Approach to Chest Pain - School of Medicine
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Transcript Approach to Chest Pain - School of Medicine
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
Perforated ulcer
Chest wall
Costocondiritis/musculoskeletal
Esophagus
Esophageal Spasm
Eosinophilic Esophagitis
Esophageal
Rupture/Perforation
GERD
Mediastinitis
RUQ pathology
Panic attack
Pearl: ALWAYS have the patient
point to the pain!
Typical vs. Atypical Chest Pain
Typical
Atypical
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
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
Typical vs. Atypical Chest Pain
UpToDate 2012
Typical vs. Atypical Chest Pain
Cayley 2005
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?
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!
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!
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
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
Case 1
Case 1
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
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
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
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
Case 1
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
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
Search “heparin infusion orders”
Pearl: If you have a moderate
or high suspicion of PE, you
can start anticoagulation while
awaiting full diagnostic workup
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
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?
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
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!
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.
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
Next Steps
Review EKG
Review CXR
Troponin
SL Nitroglycerin
Case 2
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
Pearl: Positive Troponin does not
equal ACS
Risk Stratification
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
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.
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
Pearl
Inability to ELIMINATE chest pain in a patient
with ACS using maximal medical therapy
=
Urgent call to cardiology for consideration of
immediate catheterization
Trivia
What typical ACS med should you
NOT give this patient?
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
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.
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
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
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
Thoracic aortic dissection
Management
Type A
Surgery!
Do not delay surgery, even
for LHC
Beta blockers, titrate to HR
50-60 (labetalol, esmolol)
BP control (nitroprusside)
Type B
Beta blockers, titrate to HR
50-60 (labetalol, esmolol)
BP control – add
nitroprusside or similar agent
to SBP goal 100-120mmHg
Surgery for those with end
organ damage or those who
do not respond to medical
therapy
Watch for hypotension – give
fluids if needed, consider
tamponade, MI, or rupture as
complications if hypotensive
Case 4
You are on long call on VA Blue. You are called
to admit a 53 yo M from the ED for chest pain
and EKG abnormalities
PMHx:
HTN
Dyslipidemia
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
notes a recent viral URI.
Case 4
VS: T 37.9 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 4
EKG on admission:
Case 4 - Pericarditis
Refers to inflammation of pericardial sac
Idiopathic pericarditis typically preceded by
viral prodrome, i.e. flu-like symptoms
Typically, patients have sharp, pleuritic
chest pain relieved by sitting up or leaning
forward
Goyle 2002
Case 4 - Pericarditis
Goyle 2002
Case 4 - Pericarditis
Diagnostic criteria
UpToDate 2012
Case 4 – Pericarditis
Per 2003 ACC guidelines, all patients diagnosed with
pericarditis should receive echocardiogram
High risk features:
Fever (>38ºC [100.4ºF]) and leukocytosis
Evidence suggesting cardiac tamponade
A large pericardial effusion (ie, an echo-free space of more than
20 mm)
Immunosuppressed state
A history of therapy with vitamin K antagonists (eg warfarin)
Acute trauma
Failure to respond within seven days to NSAID therapy
Elevated cardiac troponin, which suggests myopericarditis
Case 4 - Pericarditis
Treatment
UpToDate 2012
Case 5
This is a 45 yro M with PMHx of rheumatoid arthritis who
presented with progressive sob. He was found to have a Rsided 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
Case 5
Case 5 - Pneumothorax
Management of Pneumothorax
100% O2 and observation in stable patients for PTX < 3 cm in
size
Needle aspiration in stable patients for PTX >3 cm
Chest tube placement if PTX >3 cm and if needle aspiration fails
Chest tube placement in unstable patients
Pearl
Great EKG Practice Site:
http://ecg.bidmc.harvard.edu/maven/mavenmain.asp
References
Kearon C, Akl EA, Comerota AJ, Prandoni P, Bounameaux H, Goldhaber SZ, Nelson ME, Wells PS, Gould MK, Dentali F, Crowther M,
Kahn SR. Antithrombotic therapy for VTE disease: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of
Chest Physicians evidence-based clinical practice guidelines. Chest. 2012 Feb;141(2 Suppl):e419S-94S.Cayley, W.E. Diagnosing the
cause of chest pain. (2005). American Family Physician, Vol 72 (10), 2012-21.
Anderson JL et al. 2012 ACCF/AHA Focuse Update of the Guideline for Management of Patients with Unstable Angina/NSTEMI. JACC
60 (7) 2012.
Thrumurthy SG et al. The diagnosis and management of aortic dissection. BMJ 344, 2012.
Imazio M, Demichelis B, Parrini I, Giuggia M, Cecchi E, Gaschino G, Demarie D, Ghisio A, Trinchero R. Day-hospital treatment of
acute pericarditis: a management program for outpatient therapy. J Am Coll Cardiol. 2004;43(6):1042.
Goyle, K.K. and Walling, A.D. Diagnosing pericarditis. (2002). American Family Physician, Vol 66 (9), 1695-1702.
Diagnostic approach to chest pain in adults. (2014). UpToDate. http://www.uptodate.com/contents/diagnostic-approach-to-chestpain-in-adults?source=search_result&search=chest+pain&selectedTitle=1%7E150
Differential diagnosis of chest pain in adults. (2014). UpToDate. http://www.uptodate.com/contents/differential-diagnosis-of-chestpain-in-adults?source=search_result&search=chest+pain&selectedTitle=3%7E150
Evaluation of chest pain in the emergency department. (2014). UpToDate. http://www.uptodate.com/contents/evaluation-of-chestpain-in-the-emergency-department?source=search_result&search=chest+pain&selectedTitle=5%7E150
Clinical presentation and diagnostic evaluation of acute pericarditis. (2014). UpToDate. http://www.uptodate.com/contents/clinicalpresentation-and-diagnostic-evaluation-of-acute-pericarditis?source=search_result&search=pericarditis&selectedTitle=1%7E150
Treatment of acute pericarditis. (2014). UpToDate. http://www.uptodate.com/contents/treatment-of-acutepericarditis?source=search_result&search=pericarditis&selectedTitle=2%7E150
Thanks to Sumit Bose for use of a number of his excellent slides!