Transcript Slide 1

APPROACH TO CHEST PAIN
Selim Krim, MD
Assistant Professor
Texas Tech Health Sciences Center
Objectives
• Establish a differential diagnosis for chest pain
• Know what clues to obtain on history to rule-in or out MI,
PE, pneumothorax and aortic dissection
• Identify risk factors for MI
• Know how to do a focused physical exam, identifying
features that would distinguish between MI, PE,
pneumothorax and aortic dissection.
• Identify investigations required in diagnosing MI
• Outline management strategy in MI
Etiologies
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Myocardial ischemia or infarction
Pulmonary embolus
Pneumothorax
Pericarditis
Tamponade
Pneumonia
Aortic dissection
Gastritis, peptic ulcer disease
Musculo-skeletal
Shingles
As a general rule any chest pain is ischemic in
origin until proven otherwise!
Myocardial ischemia or infarction
• Pressure-type of chest pain
• Generally involves central to left-sided pain with radiation
to jaw or arms
• Exacerbated by activity, relieved with rest
• Relieved with nitro spray
• Associated with nausea, diaphoresis, syncope, shortness of
breath
• Enquire about cardiac risk factors: age, sex, smoking
history, diabetes, hypertension, hyperlipidemia, previous
myocardial infarction and family history
Myocardial ischemia or
infarction
• ↓BP indicates cardiogenic shock
• ↑JVP, pulsatile liver and peripheral edema seen in rightsided heart failure
• Oxygen desaturation, crackles, S3 seen in left-sided heart
failure
• New murmurs: mitral regurgitation murmur in papillary
muscle dysfunction
Work-up
• EKG (should be knee-jerk reflex in chest pain scenario!)
• CXR to look for signs of congestive heart failure
• Cardiac enzymes: CK (will begin to rise 6 hours after
infarct and remain elevated for 24-48 hours), troponin (will
begin to rise 12 hours after infarct and remain elevated for
2 weeks). Need to follow serially if first set negative.
Management Strategy for
NSTEMI
Initial therapy
• Morphine for pain
• Oxygen if hypoxic
• Nitro spray/drip for pain
• Aspirin
Management Strategy for
NSTEMI/NST Chest Pain
• Establish risk level using the TIMI scoring system:
• Low risk: May be discharged after symptom control
• Moderate risk: Admit for further evaluation; add beta
blockers , Ace inhibitors . Follow cardiac enzyme levels. If
Mi ruled out, Exercise or Adenosine stress test before
discharge
• High Risk: Admit for cardiac catheterization
Management Strategy for
STEMI
• Morphine, oxygen, nitro, aspirin
• Beta blockers, Ace inhibitors
• Early invasive strategy with either thrombolytic therapy or
percutaneous coronary intervention (preferred)
Pulmonary Embolism
• Sudden-onset sharp chest pain
• Exacerbated by inspiratory effort
• Can be associated with hemoptysis, sycope, dyspnea, calf
swelling/pain from DVT
• Risk factors: immobilization, fracture of a limb, postoperative complications, hypercoagulable states
(underlying carcinoma, high-dose exogenous estrogen
administration, pregnancy, inherited deficiencies of
antithrombin III, activated protein C, S, lupus
anticoagulant, prior history of DVT/PE [Virchow’s triad]
Pulmonary Embolism
• Anxious patient, sense of impending doom
• Tachycardia, tachypnea, hypoxia
• EKG: sinus tachycardia most common, S1Q3invertedT3
with large embolus (classic, but rare!), look for right-axis
deviation
• V/Q scan very sensitive but not specific
• Spiral CT with contrast show large, central emboli
• Pulmonary angiogram is gold standard but carries risk
• Consider Doppler U/S of legs
Pneumothorax
• Can be asymptomatic or present with acute pleuritic chest
pain and dyspnea
• Primary pneumothorax predominantly in healthy young
tall males
• Due to trauma (MVA accidents – associated with rib
fractures, iatrogenic – during line placement, thoracentesis)
• Increased alveolar pressure from asthma or barotraumas
(BiPAP, ventilator-associated)
• Rupture of bleb in COPD patients
Pneumothorax
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Decreased expansion of chest
Decreased breath sounds and
Decreased tactile/vocal fremitus on side of pneumothorax
Hyperresonant percussion note
Usually easily confirmed by CXR
Aortic Dissection
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Abrupt onset
The pain usually is described as ripping or tearing
Tearing or ripping pain that is felt in the intrascapular area
New diastolic murmur, asymmetrical pulses, and
asymmetrical blood pressure measurements
• Risk factors: HTN, Marfan syndrome, coarctation of
aorta..
• Widened mediastinum on a portable anteroposterior (AP)
radiograph
• TEE considered diagnostic test of choice
Case 1
A 64-year-old woman is evaluated in the emergency department 6
hours after the onset of severe crushing chest pain associated with
diaphoresis, nausea, and vomiting. Her medical history is significant
only for mild hyperlipidemia. Her medications include atorvastatin and
aspirin. Her blood pressure is 150/88 mm Hg, and her pulse rate is
88/min. The lungs are clear; she has no murmurs; examination of the
abdomen and extremities is normal. What is the best next step in the
management of this patient?
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CXR
EKG
Cardiac enzymes
CBC
Case 1
Electrocardiogram shows a 3-mm ST-segment elevation in
leads II, III, and aVF, with occasional premature
ventricular contractions. Cardiac enzymes are elevated.
What is the next step in the management of this patient?
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Thrombolytic therapy
Coronary angiogram
Beta blockers
Amiodarone
Case 2
A 72-year-old man is evaluated in the emergency department for the
sudden onset of severe sharp anterior chest pain radiating into the
back. He is a former smoker with a long history of type 2 diabetes
mellitus, chronic renal insufficiency (creatinine 2.0 mg/dL [176.84
μmol/L]), sick sinus syndrome with a DDD pacemaker implanted in
1995, and hypertension. His medications include insulin, furosemide,
ramipril, and aspirin.
Case 2
On examination, the blood pressure is 185/85 mm Hg bilaterally, and
the pulse rate is 90/min and regular. A grade 2/6 systolic murmur and a
soft decrescendo diastolic murmur are heard at the second right
intercostal space. There are abdominal and bilateral femoral bruits,
with absent distal pulses. His EKG shows no ST, T wave changes.
CXR is normal. Which of the following is the most appropriate initial
imaging study?
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Non-contrast chest CT
Chest MRI
Transesophageal echocardiography
Transthoracic echocardiography
Case 3
• A 64-year-old man is evaluated in the emergency department for
epigastric chest discomfort and episodes of dyspnea with moderate
activity. The discomfort started 2 days ago and has been intermittent,
occurring mostly at rest. He works in an office and is relatively
inactive. He had been using antacids for several months with variable
response. He has no significant medical history and takes no other
medications.
Case 3
Blood pressure is 150/85 mm Hg and heart rate is 81/min; there is no
jugular vein distention or carotid bruits; cardiac examination reveals a
normal S1 and S2, with no murmur, gallop, or clicks. Examination of
the abdomen and extremities is normal. Electrocardiogram shows
flattened T waves. What is your next step in the management of this
patient?
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Discharge him home with follow up with his physician
Admit to rule out Myocardial infarction
Emergent coronary angiogram
Thrombolytic therapy
Key Points
• Not every chest pain is MI, however every chest pain should be
considered as ischemic until proven otherwise
• A good history and physical exam may help with the diagnosis
• EKG is the best single diagnostic test to help rule out MI
• Use the TIMI scoring system to help for the diagnosis and prognosis of
MI
Thank You