Transcript Chest Pain - EMTS Gulf Coast

Chest Pain
Epidemiology
• 6 million ED visits/year
• 5-7% ED patients
• 3.3% AIS evacuations 2002, 3.5% in 2003,
3.6% in 2004, 3.2% in 2005
• 3 million patients admitted/year
• 70% found not to have acute coronary event
• 0.4% - 4.0% acute MI are sent home
Chest Pain
Pathophysiology
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Chest pain syndromes difficult to diagnose
Multiple organ systems of the chest
Share afferent (nerve) pathways
Pathology in any of these systems have
similar pattern of complaints
• Most patients have CP with acute coronary
syndrome(ACS), others may present with
only SOB, N/V, arm or jaw pain
Differential Diagnosis
of Chest Pain
Life-threatening causes
• Acute coronary syndrome(ACS)
• Aortic dissection
• Pulmonary embolism
• Tension pneumothorax
• Esophageal rupture (Boerhaave’s syndrome)
• Pericarditis; myocarditis
• Acute chest syndrome(in sickle cell disease)
Differential Diagnosis
of Chest Pain
Non-life-threatening causes
• Gastrointestinal
Biliary colic (cholelithiasis, cholecystitis)
Gastroesophageal reflux disease
Peptic ulcer disease
• Pulmonary
Pneumonia
Pleurisy
Differential Diagnosis
of Chest Pain
Non-life-threatening causes
• Chest wall syndromes
Musculoskeletal pain
Costochondritis
Thoracic radiculopathy
• Psychiatric
Anxiety
• Shingles
Chest Pain
Evaluation
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Problems
History
Risk factors
Physical exam
Rhythm strip, 9 lead ECG, 12 lead ECG
Risk stratification based on above factors
The Initial Clinical Examination
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ECG can only help if it shows acute MI
Initial ECG sensitivity 20% - 60% AMI
Sensitivity of plasma CK-MB low first 4 hrs
Can’t detect unstable angina
Therefore evaluation based on history,
physical exam and ECG
History
“The most important difference between a
good and indifferent clinician lies in the
amount of attention paid to the story of
the patient”---Farquhar Buzzard
History
• Helpful to group questions to target the
three most common life threats;
Consider ACS questions
Pulmonary embolism(PE) questions
Aortic dissection questions
History
Cardiac Questions
• 2 most important historical information
age, gender
• Advancing age, prevalence and severity of CAD
increases
• Can estimate pretest probability of CAD based on
age and gender
• Further refine pretest probability by classifying the
chest pain as typical, atypical, or non-anginal
Pretest likelihood of CAD based
on age, sex, and symptoms
Age
30-39
40-49
50-59
60-69
Asymptomatic
Men Women
1.9% 0.3%
5.5% 1.0%
9.7% 3.2%
12.3% 7.5%
non-anginal CP
Men Women
5.2% 0.8%
14.1% 2.8%
21.5% 8.4%
28.1% 18.6%
Pretest likelihood of CAD based
on age, sex, and symptoms
Age
30-39
40-49
50-59
60-69
Atypical angina
Men Women
21.8% 4.2%
46.1% 13.3%
58.9% 32.4%
67.1% 54.4%
Typical angina
Men Women
69.7% 25.8%
87.3% 55.2%
92.0% 79.4%
94.3% 90.6%
Cardiac Questions
• Example; 35y/o male with non-anginal CP has 5%
pretest probability of CAD(1 in 20)
same 35y/o with atypical angina 22% of CAD or
(1in 5)
same 35y/o with typical angina 70%(7in10)
• If patient has known previous CAD/MI raises risk
of subsequent coronary event 5 times
• If patient has cardiac history ask about prior stress
tests, cardiac caths, bypass surgery, stents
Cardiac Questions
• Character of Pain
• Many patients have atypical symptoms
• Ask questions in regard to nature (quality),
severity(1-10), duration, modifying factors
of the pain, and associated symptoms
• 40% patients with AMI have atypical CP
• 35% patients without AMI have typical CP
Cardiac Questions
• In one study of 721 patients who were
diagnosed with AMI, almost ½ presented
without CP
• SOB, weakness, dizziness, syncope,
abdominal pain
• Typical angina is a deep, poorly localized
chest or arm discomfort that is classically
exertional and relieved with rest or nitrates
Analysis of Clinical Predictors of
AMI
• Clinical features
chest pain radiation
left arm
right arm
both arms
nausea, vomiting
diaphoresis
exertional CP
AMI
Odds ratio
1.5
3.2
7.7
1.8
1.4
3.1
Analysis of Clinical Predictors of
AMI
• Clinical features
burning/indigestion pain
crushing/squeezing pain
relief with nitroglycerin
pleuritic pain
tender chest wall
sharp/stabbing pain
AMI
Odds ratio
4.0
2.1
0.9
0.5
0.2
0.5
Cardiac Questions
• Another study of 251 patients with cardiac CP
showed 88% respond to NTG, also 92% of
noncardiac CP responded to NTG
• Can you give GI cocktail to R/O cardiac CP?
a study of 97 patients who received GI cocktail
showed 8 of 11 patients admitted with possible
cardiac ischemia had complete or partial relief of
CP
Cardiac Questions
• Risk Factors
• Diabetes, hypertension, smoking, high
cholesterol, and family history
• Most CAD patients have at least one
• The absence of risk factors does not exclude
acute cardiac ischemia
Aortic Dissection
History
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Male (75%)
Seventh decade
History of hypertension (70%)
Other risk factors;
Marfan’s syndrome, atherosclerosis, prior
dissection, or known aortic aneurysm
Aortic Dissection
History
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Pain is sudden onset (83%)
Severe or “worse ever” (90%)
Sharp (64%) or tearing (50%)
Location anterior chest (60%), back (53%)
Migratory (16%), radiating (28%)
Suspect dissection in patients with clinical
changing picture
Aortic Dissection
History
• Should address 3 basic concerns regarding a
patient’s pain:
quality (sudden and severe)
radiation (especially to the back)
intensity at onset (maximal)
• Aortic dissection and MI can coexist
8% dissection involves coronary arteries
Pulmonary Embolism
History
• Clinical diagnosis of PE is difficult
• Symptoms are variable and nonspecific
• Can range from dyspnea and fatigue to
severe pleuritic CP and syncope
• Classic description of pleuritic pain,
dyspnea, and hemoptysis represents embolic
pulmonary infarction and is seen most
commonly in hospitalized patients
Pulmonary Embolism
History
• Ambulatory patients often present with
painless dyspnea
• Can have several weeks of intermittent
symptoms
• Physical exam is rarely diagnostic
• Reproducible chest wall pain does not
exclude diagnosis
Pulmonary Embolism
History
• Wide spectrum of pain quality and location
• Pain that is peripheral, increases with deep breath,
and not reproducible- suspect PE
• Isolated substernal, pleuritic CP less likely PE
• Substernal, anginal CP occurs 4% PE
• Radiation to arm distinctly unusual
• Pleuritic CP and leg pain more commonly PE than
other diagnosis
Pulmonary Embolism
Risk Factors
• Inherited hypercoagulability disorders
• Acquired disorders:
immobilization, pregnancy, BCP
malignancy, age
prior history venous thromboembolism
trauma, obesity
surgery, smoking
Pulmonary Embolism
Risk Factors
• Medical conditions
CHF
MI
stroke
hyperviscosity syndrome (polycythemia vera)
Crohn’s disease
Nephrotic syndrome
Other Conditions
• Boerhaave’s syndrome presents as spontaneous
esophageal rupture after vomiting
• Pain on swallowing
• Significant number are recently, or acutely
intoxicated
• Pericarditis refers pain to neck, shoulder and
worsens with inspiration, swallowing, and lying
supine
Physical Examination
• Stable patients with AMI rarely have physical
findings on exam
• Vital Signs
• Chest pain and hypotension-not good
• 8% PE and 15% aortic dissection are hypotensive
on presentation
• Patients with CP and hypotension are 3 times
more likely to have AMI than normotensive pts
Physical Examination
• Vital Signs
• Fever, consider noncardiac cause,
pneumonia, mediastinitis
• Low grade fever occurs 14% PE, only
2% PE pts had fever> 102F
• Tachypnea is most common sign in PE,
15% PE pts had respiratory rate <20/min
Physical Examination
• Vital Signs
• Tachycardia is nonspecific sign
• May be only clue to early pericarditis,
myocarditis
• Bradycardia, esp. due to conduction defects,
may be seen in right coronary occlusions
Physical Examination
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Vital Signs
Fifth vital sign, pulse oximetry
Hypoxia can occur in many conditions
Patient with low O2 saturations require
supplemental oxygen
• O2 saturation is normal in ¼ of pts with PE
Physical Examination
Head and Neck
• Check neck for Kussmaul’s sign
(a paradoxical increase in jugular venous
distension with inspiration)
• Seen in pericardial tamponade, right heart failure
or infarction, PE, or tension pneumothorax)
• Subcutaneous air at the root of the neck suggests
pneumothorax, or pneumomediastinitis
• Carotids bruits increase likelihood of CAD
Physical Examination
Pulmonary Exam
• Look for respiratory distress:
• nasal flaring, intercostal retractions, and
accessory muscle use
• Listen for unilateral absence of breath
sounds; consider pneumothorax, or massive
pleural effusion
• Percuss the chest for infiltrates, effusions,
and pneumothorax
Physical Examination
Pulmonary Exam
• Wheezing and rales are important findings
but are not specific for certain diseases
• Asthma, foreign body, CHF, PE all may
cause wheezing
• Rales are rare in pts with AMI, but their
presence with left heart failure, raises the
likelihood of MI by twofold
Physical Examination
Cardiac Exam
• A new murmur may signal papillary muscle
rupture
• Murmur of aortic insufficiency is an
important finding associated with aortic
dissection
• S3 gallop secondary to CHF raises
likelihood of MI 3 times
Physical Examination
Cardiac Exam
• Hamman’s crunch- crunching sound of
heart beating against mediastinal air
• Pericardial rub(creaking of new leather)
seen in pericarditis
• Beck’s triad(distant heart sounds, distended
neck veins, and hypotension) seen in
pericardial tamponade from proximal aortic
dissection
Physical Examination
Chest Wall Exam
• Even with chest wall tenderness, still have
to consider life-threatening causes
• Reproducible CP frequently seen in pts with
PE and ACS
• Costochondritis is inflammation of the
costal cartilages, may result in sharp, dull,
or pleuritic CP, rarely has swelling of soft
tissues
Physical Examination
Chest Wall Exam
• Tietze’s syndrome- fusiform swelling and pain of
only one upper costal cartilage
• Compression of cervical or thoracic nerve may
produce dull chest pain mimickings angina
(cervico-precordial angina)
• Pain worsens with neck movement, coughing,
sneezing, or axial loading of the vertebrae
• Check skin for herpes zoster (shingles); causes
unilateral pain over 1-2 dermatones
Physical Examination
Exam of the Extremities
• Look for edema, thrombosis, or pulse deficits
• Peripheral edema frequently seen in right-sided
and biventricular failure
• Usually absent in acute left heart failure
• Unilateral edema or palpable venous
thrombus(cord) suggest DVT or PE
• But most pts with PE have normal ext. exams
Physical Examination
Examination of Pulses
• Exam for symmetry and quality
• Pulse deficit is defined as asymmetrical
amplitude between the right and left sides
• Pulse deficits most common in type A
dissections(ascending aorta)
• Measured BP difference occurs 15%
• Differences > 20mmHg between arms was
an independent predictor of dissection
Physical Examination
Neurologic Exam
• Altered mental status nonspecific finding
• Associated with any cause of CP that leads
to BP instability and cerebral hypoperfusion
• 17% aortic dissection have focal neurologic
deficits due to occlusion of carotid or spinal
arteries
• Distal aortic dissections can cause spinal
cord ischemia
Diagnostic Studies
• The ECG is the most important test in the
evaluation of CP
• The initial ECG is insensitive in identifying
acute coronary syndrome
• Only 20%-60% pts presenting with acute
MI have diagnostic changes on initial ECG
Diagnostic Studies
ECG
• What diagnostic changes?
at least 1 mm elevation in one or more
inferior/lateral leads
or at least 2mm of elevation in one or more
anterioseptal leads
• 10% pts with AMI have LVH with repolarization
changes
• Tall peaked T waves may be earliest sign of AMI
Acute Anterior MI
Acute Inferior MI
Offshore Case Presentation # 1
• Chief Complaint
chest and arm pain
• History of Present Illness
38 y/o male c/o burning right sided chest
and arm pain which began after he stood up
from the supper table.
Case Presentation # 1
History of Present Illness
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Pain is burning in quality
Location is substernal and in the right arm
5 on (1-10 scale) initially, now 2
No radiation, duration > 2 hours
No associated nausea, vomiting, SOB, or
diaphoresis
• Pain increased after climbing 3 flights stairs
Case Presentation # 1
• Past History
2 weeks ago dx with acid reflux, had
substernal chest pain. PMD stated ECG was
normal, blood test normal, but cholesterol
and BP were elevated
Began Nexium, cholesterol, and BP meds,
but quit taking them
• No other past medical problems
Case Presentation # 1
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Medications- none
NKA
Risk Factors
+ HTN, cholesterol, Family hx heart
disease, smoker
- diabetes
Case Presentation # 1
• Physical Examination
• Vital signs: BP-140/88, P-76, RR-20, T97.9, O2 sat.-98%; ECG- no acute changes
Alert WM in NAD
skin warm, and dry
Ht -RR&R; Lungs- clear; Chest wallnontender; Abd- soft, nontender; Ext- equal
pulses
Case Presentation # 1
• What should we do now?
Case Presentation # 1
Treatment Plan, Physician Orders
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4 baby ASA chew and swallow
O2
IV NS TKO
NTG SL q3-5min up to 3
Nitrol paste 1” if BP stable
MS if needed
Send in emergently
Case Presentation #1
• Final diagnosis: ACS
Angiogram revealed two 95% blockages, 2
stents placed
Case Presentation # 2
• Chief Complaint
chest pain
• History of Present Illness
32y/o male with squeezing, substernal chest
pain that began while sitting in chair. Pain is
worse with deep breathing and not relieved
by drinking carbonated soda.
Case Presentation # 2
HPI
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Quality- squeezing
Location- substernal
No radiation, duration >1 hour
Intensity- 5 (1-10) scale
No associated nausea, vomiting, SOB,
diaphoresis
Case # 2
• Past History
• Hx of 2 previous episodes of chest pain
while on rig. 1st workup was neg. 2nd
revealed aortic valve problem and coronary
blockage with stent placement 1998
• Hx of HTN
• Medicines- Toprol, Avapro, and ASA qd
• NKA
Case # 2
• Risk Factors
• + HTN, smoker, Past Hx of CAD,
Family Hx of MI- GF (both sides)
- DM, elevated cholesterol
Case # 2
• Physical Exam
• Vital signs- BP 160/80, P-94, RR-16, O2 sat
98%; ECG- no acute changes
• Alert WM in NAD
skin warm and dry
heart- RR&R; Lungs- clear; Chest wall
nontender; Abd- soft, nontender; Ext- equal
pulses
Case # 2
• What should we do now?
Case # 2
Treatment Plan, Physician Orders
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O2
IV NS TKO
NTG SL q3-5min up to 3
Nitrol paste 1” if BP stable
MS if needed
Send in emergently
Case # 2
• Final diagnosis:
• Work up revealed an ascending aortic
aneurysm
• Emergent surgical repair, resection
Case # 3
• Chief complaint
Shortness of breath
• History of Present Illness
53y/o awoke from sleep with SOB. Patient
denies CP, nausea, vomiting, or diaphoresis.
No hx of previous episodes in past. Denies
cold, but did have coughing episode prior to
SOB.
Case # 3
• Past Medical History
negative
• Medicine- none
• NKA
• Risk Factors
+ smoker
- HTN, DM, cholesterol, Family Hx CAD
Case # 3
• Physical Exam
• Vital signs- BP-130/90, P-104, RR-30, T-97.4, O2
sat- 95%; ECG- sinus tach, no acute changes
• Alert WM in mild distress, not SOB now
skin warm and dry
Heart- RR&R; lungs- clear, no wheezes; Abdnontender; Ext- no swelling, equal pulses
Case # 3
• What should we do now?
Case # 3
Treatment Plan, Physician Orders
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O2
IV NS TKO
Cardiac Monitor
Emergent evacuation
Case # 3
• Final Diagnosis
Pulmonary Embolism
Questions???