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  1. DR NAZIR AHMED MEMON FRCP (LONDON) FACC (USA) FACVS (CANADA) FCPS (PAK) EVALUATION OF CHEST PAIN PROF: OF CARDIOLOGY LUMHS

  2. 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

  3. 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

  4. 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

  5. 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%

  6. 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

  7. Chest Pain • Visceral • Often referred • Aching, heaviness, discomfort • Difficult to localize pain • Somatic • Sharp, easily localized

  8. 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

  9. Initial Approach • Triage • Chest pain • Significant abnormal pulse • Abnormal blood pressure • Dyspnoea • These pts need IV, O2, Monitor, ECG

  10. Initial Approach • Evaluation: • Airway • Breathing • Circulation • Vital Signs • Focused exam • Cardiac, pulmonary, vascular

  11. Initial Approach • History: • Character of pain • Presence of associated symptoms • Cardiopulmonary history • Pain intensity, 0-10 pain

  12. 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

  13. 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

  14. 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

  15. 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

  16. Categorizing Chest Pain Assessment of Risk Factors • CAD: • Cigarette Smoking • Diabetes • Hypertension • Hypercholesterolemia • Family History

  17. Differential Diagnosis ofChest Pain • Non Cardiac • Cardiac

  18. 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

  19. 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

  20. PE Non Cardiac PTX Oesophageal disaster Chest Pain Coronary spasm Aortic disease Obstructive CAD Cardiac Myo/pericardium Stable angina Coronary disease ACS

  21. Pulmonary Embolism:

  22. 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

  23. PE: Diagnosis

  24. PE: ECG

  25. PE: Management

  26. PE: Clinical guidelines

  27. 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

  28. 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

  29. PE Non Cardiac PTX Oesophageal disaster Chest Pain Coronary spasm Aortic disease Obstructive CAD Cardiac Myo/pericardium Stable angina Coronary disease ACS

  30. 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

  31. 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

  32. Pneumothorax: Diagnosis • CXR: Look for pleural line • Can be difficult in patients with COPD • CT scan can overestimate size of PTX

  33. Pneumothorax

  34. Pneumothorax

  35. Pneumothorax: Treatment • ABCD • Assess haemodynamic stability • If < 2cm and stable, can observe • If > 2cm, chest tube If haemodynamically unstable, chest tube

  36. PE Non Cardiac PTX Oesophageal disaster Chest Pain Coronary spasm Aortic disease Obstructive CAD Cardiac Myo/pericardium Stable angina Coronary disease ACS

  37. 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

  38. Oesophageal rupture: Diagnosis • CXR: early shows mediastinal or free peritoneal air • Hours to days later: widening of mediastinum, pleural effusion

  39. 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

  40. Oesophageal rupture: Treatment • Management variable and depends on size, location, rapidity of diagnosis and underlying disease • Treatment surgical • Complications: mediastinitis , sepsis, shock, death

  41. PE Non Cardiac PTX Oesophageal disaster Chest Pain Coronary spasm Aortic disease Obstructive CAD Cardiac Myo/pericardium Stable angina Coronary disease ACS

  42. 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

  43. 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

  44. Aortic Dissection: • Predisposing factors: • Aortic aneurysm • HTN • Vasculitis • Marfan’s or other collagen diseases • CABG/cardiac catheterizaion • Drugs (crack cocaine) • Trauma

  45. Aortic dissection: Classification

  46. Aortic dissection

  47. Aortic dissection

  48. 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

  49. 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