/10, associated with nausea and diaphoresis.

  28. Case 2 • VS: T 37 HR 108 BP 105/60 RR 20 O2 sat 93% on RA • Physical exam: • Gen – actively having chest pain, diaphoretic • Lungs – crackles at bilateral bases • Heart – tachycardic, nl s1/s2, no mumurs or rub • Rest of the exam benign • Labs: CBC wnl, RFP wnl, Troponin = 0.05

  29. Next Steps • Review EKG • Review CXR • Troponin • SL Nitroglycerin

  30. Case 2

  31. Case 2 Diagnosis: UA/NSTEMI • EKG changes in Acute Coronary Syndromes: • ST elevations • ST depressions • T wave inversions • “pseudonormalization” – inversion of previously inverted T waves when compared with old EKG • New conduction block • Q waves • Importance of serial EKG monitoring: sensitivity of single EKG is only 50% sensitive for acute MI

  32. Pearl: Positive Troponin does not equal ACS

  33. Risk Stratification

  34. Unstable Angina/NSTEMI: Initial Management • “Stabilize” plaque • Dual antiplatelet therapy • Plavix load 600mg followed by daily 75mg • ASA 324mg chewable, then 81 daily • Anticoagulant • UF Heparin at low intensity protocol • Statin • Atorvastatin 80mg • Optimize Myocardial O2 supply/demand • Control HR -> Short acting metoprolol, can titrate quickly to HR <60 if BP allows. Give 5mg IV, can repeat at 5-15min intervals. Be wary of patients with heart failure! • Supplemental O2 if hypoxemic • SL nitroglycerin (0.4mg), repeat every 4-5 minutes • Morphine if still having active chest pain

  35. Case 2 continued • You are now the nightfloat intern, and the patient is signed out to you at 10PM. At midnight, you are called for continued chest pain. Improved from admission but still 5/10 severity.

  36. Next steps • Vitals • Repeat EKG • Repeat SL nitro • Assess patient in person • Call your senior! • Dose additional morphine • start IV nitroglycerin after 3-4 doses of SL nitroglycerin • Start 5 mcg/min • Increase by 5mcg/min every 20 minutes • Floor maximum: 30mcg/min

  37. Pearl Inability to ELIMINATE chest pain in a patient with ACS using maximal medical therapy = Urgent call to cardiology for consideration of immediate catheterization

  38. Trivia

  39. What typical ACS med should you NOT give this patient?

  40. Pearl: Nitroglycerin contraindicated in inferior MI • Other contraindications to NG: • Preload dependent states • Inferior MI • Aortic outflow obstruction (HOCM, severe AS) • Likelihood of hemodynamic instability • HR <50 or >100 • SBP<90mmHg or more than 30mmHg below baseline • Use of PGE inhibitors

  41. Case 3 • You are called on Hellerstein to admit a 65 yo man for ACS rule out. • Mr Q is a gentleman with a history of DMT2, NASH, remote NSTEMI, and HTN presenting with severe retrosternal chest pain. Pain is different than prior MI but is very severe. Radiates to neck. Began 3 hours ago; has subsided slightly but is still 8/10 in severity.

  42. You take report, quickly review chart, and go to assess the patient in the ER. • VS: T37.1, HR110, BP145/80 in R arm, RR16, Pox 98%RA • Focused Exam: • GEN: in discomfort but mentating well • HEENT mmm, JVP at clavicle • CV normal s1/s2, no murmurs • PULM ctab, no w/c/r • EXTR: cool • Bilateral BP: 145/80R, 110/60L • EKG identical to previous EKG which you printed from portal

  43. Thoracic aortic dissection Diagnosis • CT angiography – first line • 83-100% sensitive, specificity 87-100% • TEE – second line; good for proximal, cannot visualize descending aorta well • MRI – useful for surveillance Images: reference.medscape.com rwjms1.umdnj.eduen.wikipedia.org en.wikipedia.org

  44. Thoracic aortic dissection Risk Factors • Hypertension • Atherosclerosis • Preexisting aneurysm (known history in 13% of patients) • Inflammatory conditions affecting aorta (Takayasu, Giant Cell Arteritis, RA, syphilis) • Collagen disorders (Marfan, Ehlers-Danlos) • Bicuspid aortic valve • Aortic coarctation • Turner syndrome • History of CABG, AVR, Cardiac Cath • High intensity weight lifting • Cocaine use • Trauma

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