Chest Pain Sumit Bose, MD PGY-3
Objectives • Overview of chest pain • Differential diagnosis of chest pain • Typical vs. atypical chest pain • Evaluation of chest pain • Review patient cases
Overview • Chest pain accounts for 6 million annual visits to the EDs in the United States • Chest pain is the second most common ED complaint • Patients with chest pain present with a wide spectrum of signs and symptoms • It is up to the clinician to recognize the life-threatening causes of chest pain
Overview Cayley 2005
Pearl 1 CHEST PAIN ≠ ACS POSITIVE TROPONIN ≠ ACS
Life-threatening causes of chest pain • Acute coronary syndrome (unstable angina, NSTEMI, STEMI) • Aortic dissection • Pulmonary embolism • Pneumothorax • Tension pneumothorax • Pericardial tamponade • Mediastinitis (e.g. esophageal rupture)
Differential diagnosis UpToDate 2012
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 • 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 UpToDate 2012
Typical vs. Atypical Chest Pain Cayley 2005
Evaluation of Chest Pain • Scenario 1 - It’s 2:00 AM and you are the VA NF intern. The nurse pages you and tells you that Mr. S, a 67 yro M with known hx of CAD, who is admitted for ARF is having chest pain after he walked back from the bathroom. What would you do next?
Evaluation of Chest Pain Scenario 1: • Ask nurse for most current set of vital signs • Ask nurse to get an EKG • Ask nurse to have the admission EKG at bedside if available • Go see the patient!
Evaluation of Chest Pain • Once at bedside, determine if patient is stable or unstable • 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
Evaluation of Chest Pain • If patient is stable: • Perform a focused history • Does patient have known CAD or other cardiac risk factors? • Is the pain typical/atypical? • Is the pain similar to prior MI? • Perform a focused physical exam • Look for tachycardia, hypertension/hypotension or hypoxia on vital signs • 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
Evaluation of Chest Pain • Labs/imaging/disposition • CXR • Cardiac biomarkers • ABG? • Telemetry/ICU • Write a clinical event note!
Evaluation of Chest Pain • Scenario 2 - You are the orphan intern and you get a page from 67121 and the DACR informs you that you have a 45 yro female in the ED who is being admitted to the Hellerstein service for r/o ACS. How would you approach this patient?
Evaluation of Chest Pain Scenario 2: • Get report from ED physician about the patient • Ask ED physician about patient’s initial presentation • Get last set of vital signs • Ask ED physician to order EKG and CXR
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 • Review any labs/imaging from current ED visit
Case 1 • You are on the Wearn team and the nurse calls you and tells you that Ms. Z suddenly started having chest pain and her O2 sat went from 94% on room air to 88% on 2L via NC
Case 1 • Ms. Z is a 62 yro 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 • EKG on admission:
Case 1 • You go see the patient. The patient tells you that she was feeling better after getting duonebs during this admission, but suddenly developed chest pain that is L-sided, 8/10 and worse with breathing. She has never experienced pain like this in the past • Vital signs: Afebrile, HR 120, BP 110/70, RR 28, O2 sat 89% on 2L • 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
Case 1 - Pulmonary Embolism Cayley 2005
Case 1 - Pulmonary Embolism • Diagnostic testing • Pulmonary angiography (Gold standard) • Spiral CT (CT-PE protocol) • V/Q scan (helpful for detecting chronic VTE) • D-dimer (<500ng/ml helps exclude PE in patient with low/moderate pre-test probability)
Case 1 - Pulmonary Embolism • Treatment of PE • Anticoagulant therapy is primary therapy for PE • Unfractionated heparin • LMWH • For unstable patients, catheter embolectomy or surgical embolectomy are options • For patients at risk for bleeding, IVC filter is an alternative
Case 2 • 24 yro M is being admitted to you from the ED for chest pain and EKG abnormalities • PMHx: • SLE • Asthma • You go see the patient and he tells you that he has had this chest pain for ~2 days, but it has progressively gotten worse. His chest pain is worse with breathing. He does report getting over a recent URI few days ago
Case 2 • VS: T 38.1 HR 104 BP 140/76 RR 20 O2 sat 95% on RA • Physical exam: • Gen – in mild distress due to chest pain, leaning forward while in bed • Lungs – CTAB • Chest wall – no visible rash, chest wall NT to palpation • Heart – tachycardic, nl s1/s2, no rub • Rest of physical exam benign • Labs: • WBC = 14, RFP wnl, AMI panel x 1 = negative • CXR = negative
Case 2 • EKG on admission:
Case 2 - Pericarditis • Refers to inflammation of pericardial sac • Preceded by viral prodrome, i.e. flu-like symptoms • Typically, patients have sharp, pleuritic chest pain relieved by sitting up or leaning forward
Case 2 - Pericarditis Goyle 2002
Case 2 - Pericarditis Goyle 2002
Case 2 - Pericarditis • Diagnostic criteria UpToDate 2012
Case 2 - Pericarditis • Treatment UpToDate 2012
Case 3 • You are evaluating a patient on the Carpenter team with chest pain • Patient is a 67 yro M with PMHx of HTN, HLD, DM-2 and CAD s/p PCI to the LCx in 2007 who is admitted for L leg cellulitis. He develops new onset chest pain that is retrosternal, 7/10, associated with nausea and diaphoresis. Says pain is radiating to his L jaw and is similar to the chest pain he had during his last MI
Case 3 • VS: T 37 HR 108 BP 105/60 RR 20 O2 sat 93% on RA • Physical exam: • Gen – actively having chest pain, diaphoretic • Lungs – rales at bilateral bases • Heart – tachycardic, nl s1/s2, no mumurs or rub • Rest of the exam benign • Labs: CBC wnl, RFP wnl, Troponin = 3.2, CKMB = 9, CK = 345
Case 3 - NSTEMI • Risk stratification?
Case 3 - NSTEMI • Management of UA/NSTEMI • Aspirin • Inhibits platelet aggregation • HR control with beta-blocker • Titrate to goal HR ~ 60 beats/min • Statin • Nitroglycerin SL • Use if patient having active chest pain • DO NOT USE if patient is hypotensive and concern for RV infarct
Case 3 - NSTEMI • Management of UA/NSTEMI • Plavix • P2Y12 receptor blocker • Inhibits platelet aggregation • Anticoagulation • Heparin/LMWH • Inhibits thrombus formation • Oxygen • For O2 sat <90% • Morphine • For refractory chest pain, unrelieved by NTG SL
Pearl 2 USE THE CHEST PAIN ORDER SET!
Case 4 • You find out the patient is having crushing chest pain radiating to the back. His BP in the R arm = 193/112 and in the L arm = 160/99 • What diagnosis is on top of your differential?
Case 4 - Aortic Dissection • Stanford Classification • Type A – Involves ascending aorta • Type B – Involves any other part of aorta • Diagnostic Imaging • CXR • CT chest with contrast • MRI chest • TEE
Case 4 - Aortic Dissection • Management of Aortic Dissection • Type A dissection – Surgical • Type B dissection – Medical • Mainstay of medical therapy • Pain control • HR and BP control • Goal HR = 60 beats/min, goal SBP = 100-120 mmHg • Use IV beta-blockers (i.e. Labetalol, Esmolol) • Can also use Nitroprusside for BP control • AVOID Hydralazine
Case 5 • This is a 45 yro M with PMHx of rheumatoid arthritis who presented with progressive sob. He was found to have a R-sided pleural effusion and underwent an US guided thoracentesis with removal of 1.5 liters of pleural fluid. Two hours after his procedure, he develops new onset R-sided chest pain