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DR NAZIR AHMED MEMON
FRCP (LONDON) FACC (USA) FACVS (CANADA) FCPS (PAK)
EVALUATION OF CHEST PAIN
PROF: OF
CARDIOLOGY
LUMHS
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
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
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
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%
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
Chest Pain

Visceral




Often referred
Aching, heaviness, discomfort
Difficult to localize pain
Somatic

Sharp, easily localized
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
Initial Approach

Triage





Chest pain
Significant abnormal pulse
Abnormal blood pressure
Dyspnoea
These pts need IV, O2, Monitor, ECG
Initial Approach

Evaluation:





Airway
Breathing
Circulation
Vital Signs
Focused exam

Cardiac, pulmonary, vascular
Initial Approach

History:




Character of pain
Presence of associated symptoms
Cardiopulmonary history
Pain intensity, 0-10 pain
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
Categorizing Chest Pain
Chest Wall Pain
1.
•
•
Sharp, Precisely localized
Reproducible: Palpation, movement
Pleuritic or Respiratory CP
2.
•
•
Somatic pain, Sharp
Worse with breathing/coughing
Visceral CP
3.
•
Poorly localized, aching, heaviness
1.
Chest wall

Costosternal synd
Costochrondritis
Precordial catch synd
Slipping Rib Synd
Xiphodynia
Radicular Synd
Intercostal Nerve
Fibromyalgia







2.
Pleuritic

Pulmonary Embolism
Pneumonia
Spontaneous pneumo
Pericarditis
Pleurisy




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
Categorizing Chest Pain
Assessment of Risk Factors

CAD:





Cigarette Smoking
Diabetes
Hypertension
Hypercholesterolemia
Family History
Differential Diagnosis of
Chest Pain
 Non
Cardiac
 Cardiac
Non Cardiac Chest Pain

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
Cardiac Chest Pain







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
PE
Non Cardiac
PTX
Oesophageal disaster
Chest Pain
Coronary spasm
Aortic disease
Obstructive CAD
Cardiac
Myo/pericardium
Stable angina
Coronary disease
ACS
Pulmonary Embolism:
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
PE: Diagnosis
PE: ECG
PE: Management
PE: Clinical guidelines
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
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
PE
Non Cardiac
PTX
Oesophageal disaster
Chest Pain
Coronary spasm
Aortic disease
Obstructive CAD
Cardiac
Myo/pericardium
Stable angina
Coronary disease
ACS
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
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
Pneumothorax: Diagnosis



CXR: Look for
pleural line
Can be difficult in
patients with COPD
CT scan can
overestimate size of
PTX
Pneumothorax
Pneumothorax
Pneumothorax: Treatment


ABCD
Assess haemodynamic
stability
 If < 2cm and stable,
can observe
 If > 2cm, chest tube
If haemodynamically
unstable, chest tube
PE
Non Cardiac
PTX
Oesophageal disaster
Chest Pain
Coronary spasm
Aortic disease
Obstructive CAD
Cardiac
Myo/pericardium
Stable angina
Coronary disease
ACS
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
Oesophageal rupture: Diagnosis

CXR: early shows
mediastinal or free
peritoneal air
 Hours to days
later: widening
of mediastinum,
pleural effusion
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
Oesophageal rupture: Treatment



Management variable
and depends on size,
location, rapidity of
diagnosis and
underlying disease
Treatment surgical
Complications:
mediastinitis , sepsis,
shock, death
PE
Non Cardiac
PTX
Oesophageal disaster
Chest Pain
Coronary spasm
Aortic disease
Obstructive CAD
Cardiac
Myo/pericardium
Stable angina
Coronary disease
ACS
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
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
Aortic Dissection:

Predisposing factors:







Aortic aneurysm
HTN
Vasculitis
Marfan’s or other collagen diseases
CABG/cardiac catheterizaion
Drugs (crack cocaine)
Trauma
Aortic dissection: Classification
Aortic dissection
Aortic dissection
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
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
PE
Non Cardiac
PTX
Oesophageal disaster
Chest Pain
Coronary spasm
Aortic disease
Obstructive CAD
Cardiac
Myo/pericardium
Stable angina
Coronary disease
ACS
Pericarditis




Chest pain (anterior chest, sharp, pleuritic,
exacerbated by inspiration, can decrease with
leaning forward, radiation to trapezius)
Often first sign of other systemic disease
Multiple possible etiologies, viral and
autoimmune most common in US
Consider TB outside US
Pericarditis: Diagnosis

Typically need 2/4:





Chest pain
Friction rub
ECG changes (wide spread ST elevation with PR
depression)
Pericardial effusion
Consider tamponade (sinus tachycardia, JVD,
pulsus paradoxus, Kussmaul’s sign)
Pericarditis: ECG:
Pericarditis: Treatment



NSAIDs are mainstay of therapy (IBU or high
dose ASA
Can also use colchicine or glucocorticoids
Tamponade: conservative management with
monitoring, serial echo, volume expansion
and treatment of underlying cause vs.
pericardiocentesis
Myocarditis





Presentation variable
Viral most common etiology in developed
countries
Presents with HF, chest pain, sudden cardiac
death or arrhythmias
Workup with biomarkers, ECG, CXR, TTE,
cardiac MR and endomyocardial biopsy
Consider in young male with new onset HF
PE
Non Cardiac
PTX
Oesophageal disaster
Chest Pain
Coronary spasm
Aortic disease
Obstructive CAD
Cardiac
Myo/pericardium
Stable angina
Coronary disease
ACS
Acute coronary syndrome
Pathogenesis of UA/NSTEMI
Acute Coronary Syndrome
Definition
“… any constellation of clinical
symptoms that are compatible
with acute myocardial
ischemia..."
ACC/AHA 2007 Guidelines for the Management of Patients with Unstable Angina/Non-ST Elevation Myocardial Infarction
Pathophysiology:
Acute coronary perfusion deficit
 Mechanism:


coronary plaque rupture (95%) lead to partial or
total coronary occlusion
coronary spasm



Prinzmetal angina (transient ST elevation)
myocardial infarction (if the ischemic period is to long)
coronary embolisation
Acute coronary syndrome: diagnosis

current complaint:

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
Unstable Angina / NSTEMI
Definition
“… ST-segment depression or
prominent T-wave inversion
and/or positive biomarkers of
necrosis… in the absence of STsegment elevation and in an
appropriate clinical setting..."
ACC/AHA 2007 Guidelines for the Management of Patients with Unstable Angina/Non-ST Elevation Myocardial Infarction
Unstable Angina / NSTEMI
(Unstable Angina)
ACC/AHA 2007 Guidelines for the Management of Patients with Unstable Angina/Non-ST Elevation Myocardial Infarction
Unstable Angina / NSTEMI
STEMI
LBBB
Physical Exam
T 36oC, P 85, BP 140/80, R 15, Pain 2/10
General – no distress
Neuro - A&O
CVS - normal inspection, PMI normal and
nondiplaced, no heave, regular rhythm with
normal sounds, no murmers or rubs, JVP 7 cm,
radial and pedal pulses normal
Pulmonary - clear
Abdomen – nontender without hepatomegaly
Extremities – no edema
Chest X-Ray
Quality – exposure and rotation
Bony structures
Mediastinum
Heart
Costophrenic angles
Lung fields
TIMI Risk Score
HISTORICAL
Age  65
POINTS
1
 3 CAD risk factors
1
Known CAD (stenosis  50%)
1
ASA use in past 7 days
1
(FHx, HTN,  chol, DM, active smoker)
PRESENTATION
Recent (24H) severe angina
1

1
1
cardiac markers
ST deviation  0.5 mm
RISK SCORE = Total Points (0 - 7)
www.timi.org
RISK OF CARDIAC EVENTS (%)
BY 14 DAYS IN TIMI 11B*
RISK
SCORE
DEATH
OR MI
DEATH, MI OR
URGENT REVASC
0/1
2
3
4
5
6/7
3
3
5
7
12
19
5
8
13
20
26
41
*Entry criteria:UA or NSTEMII defined as ischemic pain
at rest within past 24H, with evidence of CAD (ST segment
deviation or +marker)
Antman et al JAMA 2000; 284: 835 - 842
A Chest Pain Case
A Chest Pain Case
CAD risk factors
- + Family history
- HTN
- Dyslipidemia
Home meds
- ASA 81 mg po daily
- HCTZ 25 mg po daily
Biomarkers
- CK 413
- MB 7 with index of 2
- Troponin I 6.8
TIMI Risk Score
-5
HISTORICAL
Age  65
POINTS
1
 3 CAD risk factors
1
Known CAD (stenosis  50%)
1
ASA use in past 7 days
1
(FHx, HTN,  chol, DM, active smoker)
PRESENTATION
Recent (24H) severe angina
1

1
1
cardiac markers
ST deviation  0.5 mm
RISK SCORE = Total Points (0 - 7)
A Chest Pain Case
CAD risk factors
- + Family history
- HTN
- Dyslipidemia
Home meds
- ASA 81 mg po daily
- HCTZ 25 mg po daily
Biomarkers
- CK 413
- MB 7 with index of 2
- Troponin I 6.8
TIMI Risk Score
-5
RISK OF CARDIAC EVENTS (%)
BY 14 DAYS IN TIMI 11B*
RISK
SCORE
DEATH
OR MI
DEATH, MI OR
URGENT REVASC
0/1
2
3
4
5
6/7
3
3
5
7
12
19
5
8
13
20
26
41
*Entry criteria:UA or NSTEMII defined as ischemic pain
at rest within past 24H, with evidence of CAD (ST segment
deviation or +marker)
Other reasons for  Troponins
Heart failure
Pulmonary embolus
Renal failure
Thygensen, et al JACC 50: 2173, 2007
ACS
STEMI
Open artery theory
STEMI ≤ 12 h
Primary PCI
((CABG))
Thrombolysis
NSTE-ACS
STEMI >12 h
risk stratification
cardiogenic
shock ≤ 36 h
high risk
•early high risk
•late high risk
rescue PCI
((CABG))
PCI ((CABG))
PCI ((CABG))
med. th.
non-inv.im. (echo, stress-test etc.
First primary PCI in 1993
First primary PCI
program in 1999
24-hour organised primary PCI
in Budapest since 01.01.2003.
In-hospital
mortality
(STEMI)
In-hospital mortality dramatically decreased under the last 30 years:
35
30
CCU + defibrillator
30
25
20
thrombolysis
15
primary
PCI
15
10
10
5
7
0
60-s
70-s
80-s
90-s
STEMI



Quick diagnosis (Typical chest pain and ECG )
Time window?
Prehospital therapy



aspirin 250 mg
morphine
nitroglycerin




again the pain, hypertensive state, left ventricular failure
Attention! Right ventricular infarction can cause sever
hypotension!
O2
Send the patient to the hospital
ACS
STEMI
Open artery theory
STEMI ≤ 12 h
Primary PCI
((CABG))
Thrombolysis
UA/NSTEMI
STEMI >12 h
risk stratification
cardiogenic
shock ≤ 36 h
high risk
•early high risk
•late high risk
rescue PCI
((CABG))
PCI ((CABG))
PCI ((CABG))
med. th.
non-inv.im. (echo, stress-test etc.
Inferior STEMI
RCA PCI
RCA occlusion
After stenting ►
In the CCU a lot of technical devices
(IABP,respirator, dialysator) are necessary
IAB Inflation
IAB Deflation
Complication of myocardial infarction

Arrhythmias

Life-threating:



Ventricular failure (LV mass loss >40%)




Ventricular tachycardia / ventricular fibrillation – sudden death (I.
symptom?)
II-III degree AV block – asystolie
pulmonal oedem
cardiogenic shock
right ventricular failure – impared filling pressure (CAVE: NITRO!)
Mechanical complication



mitral papillar rupture – acute mitral regurgitation
ventricular septal rupture
free wall rupture – pericardial Tamponade
Acute mitral flail, chordal rupture
Cardiac rupture syndromes
complicating STEMI
Rupture of the ventricular septum
Anterior myocardial rupture
Complete rupture of a necrotic papillary muscle
Pericardial Tamponade
Pericardial Tamponade
Pericardial Tamponade
Pericardial Tamponade
Conclusion







The acute coronary syncrome is an acute, life-threating
coronary event
Need an urgent hospitalisation
Short anamnesis (mostly the pain!!), physical examination
rapidly perfom an ECG
according to the ECG: NSTE-ACS or STEMI
In case of NSTE-ACS: risk stratification
In case of STEMI:

If the patient has typical chest pain + typical ECG with acut STEMI –
it is enough to diagnose!

If the time-window is <12 hours: reperfusion therapy (primary
PCI or if pPCI is not feasible thrombolytic therapy)
ACS: General principles

Unstable Angina





Rest angina: Usually >20 minutes duration
New onset severe angina
Increasing angina
NSTEMI
STEMI
ACS: Management






Initial therapy: Oxygen, nitro, ASA, ECG
HR control
Antiplatelets: Clopidogrel, Prasugrel
Anticoagulation:
Pain control:
Conservative vs. Invasive management
ACS: Cautions







B blockers
Morphine
Inferior MI (RV infarct)
Compare ECGs
UH vs. LMWH
Repeat ECGs
Always consider chief complaint
ACS: A word about troponin



Just because there is no troponin, doesn’t
mean it’s not ACS
Just because there is troponin, doesn’t mean
it’s ACS
Troponin is prognostic more than diagnostic
Practical application:




Called by nursing to evaluate patient with
chest pain
Ask for vitals over phone, stability of the
patient and brief details
ECG
Go see the patient
Practical application

Focused history and physical exam









Focused history and chart review
Vitals: BP in both arms, pulsus paradoxus
GEN: Distress
Neck: JVD, carotid bruits
Lungs: Crackles, wheezing, effusions
Precordium: Heaves, reproducible pain
CVS: Regular/irregular, new murmurs, rubs or gallops, muffled heart
sounds
Abd: Pulsatile masses, renal bruits
Ext: LE edema, peripheral pulses
Practical application






ECG: compare to old, repeat frequently
Other imaging studies as indicated by
presentation: CXR, stat TTE, CT scan
Biomarkers if applicable
KEY: Commit to a diagnosis
Begin initial therapy
Call for help at any point you are not
comfortable
Conclusions:



Chest pain is one of the most frequently encountered
complaints in both the inpatient and outpatient
settings and is a significant financial burden on our
health care system
Clinicians must be able to rapidly and accurately
assess a patient with chest pain to maximize patient
outcomes and minimize unnecessary workup
The evaluation of chest pain requires good history
and physical exam skills, ECG, CXR and few other
diagnostic tests
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