Chest Pain

1. Chest Pain James Nixon, MD Assistant Professor Internal Medicine and Pediatrics

2. Case #1 A 65 year old female comes to the emergency room after awakening at 7:00 AM with Chest pain and SOB. Her husband is concerned that she might be having a heart attack.

3. What would be the differential for her chest pain?

6. Chest Pain • Stable angina pectoris • 11 percent of chest pain episodes • Unstable angina or myocardial infarction • 1.5 percent of chest pain episodes

7. What are risk factors you would ask about for cardiac etiologies for chest pain? • Smoking • Family history • Hyperlipidemia • Left ventricular hypertrophy • Hypertension • Cocaine • Age • Past History

8. Location Associated Symptoms Quality Chronology Onset Duration Intensity Exacerbating Relieving Situation What characteristics of the chest pain might make you more concerned for cardiac chest pain?

11. General Appearance may suggest seriousness of symptoms. Vital signs marked difference in blood pressure between arms suggests aortic dissection Palpate the chest wall Hyperesthesia may be due to herpes zoster Complete cardiac examination pericardial rub signs of acute AI or AS Ischemia may result in MI murmur, S4 or S3 Determine if breath sounds are symmetric and if wheezes, crackles or evidence of consolidation Any exam findings that might help distinguish cardiac from non cardiac chest pain?

12. Any tests that might help that you can do in the ER? • EKG • ST elevation of > 1mm or new Q in 2 leads • Sens 45% • Above + ST depression or T-wave inversion • Sens 79% • False positive rate = 17%

13. Any tests that might help that you can do in the ER? • Troponin, CK, myoglobin • CK-MB 88-90% sensitive at 4-6 hours • CK-MB 95-100% sensitive 8-12 hours after CP onset • 2-3% of skeletal muscle is MB fraction • one study of 710 patients, an increase in CK-MB by > or =1.6 ng/mL at two hours compared to baseline for acute infarction • Sensitivity - 94% • Specificity - 92 % • Positive predictive value - 79 % • negative predictive value - 98 % Fesmire FM; Percy RF; Bardoner JB; Wharton DR; Calhoun FB. Serial creatinine kinase (CK) MB testing during the emergency department evaluation of chest pain: utility of a 2-hour delta CK-MB of +1.6ng/ml. Am Heart J 1998 Aug;136(2):237-44

15. Any tests that might help that you can do in the ER? • Chest X-Ray

18. Labs • CK-MB = 15.1 • Troponin T = 27

19. Case #2 A 57 year old male comes to Clinic complaining of substernal chest pain that comes on with exertion and goes away with rest.

20. What is his pre-test probability for having coronary artery disease?

22. What tests could help determine if this man truly does have coronary artery disease causing his symptoms?

23. Exercise Stress Test

25. Likelihood Ratio Nomogram EST LR+ 11 LR- 0.23

27. Likelihood Ratio Nomogram Exercise Echo LR+ 7.4 LR- 0.21

28. Case #3 • A 57 year old male comes in to the ER with sudden onset of “tearing chest pain” that radiates to his back. • What is your differential? • What exam findings might you look for? • What tests could you do and why? • What are the treatments for the most likely diagnoses?

29. What is your differential?

30. What exam findings might you look for? • Acute MI • Hypotension in one extremity • Aortic murmur • Neurologic deficits, including paraplegia, stroke, or decreased consciousness • Syncope, tamponade, and sudden death due to rupture of the aorta into the pericardial space • Shock, hemothorax, and exsanguination • Acute lower extremity ischemia

31. 60 to 80 year-old men with a long history of systemic hypertension • Disorders of collagen (Marfan's syndrome, Ehlers-Danlos syndrome,syphilis) • Bicuspid aortic valve • Aortic coarctation • Trauma

32. 96 percent of acute aortic dissections can be identified based upon some combination of the following three clinical features • Immediate onset of aortic pain with a tearing and/or ripping character • Mediastinal and/or aortic widening on chest radiograph • Variation in pulse and/or blood pressure between the right and left arm Von kodolitsch Y, Schwartz AG, Nienaber CA. Clinical prediction of acute aortic dissection. Archives of Internal Medicine 2000;160:2977.

33. What tests could you do and why? • CXR-sensitivity 63% • CT sensitivity 94%, specificity 87% • TEE • MRI sensitivity 98%, specificity 85% • Aortogram sensitivity 88%, specificity 94%

38. What are the treatments for the most likely diagnoses?

39. Case #4 A 72 year old obese diabetic male complains of 2-3 month history of progressive fatigue and more trouble with his breathing when he is doing housecleaning. He also is concerned because for the past two weeks he is waking up short of breath in the middle of the night. • What is your prioritized differential? • (What is most likely and what would concern you the most?) • What questions would help you refine your differential? • What would you look for on physical exam? • What test would you do to help refine your diagnosis?

40. What is your prioritized differential? (What is most likely and what would concern you the most?)

41. What questions would help you refine your differential?

42. S3 Murmur Elevated JVP Tachycardia Diaphoresis Vasoconstriction Crackles Edema Hepatomegaly Heave Lateral displacement apical impulse What would you look for on physical exam?

43. What test would you do to help refine your diagnosis? • CXR • EKG • Echocardiogram

46. Case #5 • A 65 year old male with known coronary artery disease and long history of stable angina pectoris after walking 2 blocks presents complaining of chest pain occurring with simply walking across the room. • Does he still have stable angina pectoris? • What are potential causes for his worsening chest pain? • What would you do now?