Chest Pain and Shortness of Breath:Pattern Recognition and Treatment of

Potential Emergencies

James Hoekstra, MD, FACEP

Wake Forest University

Atraumatic Chest Pain: Differential Dx

• Acute Coronary Syndrome (STEMI, UA, NSTEMI)• Pulmonary Embolus• Thoracic Aortic Dissection• Borehaave’s Syndrome• Pneumothorax• Pneumonia/Bronchitis• Musculoskeletal CP/Costochondritis• Pleurisy• GERD• Cancer

Classic History and Physical Patterns

• Quality of Pain

• Location

• Radiation

• Duration/Chronology

• Exacerbating/Alleviating Factors

• Associated Symptoms

• Risk Factors

Case #1

• 56 yo male presents with midline chest tightness for one hour, constant.

• Radiates to jaw, left arm• SOB, diaphoresis, nausea• Intermittent, exertional in past• Hx of HTN, Cholesterol, FH AMI • BP 150/90, P 100, exam normal, nontender• ECG with NSST changes

Acute Coronary Syndromes

STEMIUA/NonSTEMIPresumed ACS

History, PhysicalEKG

Chest Pain

STEMI UA/NSTEMI/High Risk

Mod Risk Low RiskDefinite

Non-Cardiac

Initial Risk Stratification SchemeInitial Risk Stratification SchemeInitial Risk Stratification SchemeInitial Risk Stratification Scheme

ED Risk Stratification Tools

• Clinical History

• Initial ECG

• Continuous or Serial ECG

• Serum Markers of AMI

• Provocative Testing/Imaging

Serum Markers

• Myoglobin: Early peak in serum after MI, nonspecific, good negative predictive value for MI.

• CKMB: Gold standard for many years. False elevation in muscle damage, renal failure. Must take relative index into account. Good risk stratifier

• TnI, TnT: Peaks at same time as CKMB, prolonged elevation in serum after MI, more sensitive and specific for MI than CKMB, but low levels (<1.0) can still be false positives. Best predictor of increased risk for bad outcomes

TIMI Risk Score For ACS

Antman et al JAMA 2000;284: 835 Download www.timi.org

TIMI > 4 is high risk

Non STE ACS Features

High Risk FeaturesHigh Risk Features Accelerated pattern of anginaAccelerated pattern of angina

Ongoing rest pain > 20 minOngoing rest pain > 20 min

Signs of CHFSigns of CHF

Hemodynamic instabilityHemodynamic instability

Arrhythmias - Atrial or ventricularArrhythmias - Atrial or ventricular

Advanced age (> 75 years)Advanced age (> 75 years)

Ischemic ECG changes Ischemic ECG changes

Elevated cardiac markersElevated cardiac markers

ACS Risk Stratification Levels• Level 1: STEMI: ST segment elevation MI• Level 2: NSTE ACS: ST depression, positive

markers (objective findings)• Level 3: Moderate Risk: No ECG or marker

changes but high risk of UA by history, risk factors, known CAD, high TIMI risk

• Level 4: Low: No ECG or marker changes and possibility of UA (atypical story, low TIMI risk)

• Level 5: Noncardiac Pain

Class I ED Treatment of STEMI(ST Elevation, BBB, Pain<12 Hours)

• Targeted ED Protocol, Door to Needle <30 minutes• O2, IV, monitor• ASA immediately• Nitrates, beta blockers• Heparin weight based dosing (max 4000/1000)• Clopidogrel 300 mg • Thrombolytics in less than 30 minutes or PCI less than

90 minutes• PCI should be utilized with IIb/IIIa therapy• Treatment of Complications

Thrombolytic Therapy Inclusions

• Symptoms >30 minutes<12 hours

• ECG ST elevation >2mm in 2 contiguous precordial leads or >1mm in 2 contiguous limb leads, or ST depression >2mm in precordial leads with reciprocal ST elevation in II, AVF, V6

• New BBB

• Patient Consent

Thrombolytic Therapy Exclusions

• Active Bleeding• Altered Mental Status• Major CNS Surgery <6

weeks PTA• CVA <2 yrs PTA• Bleeding Diathesis• SBP >180, DBP >110

• CNS AVM, Aneurysm, Tumor

• AAA• Hemorrhagic Pancreatitis

Thrombolytic Therapy Relative Contraindications

• Recent Surgery or Trauma <2 wks

• Pericarditis• Coumadin Use• Liver Disease• Presumed SBE• Diabetic Retinopathy

• Cardiogenic Shock• Peptic Ulcer Disease• Recent GI/GU bleed• Pregnancy• Thrombophlebitis

Facilitated PCI

• Primary angioplasty or stent placement is the gold standard treatment of STEMI in cath lab centers.

• ASA, NTG, Heparin weight based dosing• Abciximab either prior to or at the same time as

PCI decreases reocclusion and has some fibrinolytic effects equal to streptokinase.

• Benefits of cath over thrombolytics lost if time from door to cath lab greater than 90 minutes.

WFU Treatment of STEMI(ST Elevation, BBB, Pain<12 Hours)

• IV, O2, Monitor• ASA 325 mg po• Nitrates, beta blockers, MS as indicated• Clopidogrel 600 mg po• Heparin 40 U/kg IVP (max 4000), 7 U/kg/hr infusion • Abciximab 0.25 mg IVP, 0.125 mcg/kg/min (max 10 mcg/min) infusion

prior to PCI started in the ED• Call Cardiology for PCI FAST

ED Treatment of NSTE ACS (ST Depression, Transient ST elevation, or +Markers)

• O2, IV, monitor

• ASA immediately

• Nitrates/BB/Pain relief

• Clopidogrel 600 mg po

• LMWH (better than heparin)

• PCI in high risk, continued symptoms

• IIb/IIIa therapy, initiated in the ED

Dosing• ASA 325 mg PO on arrival• Clopidogrel 300 mg po and• Enoxaparin 1mg/kg Subq q 12 hr or Heparin 60 U/kg IVP, 12 U/kg/hr infusion and• Eptifibatide 180 mcg/kg IVP, 2 mcg/kg/min infusion (preferred) or Tirofiban 0.4mcg/kg/min for 30 min, then 0.1mcg/kg/min infusion

or Abciximab 0.25 mg/kg IVP, 10mcg/min infusion (only if going to

cath immediately, heparin reduced to 7 U/kg/hour)

ED Treatment of Moderate Risk CP (High or Moderate Risk UA, Nonspecific ECG and -Markers)

• O2, IV, monitor• ASA immediately• Nitrates/BB/Pain relief• Enoxaparin Subq • Clopidogrel 300 mg• Admit to Telemetry Bed• Serial enzymes • Protocol driven care• Angiogram versus provocative testing prior to discharge• Any positive enzymes or ECG leads to Level 2 Treatment

ED Treatment of Low Risk CP: Day Hospital Chest Pain Evaluation

Intermediate Risk Chest Pain Resolved, Neg ECG, Neg Enzymes

• ECG, CK, CKMB, TnI on arrival• Day Hospital Admission• Serial ECGs as indicated• CK, CKMB, TnI at 0,4, and 8 hours• Stress Thallium or Dobutamine Echo• Admit if positive stress, enzymes, or ECG changes• D/C if negative

CPC Flow SummaryNon ST-elevation patients suspicious for ACSNon ST-elevation patients suspicious for ACS

Risk StratificationRisk Stratification

• History and ageHistory and age• ECG/ECG criteriaECG/ECG criteria• Serum markersSerum markers

• History and ageHistory and age• ECG/ECG criteriaECG/ECG criteria• Serum markersSerum markers

PositivePositive(High Risk)(High Risk)

AdmitAdmit

• Serial markersSerial markers

• Serial ECGsSerial ECGs

• ST-trend monitoringST-trend monitoring

• Serial markersSerial markers

• Serial ECGsSerial ECGs

• ST-trend monitoringST-trend monitoring

PositivePositive

NegativeNegative

• GXTGXT

• RadionuclideRadionuclide

• Stress EchoStress Echo

• GXTGXT

• RadionuclideRadionuclide

• Stress EchoStress Echo

Negative Negative (Low/Moderate Risk)(Low/Moderate Risk)

Chest Pain CenterChest Pain Center

TreatTreatAccordinglyAccordingly

DischargeDischarge

PositivePositive NegativeNegative

Case #2

• 44 year old female presents with sharp, left sided chest pain, no radiation

• Acute onset• Pleuritic• Short of breath, apprehensive, cough, no sputum• Recent surgery on left knee• Family history of DVT• BP 110/60, P 115, Pulse Ox 98%• Normal exam, not reproduceable

Pulmonary Embolism:DVT and PE

VTE/PE Risk Stratification: Patient Factors: Clinical

• Previous VTE

• Malignancy

• Age > 70

• Obesity

• Prolonged bed rest

• Severe medical illness

• Pregnancy / postpartum

• Stroke

• Myocardial infarction

• Varicose veins

• Oral contraceptives

• Antipsychotic drugs?

• Travel*

*“Economy class syndrome”

VTE/PE Risk Stratification:Patient Factors: Molecular

• Antithrombin III deficiency

• Protein C deficiency

• Protein S deficiency

• Heparin cofactor 2 deficiency

• Activated protein C resistance

• Prothrombin G20210A mutation

• Hyperhomocysteinemia

• Elevated factor XI levels

• Elevated Factor VIII levels

• Myeloproliferative disease

• Hyperhomocysteinemia

• Antiphospholipid antibodies

– lupus anticoagulant

– Anticardiolipin Abs

Inherited Acquired

Pulmonary Embolism: Patient History*†

• Dyspnea 73%

• Pleuritic CP 66%

• Cough 37%

• Leg swelling 28%

• Leg pain 26%

• Hemoptysis 13%

• Palpitations 10%

• Syncope <10%

• Wheezing 9%

• “Anginal” CP 4%

• Sudden death ?

†No previous cardiopulmonary disease*PIOPED (JAMA 1990;263:2753-9)

Pulmonary Embolism:Physical Examination*†

• Tachycardia 70%

• Tachypnea 30%

• Crackles 51%

• Loud P2 23%

• Diaphoresis 11%

• Hypotension 8%

• Fever 7%

• Wheezing 5%

• RV lift 4%

• Homans’ 4%

• Pleural rub 3%

• Cyanosis 1%

* From PIOPED (JAMA 1990;263:2753-9) †No previous cardiopulmonary disease

Suspected PE: A Simple Clinical Model and D-dimer to Assess Pretest Probability

(n=946 patients)Specific Factors Points

Clinical DVT (objective swelling, tenderness) 3.0

Heart rate > 100 beats/ min 1.5

Immobilization > 3 days or surgery in previous 4 wks 1.5

Previous DVT/PE 1.5

Hemoptysis 1.0

Malignancy 1.0

PE as likely, or more likely than alternative dx 3.0

Pretest probability of PE: Low: <2.0 Moderate: between 2.0 and 6.0

High: >6.0Wells PS et al. Ann Intern Med 2001;135:98-107.

Pulmonary Embolism:Laboratory Tests

D-dimer

• ELISA D-dimer very sensitive for DVT/ PE

• Very nonspecific! (Commonly positive in other settings!)

• ELISA most sensitive (latex agglutination not sensitive)

• Newer D-dimer tests are more rapid bedside assays

• Most useful if negative and pretest probability is low

Ahearn GS, Bounameaux H. Sem Respir Crit Care Med 2000;21:521-36.Tapson VF et al. Am J Respir Crit Care Med 1999;160:1043-66.

Pulmonary Embolism:Laboratory Tests

Arterial blood gas

• pO2 usually abnormal (low)

• pCO2 usually abnormal (low)

• Alveolar-arterial oxygen difference nearly always abnormal*

*May be normal, particularly in young patients

150-1.25(pCO2)-pO2=A-a gradient on room air

Pulmonary Embolus Workup

Low Risk Intermediate Risk High Risk

D Dimer Helical CT Helical CT

- + - + - +D/C Dopplers Admit Admit Admit

- + for

D/C Admit Angio

Pulmonary Embolus Rx

• IV, O2, Monitor

• Ventilatory and Oxygenation Support

• IV Fluids

• Heparin or Enoxaparin

• Thrombolytics if low BP, Poor Oxygenation

Case #3

• 75 year old female presents with SOB of two days duration

• Tightness, DOE, Orthopnea, PND, leg swelling

• Hx of HTN, MI, CAD

• BP 210/110, P 60, R 24

• Rales in bases, JVD, ankle edema

Heart Failure PathophysiologyHeart Failure Pathophysiology

Myocardial injuryMyocardial injury Fall in LV performanceFall in LV performance

Activation of RAAS, ET,Activation of RAAS, ET,and othersand others

Myocardial toxicityMyocardial toxicity Peripheral vasoconstrictionPeripheral vasoconstrictionHemodynamic alterationsHemodynamic alterations

Remodeling andRemodeling andprogressiveprogressive

worsening ofworsening ofLV functionLV function Heart failure symptomsHeart failure symptomsMorbidity and mortalityMorbidity and mortality

ANPANPBNPBNP

-

-

Causes of CHF

• CAD• HTN• Valvular Disease (aortic and mitral)• Cardiomyopathy (Etoh, amyloid, idiopathic, etc)• High Output:

– Thyrotoxicosis– Anemia– AV Fistula– Beri Beri, Pagets

Causes of Acute CHF Exacerbation

• AMI/Ischemia

• Arrhythmias (afib)

• Accelerated HTN

• Acute Valve Decompensation

• Big PE (right sided failure, shock)

Heart Failure Signs and Symptoms Heart Failure Signs and Symptoms

Symptoms Include: Dyspnea Shortness of breath

Fatigue Feeling of tiredness

Peripheral Edema Swelling of legs and ankles

Orthopnea Pulmonary congestion

Weight gain Due to fluid retention

Rales Abnormal lung sounds

Right versus Left Heart Failure

• Left Heart Failure– SOB

– DOE

– Orthopnea

– Rales

– S3

– Wheezes

– Tachycardia

– Fatigue

• Right Heart Failure– Peripheral Edema

– Abdominal Swelling

– JVD

– Liver Enz Elevation

– HJR

– Most common cause is left heart failure, but COPD is common as well

CHF Lab and Xray Findings

• CXR: Vascular congestion, cardiomegaly, butterfly infiltrates, Kirley B lines, effusion

• ABG or Pulse Ox: Hypoxia• ECG: LVH and strain patterns, nonspecific• Enzymes: Rule out AMI as a cause• Cardiac Output: Swan CO or CI, bioimpedance, etc. not

practical in the ED.• BNP Levels: Elevated with atrial wall stretch >100• Echocardiogram: Low EF, Valves

Therapy of CHF in the ED

• Airway Control• IV, O2, Monitor• Sitting Posture• Oxygenation Adjuncts: BiPAP, CPAP• Nitrates and Afterload Reducers• Diuretics• Continuous Monitoring of Urine Output, Hemodynamics• It’s Not That Simple

Current Treatment of Acute Heart FailureCurrent Treatment of Acute Heart Failure

Diuretics

Reducefluid

volume

Vasodilators

DecreasePreload

AndAfterload

Inotropes

AugmentContract-

ility

Case #4

• 76 yo male presents with acute, severe chest pain of 15 minutes duration

• Midsternal, radiates to back, pleuritic

• Sweaty, vomiting, writhing, SOB

• Hx HTN, PVOD

• BP 220/140, P 110, R 24

• Normal Exam

Thoracic Aortic Dissection

Aortic Dissection: Clinical History

• Risk Factors: HTN, collagen synthesis defects, pregnancy, aortic stenosis, advanced age

• History: Severe, intermittent chest pain, tearing in nature, radiation to back, migratory

• May be signs of peripheral embolus, inequality of pulses, stroke signs, or pulses lost

• Usually hypertensive, but my be hypotensive if volume loss in chest or mediastinum

Aortic Dissection: Lab and Xray

• Chest Xray: Nonspecific. May have tortuous aorta, medistinal widening, pleural effusion, dilated aorta, separation of calcifcations from wall

• ECG: nonspecific• Chest CT: Best screening test, unlikely if

negative• Aortography or TEE: More specific, but less

readily avalable

Aortic Dissection: Treatment

• ABC, IV (X2) O2, Monitor

• Blood Pressure Control: – Nipride– Beta Blockers

• Consulation with CT Surgery

• Surgery if Proximal, Medical if Distal

Case #4

• 44 yo alcoholic presents with acute onset of midsternal CP post vomiting

• Pleuritic, diaphorsis, SOB, radiates to neck, back

• Sweats and chills, no cough or sputum

• BP 90/60, P 130, T 101

• No pain with palpation, clear lungs

• Palpable sub q crepitance in left neck

Esophageal Perforation

• Acute onset pleuritic CP post vomiting

• Fever, SOB, hemodynamic instability, sub q or mediastinal gas

• EtOH, forced vomiting, instrumentation

• Dx CXR, CT Chest,gGastrografin swallow, EGD

• Rx: Abx, fluids, prepare for surgery

Case #5

• 32 year old male with acute onset left sided CP, SOB

• Four hours duration nonrelenting

• Pleuritic, nonradiating, left sided

• Hx HIV, AIDS

• BP 110/60, P 110, R 28

• No breath sounds on left

Spontaneous Pneumothorax

• Acute, one sided pleuritic CP• Decreased BS, hypoxia, SOB• Watch for tension pneumo, but rare in

spontaneous• Repeat offenders, COPD, asthma, HIV, IVDA,

instrumented• Dx CXR• Rx Observation, aspiration, chest tube, surgery

Case #6

• 24 year old female presents with burning, central chest pain of three days duration

• Worse with cough, deep breath

• Cough, fever, sputum, URI sx

• BP 110/60, P 130, R 24, T 101

• Rales and wheezed on chest exam

Pneumonia/Bronchitis

• Cough, Fever, Sputum, and chest pain with cough

• Pathogens vary with age, comorbidities, and season

• Dx: Clinical, CXR

• Rx: Antibiotics if pneumonia, NSAIDS, cough suppressants, albuterol

Case #7

• 30 year old male with chest pain for one week duration.

• Anterior, left parasternal, sharp, worse with movement, deep breath

• No SOB, no associated Sx

• History of recent URI, resolved

• Exam normal, but chest wall tender

Musculoskeletal Chest Pain/Costochondritis

• Gradual onset, localized, worse with movement, deep breath, palpation

• No SOB, no lung sx, no assoc sx

• Tender to exam

• Hx of trauma, stress or strain

• Workup: CXR and ECG unless young

• Rx NSAIDs, pain meds

Case #8

• 44 year old male with burning substernal CP

• Present for weeks

• Exacerbated by foods, hot drinks, lying flat

• Worse in AM

• Hx of smoking, EtOH

• Exam normal, but some epigastric tenderness

GERD

• Acid irritation/ulceration of esophagus• Burning midsternal pain, worse with GI utilization• Better with GI cocktail (beware of indescriminate use)• Often Dx of exclusion• Workup: CXR and ECG unless young• Rx: Reflux precautions, H2 blockers, proton pump

inhibitors

Shortness of Breath

• Often overlaps with chest pain diagnoses

• Impairment of Oxygenation or Ventilation

• Stimulation of Respiratory Drive– O2– CO2– Pain

• Apprehension/Psychogenic

Shortness of Breath DDx

• Asthma/COPD/Emphysema• CHF• PE• ARDS• Pneumonia/Bronchitis• Restrictive Diseases (CA, Effusion, Collapse)• Anxiety/Hyperventilation/Psychogenic• Upper airway obstructions (croup, angioedema, CA)