Emergency lectures - Chest pain

Chest Pain

Hugh Hemsley MDRiverside Regional Medical CenterVirginia, USAFebruary 2011

Chest PainCardiovascular disease is the number 1 cause

of death in the United States5.4% of all visits to the ED are for chest painEtiology can be difficult to diagnose

Includes diseases of the chest and abdomenDiseases can vary from benign to life-

threateningDifferent diseases can present with similar

signs and symptoms

Evaluation of Chest PainGOAL-Early detection and safe management

of life-threatening diseasesComplete history is very importantTimely and appropriate testingDo not focus on a benign disease and miss a

life-threatening illness

Chest Pain2.5% of patients with an acute MI are sent

home 20% of all ED malpractice claims are for

misdiagnosed chest pain complaints.

Chest PainWhy do diseases of different organ systems

present with similar symptoms?Visceral versus somatic pain

Visceral PainSensory nerves from internal organs enter

the spinal cord at multiple levels and thus the pain is difficult to describe and localizeAching, pressure, heaviness

Somatic PainBone, skin, muscle, parietal pleuraSensory nerves from these structures enter

the spinal cord at specific levels and the pain is easily described and localizedSharp, stabbingPatients will point to an area of well localized

pain

Causes of chest pain Cardiovascular

A.C.S. Pericarditis Aortic dissection Aortic stenosis

Pulmonary Pulmonary embolism Pleurisy Pneumothorax Pneumonia

Pediatrics Kawasaki disease Hypertrophic cardiomyopathy Congenital heart disease

Gastrointestinal Esophageal reflux Esophageal spasm Esophageal rupture Peptic ulcer disease Gallbladder disease Pancreatitis

Chest Wall Pain Herpes Zoster Costochondritis Cervical radiculopathy Rib fracture Anxiety

Evaluation of chest painMaintain a high index of suspicion for life-

threatening illness in all patients complaining of chest pain.

Rapid triage of all patients complaining of chest pain

Is the patient at risk for serious illness?Abnormal vitals signsPatient looks sick, diaphoretic, short of breath,

altered level of consciousness.Risk factors or history of cardiovascular

disease Cardiac monitor, IV, oxygen EKG within 10 minutes of patient arrival

HistoryComplete history most importantFocus on the characteristics of the pain,

associated symptoms, risk factors, and history of cardiovascular disease

Pain scale 1-101-no pain10-worst possible pain

HistoryDuration of the pain

Pain lasting seconds probably not cardiacConstant pain for longer than 8-12 hours with

negative workup probably not cardiac

Intensity of painImmediate onset of severe pain think aortic

dissectionACS pain gradually reaches maximum intensity

HistoryQuality of the pain

Burning pain more likely gastrointestinalTearing pain typical of aortic dissectionSharp, stabbing pain usually not ischemic

Up to 20% of patients with an acute MI describe pain as sharp

Pleuritic pain-worse with breathing or coughing Lung, musculoskeletal, pericardial Pleuritic chest pain is described in up to 6% of MI

patients.

HistoryChest wall pain-well localized pain reproduced

by movement or palpation of the affected areaACS-visceral pain radiates to the jaw, arms,

and neckACS-associated symptoms

Shortness of breath, nausea, diaphoresis, fatigue, vomiting, palpitations

Risk factorsAge > 40MalePost-menopausal femaleHypertensionHyperlipidemiaCigarette smokingDiabetesFamily historyObesityDrug abuse-cocaine

The absence of risk factors does not rule out cardiac disease

Acute Coronary SyndromeACSUnstable Angina

New onset of symptomsSymptoms that occur at restA change in the patient’s usual pattern of anginaNo ST elevation, no elevation of cardiac enzymesEKG will be normal about 50% of patientsEvidence of ischemia-ST depression or T-wave

inversion

ACSAcute Myocardial Infarction

STEMI ST elevation of >1 mm in at least 2 contiguous

leads Elevated cardiac enzymes

Non-STEMI ST depression and T wave inversion New left bundle branch block or Q waves Elevation of cardiac enzymes

STEMI-ST elevation MI

Non-STEMI

ACSPain starts following exertion, eating, exposure to cold or emotional stress, can occur at restPressure, heaviness, tightness, squeezing,

“an elephant is sitting on my chest”

Pain radiates to the shoulders, arms, or jawAssociated symptoms-diaphoresis, shortness

of breath, nausea, vomiting, weakness palpitations

Anginal EquivalentsAtypical Chest PainUp to 33% of ACS will not have chest pain

Dyspnea with exertion or at restShoulder, arm, or jaw pain onlyNauseaLightheaded, dizzy, or syncopeGeneralized weaknessDiaphoresisAcute change in mental statusPalpitations

Anginal equilavents are more common in females, diabetics, and the elderly

EKGThe best test to rapidly diagnose an acute MIObtain within 10 minutes of patient’s arrival Up to 50% of initial EKGS will be normal or

have non-diagnostic changesSerial EKGS

BiomarkersTroponin T and I

Preferred markerProtein located in cardiac musclePoor sensitivity first 6 hours after onset of symptomsRepeat in 8-12 hours after onset of symptomsCan be elevated with

Pulmonary embolism Aortic dissection Renal failure Sepsis Cardiac trauma or surgery CHF

BiomarkersCPK

Located in cardiac and skeletal muscleCPK/MB is the cardiac isoenzymePoor sensitivity first 6 hours after onset of symptomsRepeat testing in 8-12 hoursUseful in detecting reinfarction

MyoglobinFound in skeletal and cardiac muscleGood sensitivity early after onset of symptoms

but poor specificity

BiomarkersTest Onset Peak

Duration

CPK/MB 3-12 hours 18-24 hours36-48 hours

Troponin 3-12 hours 18-24 hoursUp to 10 days

Myoglobin 1-4 hours6-7 hours 24 hours

Repeat in 8-12 hours

Pulmonary EmbolismMajority form in the deep veins of the pelvis

and lower extremitiesSize of the clot will determine signs and

symptomsLarge clots can cause syncope, abnormal

vitals, sudden death

Pulmonary EmbolismRisk factors

Previous DVT or PEPregnancyCancerRecent surgeryProlonged bed restAge>50SmokingOral contraceptivesObesityInherited blood disorders

Pulmonary EmbolismSigns and symptoms

DyspneaPleuritic chest painTachycardiaCoughHemoptysisCoughFever rarely >102SyncopeEvidence of DVT in the extremities

Pulmonary EmbolismEKG-obtain to rule out cardiac etiology

Sinus tachycardiaNon-specific ST and T wave changesRight heart strain pattern RBBB

Chest x-ray-obtain to rule out other causesUsually normal or non-specific changes

Arterial blood gas-ABGNot useful in the diagnosis of a PECan have a normal PO2 and A-a gradient with PE

Pulmonary EmbolismD-Dimer

Fibrin degradation productTest sensitivity 95%, specificity low 50%What can elevate the D-Dimer

Pregnancy Cancer Trauma Recent surgery Disseminated intravascular coagulation DIC

Pulmonary EmbolismNegative D-Dimer and “low risk” no further

testing neededWho is “low risk”?

Well’s CriteriaSimplified Geneva ScorePERC score

High risk patients-Do not obtain a D-Dimer immediately to go other testingCT ScanV/Q ScanPulmonary angiogram

PericarditisInflammation of the pericardial sacPain is due to irritation of the parietal pleuraSharp pleuritic substernal pain

Radiates to the back, neck, or shoulderWorse with cough, inspiration, supineImproves with leaning forward

Pericardial friction rub, tachycardia, dyspneaEKG-diffuse ST elevationTroponin is elevated in up to 22%

Pericarditis EKG

Spontaneous PneumothoraxSudden rupture of a lung bleb

Tall thin males age 20-40Underlying lung diseaseSmokers

Sudden onset of sharp pain, worse with inspiration, and SOB

Physical exam-decreased breath sounds on the affected side

Tension pneumothorax-Immediate life threatDecreased venous return to the heartSevere respiratory distress, tachycardia, hypotension

Pneumothorax

Tension Pneumothorax

Aortic DissectionStarts as a tear in the intima of the aorta that spreads through

the medial wall under elevated systolic aortic pressure

Mortality untreated28% in 24 hours50% in 48 hours70% in one week

Risk factorsHypertensionPregnancyLupus, syphilis, endocarditisMarfan’s disease

Aortic DissectionSigns and Symptoms depend on the location of

the tear and involvement of the aortic root, coronary ostia, or branches of the aorta

HistorySudden onset of sharp, tearing, maximal painPain radiates to the neck or back

Aortic DissectionPhysical exam

Majority will be hypertensiveDifference in blood pressure between armsMurmur of aortic regurgitation Neurologic deficits

Chest pain with neurologic deficit, THINK DISSECTION

EKG-useful to rule in or out MIChest Xray

Widened mediastinumRule out other etioloiges

Aortic Dissection

Gastrointestinal Etiology in up to 40% of chest pain

complaintsDifficult to discern from ACSPain described as burning, pressure, or dullAcid Reflux

Substernal, epigastric burning painPain worse with alcohol, caffeine, certain foodsWorse supine and in the morningRelieved with antacids

GastrointestinalEsophageal spasm

Often associated with reflux diseaseDull, pressure, substernal pain lasting for

hoursCan be relieved with Nitroglycerin

NTG relaxes smooth muscles Pain relief with NTG NOT diagnostic of ACS

Peptic ulcer diseasePancreatitis and gallbladder disease

Include lipase and liver function tests in your workup

Boerhaave’s SyndromeForceful vomiting after excessive eating and

drinking causes esophageal rupture.Mediastinal contamination of stomach

contentsSudden onset of severe pain radiating to the

backMortality is 10-50% and directly related to

the delay in making the diagnosis and initiating treatment

Boerhaave’s Syndrome

Chest Wall Pain The cause in up to 30% of ED visitsWell localized, sharp, positional painReproducible by palpating a specific area of

the chest wallCostochondritis-pain and tenderness at the

costochondral or costosternal jointsTreat with rest, heat, NSAID

Mental IllnessThe cause in up to 10% of ED visitsPatients are poor historians with vague

symptomsHyperventilation can cause non-specific ST-T

wave changesA diagnosis of exclusion

Chest PainCervical disc disease

Nerve root compression causes chest pain

Herpes ZosterSharp burning pain before the rashPain and herpetic rash in a dermatome

distribution

Herpes Zoster

Thank you