Chest Pain James Ignatius Nicole Qaqish 7/19/2010
Classification • Cardiac Vs Non-Cardiac causes • Cardiac: Ischemic Vs Non-ischemic pathology • Ischemic: Angina, Myocardial Infarction • Non-Ischemic: Pericarditis • Non Cardiac: G.I (GERD, PUD), Pulmonary (PE, Pneumothorax, Pneumonia, Pleurisy, and Pul. HTN)
Chest Pain Questions • “LIQUOR’D” mnemonic • L = location, (retro, substernal… • I Intensity (1 -10) • Q Quality (Sharp, Pressure, dull…) • U Upsetting/Aggravating Factors • O Onset • R Releiving factors + Radiation • D Duration
Angina • Chest pain that occurs when the coronary arteries do not deliver an adequate amount of oxygen-rich blood to the heart • Categorized as stable, unstable, and Variant (Prinzmetal’s )
Stable Angina • Clinical findings of stable angina: • Substernal , high pressure/heavy feeling • Duration from 1 – 5 minutes • Instigated by physical exertion • Relieved with rest or nitrates
Unstable Angina • Clinical findings of Unstable Angina: • Occurs even at rest • unexpected • More severe and lasts longer than stable angina, maybe as long as 30 minutes • May not disappear with rest or use of nitrates
Variant Angina • Transient coronary vasospasm that is associated with a fixed atherosclerotic lesion (75%) • Pt tends to be younger and in seemingly good health • Occurs at rest and and associated with ventrcular dysrhythmias • Nitrates and CCB’s are often effective
Diagnosis • Resting EKG – normal in pts with Stable Angina, ST/T wave changes in unstable Angina and Variant Angina • Stress Echo-detect ischemia, asses LV function and valve disease
Treatment • Lifestyle changes • Pharmacotherapy – Aspirin, Beta, Blockers, CCB, Nitrates • Revascularization (CABG)
Myocardial Infarction • Interruption of blood supply which causes necrosis of the myocardium. • Atheromatous plaque ruptures into lumen and thrombus forms on top of the lesion causing occlusion • MI has a 30% mortality rate.
Myocardial Infarction • Clinical Features: • Crushing substernal chest pain(usually >30 minutes) • Radiation to arms, neck, jaw, back (Left side) • Diaphoresis, Nausea, Vomiting, Dyspnea, Syncope
Diagnosis EKG changes: ST elevation – transmural injury and can be diagnostic of acute infarct ST depression – Sunbendocardial injury Q wave – evidence for necrosis, usually indicative of an old MI. Not seen acutely
Diagnosis • Cardiac enzymes – Gold Standard. • 3 sets q8 in 24 hours • CKMB – increases within 4-8 hours, peaks at 24hrs, and returns to normal 48 -72 hrs later • Trop I – More specific/sensitive than CKMB. • TropI falsely increased in Renal failure
Treatment • Admit pt to CCU, Insert IV, , administer oxygen, nitrates, morphine • Aspirin, b-blockers, ACE Inhibitors reduce mortality • Lovenox can slow progression of thrombosis. • Cardiac Rehab- exercise + lifestyle changes post MI
Pericarditis • Inflammation of fibrous sac which covers the heart • Causes: Viral Infection (Coxsackie B, Echovirus, Hep. A/B) MI, Uremia, • Pts usually recover in 1-3 weeks
Pericarditis • Clinical Features: • Pleuritic chest pain that is positional(worsened by lying down, inspiration). Pain is releived by sitting up + leaning forward • Friction Rub – scratching, high-pitched sound caused by rubbing of visceral and parietal pleura
Pericarditis • Diagnosis • EKG – ST elevation and PR depression , then ST returns to normal, Twave inverts, then returns to normal. • Treatment: Treat underlying cause and offer NSAIDS for pain
GERD • Inaappropriate relaxing of LES causes backwards flow of stomach contents into esophagus. • Contributing factors: ETOH, coffee, fatty food intake, increased age, and Hiatal Hernia
GERD • Clinical Features: • Burning, retrosternal pain after meals • Cough, nausea, vomiting • Hoarseness , sore throat • Reflex saliva hypersecretion
GERD • Diagnosis: • Endoscopy w/ Biopsy- Can detect cancer complication or GERD • 24 hr pH monitoring of LE – Gold Standard. Highly specific/sensitive
GERD • Treatment: • Phase I- diet changes + antacids • Phase II – Add H2 blocker (Ranitidine) • Phase III – Switch to PPI if symptoms don’t resolve • Phase IV – Add pro – GI motility Agent (bethanechol/metoclopramide) • Phase V – combo (H2 or PPI) + BTH/MET
Peptic Ulcer Disease • A peptic ulcer is erosion in the lining of the duodenum. • Causes: H. pylori infection, NSAID, Zollinger-Ellison syndrome, Smoking, Stress • Clinical Features: • Epigastric pain that is achy • Nausea, vomiting, weight loss, Upper GI bleed
Diagnosis • Endoscopy is most accurate test • Histological evaluation of endoscope biopsy – Gold Standard for H. pylori infection • Urease Breath Test – Shows active infection, and efficacy of antibiotic therapy • Serum gastrin- specific test for ZE Syndrome
Treatment • Lifestyle mods(Reduce smoking,stress, ETOH, NSAID) No food before bedtime! • If H. pylori is present use Triple or Quadruple therapy • Triple ( PPI + 2 antibiotics) • Quadruple (PPI + Peptobismol + 2 Antibiotics)
Treatment • H2 blockers help with ulcer healing • Surgical intervention need for complications of PUD like bleeding, perforation
Case Study • A 30 year old woman comes to the clinic complaining of chest pain. For the last 2 years, she has had intermittent nocturnal chest pain that lasts up to 10 minutes. The pain is substernal and radiates to her throat. It is 6/10 and wakes her up from sleeping. She has mild nausea and a clammy feeling. In the past, she has used antacids and PPI which did NOT help. Aerobic exercise sometimes instigates this pain.
Case Study • She reports being quite healthy except for having Raynauds phenomenon in winter and migraines treated with sumatriptan. Social history is remarkable for cocaine use. Vital signs and physical exam are unremarkable. Holter monitor study is arranged. What findings would be most likely evident during an episode of her chest pain?
Case Study • A) PR segment depression • B) Normal electrocardiographic tracing • C) Prolonged QT interval with increased duration at night • D) Transient St elevation in inferior Leads
Answer • D) This patient has a classic presentation of Variant Angina, which is caused by coronary vasospasm that induces transient ischemia and ST elevations. Patients are usually young women w/o classic CVS risk factors. It usually occurs at night and can be worsened by cocaine and serotonergic agents like sumatriptan.
Answer • Vasospams can occur in any distribution but tend to favor the right coronary artery which supplies the inferior portion of the heart • A = Pr depression is indicative of pericardits. Viral infection in Hx would have been a clue and leaning forward in bed would have produced relief.
Answer • B= ST elevations and T wave changes are associated with variant angina. EKG can not be normal • C= There is no reason to suspect QT interval prolongation. Pts who have syncopal episodes may have QT prolongation and it would not worsen at night.
Respiratory Induced Chest Pain By Nicole Qaqish 7/19/2010
Clinical Presentations • Shortness of breath • Cough • Pleuritic chest pain
Initial Approach to Chest Pain • Ensure adequate A,B,C’s, asses vital signs, Detailed history on the chest pain • Rule out Life threatening Lung/ Cardiac conditions. • Categorize the chest pain • Pleuritic ( Pain upon inspiration) • Visceral ( Dull, Tightness, that is poorly localized) • Chest wall pain
Approach to Chest Pain • Many Respiratory induced chest pain have similar symptoms. • Evaluate any risk factors the patient might have. • Pulmonary embolism ( Hypercougable states, H/O DVT’s, recent immobilization) • Pneumothorax ( trauma, recent ventilation) • Pnuemonia ( age >65, Immune deficient, Hospitalization causing noscomial pneumonia
The Physical Exam • Inspection – rate and pattern of breathing • Palpation – Focal tenderness, rib fractures • Percussion – Determine Resonance within the lung tissue • Hyperresonance (pneumothorax) vs dull percussion (pneumonia) • Auscultation – the quality and intensity of breath sounds. Adventitious sounds such as rales, rhonchi, friction rubs can also be heard and be diagnostic for specific lung conditions.
Imagining • Chest –Xray • initial diagnostic imaging performed • Can show consolidation, air/ fluid, opacification • Further diagnostic imaging • CT scan • V/Q scan- to observe the perfusion and ventilation throughout the pulmonary vasculature.
Most Common Causes of Respiratory induced chest pain • Pulmonary Embolism • Pneumothorax • Pleurisy • Pneumonia • Pulmonary Hypertension
Pulmonary Embolism • Thrombosis from the venous system that embolizes in the pulmonary vasculature • Clinical Manifestations • Dyspnea (73%) • Pleuritic chest pain (66%) • Cough (37%) • Hemptopysis (13%) • Acute Cor Pulmonale • Physical Exam • Tachypnea • Tachycardia • Rales • Cyanosis • Pleura friction rub
Pulmonary Embolism • Imaging: • CXR- normal • V/Q scan- Diagnostic imaging in PE • distribution of blood flow (perfusion scan) and the distribution of alveolar ventilation (ventilation scan) are obtained following the inhalation of a radioactive gas and the IV injection of labeled albumin.
Pneumothorax • Presence of air between the two layers of pleura, resulting in partial or complete collapse of the lung. • Clinical Manifestations: • Sudden onset of shortness of breath • Unilateral sharp chest pain • Physical Exam: • Tachycardia • Unilateral Hyperresonance • Decreased breath sounds
Pneumothorax • Chest X-Ray- Diagnostic
Pleuritis • Pleura membrane inflammation. • Clinical Manifestations: • Sharp chest pain with inhalation • Shortness of breath • Fever/ Chills • Physical Exam: • Pluritic friction rub upon auscultation
Diagnosis • CXR-It may show air or fluid in the pleural space. It also may show what's causing the pleurisy –for example, pneumonia, a or a lung tumor. • CT- may show pockets of fluid, lung abscess or pneumonia • Blood tests can show bacterial or viral infectious process • Thoracocentesis and biopsy can be used to determine the specific cause
Pneumonia • Inflammation of the parenchyma of the lung due to an infectious process. • Clinical Manifestation: • Fever/ Chills • Shortness of Breath • Pleuritic chest pain • Dry cough • Physical Exam: • Pulse- temperature dissociation ( normal pulse with high fever) • Dull Percussion • Rales/Rhonchi and decreased breath sounds upon auscultation
Pneumonia • Chest X-ray can be Diagnostic.
Pulmonary Hypertension • Increase blood pressure in lung vasculature; Mean arterial pressure <25mmHg at rest or <30 mmhg during exercise. • Clinical Manifestations: • Shortness of Breath • Fatigue • Non productive cough • Angina • Cyanosis • Peripheral edema • Syncope • Physical Exam: • JVD • Parasternal lift due to RV dilation • Wide Split S2 and loud P2 in pulmonic area upon Auscultation
Pulmonary Hypertension • ECG- right axis deviation (RVH) • CXR- Dilated pulmonary vessels with right ventricle enlargement. • Echocardiogram- Dilated pulmonary Artery, Dilation of RA/RV, right heart catherization reveals increased pulmonary artery pressure