Chest Pain Cases

Chest Pain l April 8, 2023 l 1

Chest Pain

Moises Auron, MD FAAPAssistant Professor of Medicine CCLCM of CWRUAugust 28, 2009


• Describe differential diagnosis, evaluation, and initial management of chest pain

• Identify risk factors for coronary artery disease

• Identify biases that might interfere with clinical reasoning in determining the cause of chest pain

Objectives


CASE # 1

• Emergency Room

• 33 years old male – stock broker

• Chest pain

• Shortness of breath

• Palpitations (“I feel I have a butterfly in my chest”)


– What activities precipitate pain? – stress (stock market); sudden onset

– What alleviates pain? – rest

– Quality of the pain – sharp, stabbing

– Associated symptoms – Diaphoresis; impending death feeling

– Where is the pain located? – retrosternal with no radiation

– Severity of pain – 6/10

– How long since episodes first began? Weekly for the past month.

– How long does the pain last each episode? – 10 min to 30 minutes

What information would you want to know?


Torre D. Chest Pain. In: Torre DM, et. al. Kochar’s Clinical Medicine for Students, 5th Ed. Baltimore, MD. LWW; 2009: 31-36.


Other important information

– Past medical history

– Diabetes mellitus diagnosed at age 12 y/o

– HbA1c 12

– No history of syncope

– Social History

– Smoker 2 ppd for the past 5 years.

– Use Ritalin and cocaine weekly for the past year

– Family History

– Father had a Myocardial Infarction at Age 57 y/o

– No history of syncope or sudden cardiac death


What characteristics would suggest non-cardiac origin?

• Unrelated to physical activity or emotional stress

• Associated with arm or chest movement

• Quality of pain: sharp, stabbing, pleuritic, burning

• Duration of pain: fleeting


What characteristics would suggest cardiac origin?• Age and Sex (Male > 45 y/o; Female > 55 y/o)

• Smoker – increase risk of CAD 2-4x

• Diabetes – increase risk of mortality 2-4x

• Drug use

• Associated symptoms (autonomic features)

• Family history (Male < 55 y/o; Female < 65 y/o)

• Risk factors (Total cholesterol, LDL, HDL, Hypertension)

–Framingham Study

• Others (Obesity, Sedentarism)

–Metabolic Syndrome


http://www.framinghamheartstudy.org/index.html

http://www.framinghamheartstudy.org/index.html


Metabolic Syndrome (NCEP/ATP III)

Circulation. 2002;106:3143-3421.


Coronary Heart Disease Equivalents

• Diabetes Mellitus

• Peripheral Arterial Disease– ABI Index < 0.9

• Abdominal Aortic Aneurysm

• Carotid Artery Disease

• Framingham 10 y Risk > 20%

• Erectile Dysfunction2

1. NCEP/ATP III. Circulation. 2002;106:3143-3421..2. Tikkanen MJ. Int J Clin Pract. 2007; 61(2):265–268


Back to the Case – Physical exam

• VS – 190/100; HR 110; BMI 40

• General – diaphoretic

• Eyes – constricted pupils (miosis), conjunctival injection

• Nose – septal perforation

• Cor - Rapid, irregular heartbeat

• Chest – mild expiratory wheezing

http://amrc.org.hk/files/Image/alu_issue61_05.jpg


What Ancillary Tests Would You Order?

• CXR

• EKG

• Toxicology screen (blood and urine)

• Cardiac enzymes

–Troponin I/T

–CK, CK-MB

• Hb A1c

• Lipid profile


Cardiac enzymes in Myocardial Infarction


Cardiac microfibrillary thin filament

Parmacek MS, Solaro RJ. Prog Cardiovasc Dis. 2004; 47 (3): 159-176


Use of Troponin in Acute Chest Pain evaluation

Hamm CW. Circulation. 2000;102:118-122


Troponin in Unstable Angina: Prognostic implications

Hamm CW. Circulation. 2000;102:118-122


Troponin I in Acute Coronary Syndromes

Antman EM, et al. NEJM. 1996;335:1342-9.Ohman EM, et al. NEJM. 1996;335:1333-41.

N = 855N = 1404


Back to the Case - EKG


EKG Leads

• I, aVL – Lateral

• II, III, aVF – Inferior

• V1-V3 – Septal

• V4 – Apical

• V5-V6 – Anterior

• Right leads – V4R – Right ventricle (correlates with inferior leads)

http://www.physio-control.com/uploadedFiles/learning/clinical-topics/3009848-000%20Placement%20of%20Precordial%20Leads.pdf


EKG Changes: Ischemia

BMJ. 2002;324(27): 1023-26


EKG Changes: Lesion

BMJ. 2002;324(27): 1023-26


Patophysiology of Acute Coronary Syndromes

ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction. Circulation. 2004;110;e82-e293.

Ischemic discomfort


Patophysiology of Acute Coronary Syndromes

ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction. Circulation. 2004;110;e82-e293.


Chest Roentgenogram


What would be important aspects of aftercare?• Diabetes management

– Pneumovax

– Aspirin

– HbA1c

– Lipid check

– Foot exam

– Ophthalmologic exam

– Microalbumin (or ACEI)

• Hypertension control

• Smoking cessation

• Chemical Dependency Rehabilitation


CASE # 2

• Medical office

• 63 year old African-American male

• Poor follow-up with a physician

• Nausea without emesis for three hours

• Has “heartburn” unresolved with TUMS

• Had an episodes of diaphoresis and “dizziness” that lasted 30 minutes, before coming to the office.


– What activities precipitate pain? – exercise – played 9 holes of golf, walking instead of cart.

– What alleviates pain? – nothing; normally TUMS or antacids (Maalox, Mylanta, MOM)

– Quality of the pain – heartburn

– Associated symptoms – Diaphoresis; nausea

– Where is the pain located? – retrosternal with no radiation


– How long since episodes first began? Heartburn since age 40, increasing in frequency in the past year.

– How long does the pain last each episode? – Less than 10 minutes (usually resolves with antacids.



Differential diagnosis

• Acute myocardial infarction

• GERD

• Hiatal hernia

• Esophageal spasm


Other important information

• Past Medical History– Hypertension for the past 10 years

–On Candesartan 32 mg daily and HCTZ 12.5 mg daily

– GERD (no formal diagnosis)

– Overweight

– Hyperlipidemia on OTC fish oil

• Social History– Retired airline pilot; accountant

– Smoker 1.5 ppd for the past 30 years

– Diet: fast food

– Alcohol: when not flying 1-2 beers daily


Family History

Age 49 65, pancreas CA

66, DM, CAD HTN 60, HTN, DM


What are the patient risk factors?

• Male > 55 years old

• Smoker

• Hyperlipidemia

• Hypertension

• Overweight

• Sedentarism

• Family history (Father passed < 55 y/o)


• The company he works for, filed Chapter 11

• Has been requiring TUMS 6-8 times a day x 2 weeks

• Nausea when walking long distances

• No nausea after spicy foods or when lying after eating.

• Heartburn occurs when he in emotional stress

Patient symptoms


What features would suggest GERD/esophageal cause?

• Spicy food

• Caffeine

• Smoking

• Chocolate

• Mint

• Alcohol

• Large meals

• Lying horizontally immediately after eating

• Obesity

• Relief with antacids or avoiding precipitating factors

http://images.google.com/imgres?imgurl=http://i230.photobucket.com/albums/ee68/LittleWitch333/mexican_food_neon.jpg&imgrefurl=http://fun140.com/quizzes/17-what-mexican-food-are-you/take&usg=__0fbaTT93osCI4hlp80TG95YNUB8=&h=317&w=380&sz=42&hl=en&start=9&um=1&tbnid=TFdXdx4TTcpJ-M:&tbnh=103&tbnw=123&prev=/images%3Fq%3Dmexican%2Bfood%26hl%3Den%26um%3D1


On further interrogation…

• Eats fast food, and drinks a 2L bottle of Coke daily

• Complains of frequent urination and blurry vision

• Is any of this relevant to the cause of his nausea?

– Diabetes (risk equivalent for coronary artery disease)

– Erosive gastritis due to phosphoric acid (cola drink)

• Could this be diabetic gastroparesis?

– Unlikely


Physical exam:

• VS: 100/60, 55, 12, 99%RA, BMI 38

• Gen: Diaphoresis

• Neck: JVD 6 cm

• Cor: Gallop

• Lungs: clear, no wheezing

• Abdomen: pulsatile mass, enlarged liver, hypoactive bowel sounds

• Extremities: slight pedal edema

What are you going to do next?


Case continuation…


Case continuation…

• Why is the patient presenting this way?

O'Rourke RA. Diagnosis and management of right ventricular myocardial infarction. Curr Probl Cardiol. Jan 2004; 29(1):6-47.


What treatments can you initiate?• Aspirin

• Oxygen

• Sublingual nitroglycerin? Morphine?

– What concerns would you have?

– Right-sided / Inferior MI

– Low blood pressure

– Antihypertensive medications

• IV Fluid bolus (in the E.R.)


Pfisterer M. Right ventricular involvement in myocardial infarction and cardiogenic shock. Lancet 2003; 362: 392–94.


Where are you going to send the patient?

• Home?

• Emergency Room?

• How would you get him there?


CASE # 3

• 42 year old African-American Female

• Sharp stabbing pain while in line for voting

• Sudden onset

• Lasted briefly – not more than 5 minutes

• Many stressors


What is in your differential?

– Panic attack

– Costochondritis

– Pneumothorax

– Pericarditis

– Pleuritis

– Pneumonia

– Pulmonary Embolism

– Angina


What are some important aspects of history to help determine the cause of her symptoms?

• Couldn’t breathe

• Tingling

• Diaphoresis (no fever)

• Has had this problem before

• Smokes 2 ppd, starting at age 27

• Mother died at age 46 of massive heart attack

• Doesn’t go to the doctor, since having an emergency TAH/BSO after having her son four years ago (not on HRT)


What would you expect to find on exam?

• VS: HR 110, BP 110/70, BMI 25

• General: Rapid speech, tearfulness, “smoker’s fetor”

• Neck: no goiter

• Cor: Tachycardic, no gallop

• Chest: Bilateral expiratory wheezing and decreased breath sounds

• Extremities: no swelling, no tremor, pulses 2+


What tests (if any) would you do?

– Electrocardiogram

– Chest X-ray

– TSH

– CBC

– Fasting blood sugar

– Lipid panel

– Stress test


Indications for exercise stress testing

Kleczka J. Coronary Artery Disease. In: Torre DM, et. al. Kochar’s Clinical Medicine for Students, 5th Ed. Baltimore, MD. LWW; 2009: 148-168


What would be your recommendations to this patient?

– Smoking cessation

– Counseling, including cognitive behavioral therapy

– Seek (financial and other) support with kids

– Limit salt and fat intake

– Regular exercise

– Register for absentee ballot or vote early in future elections


CASE # 4

• 35 year old man with chest pain and nausea

• Working a lot

• Not getting much sleep

• Looks tired

• Came to ED day before and was sent home

• Sweating a lot but feels cold


– What activities precipitate pain? –sudden onset, straining

– What alleviates pain? – nothing

– Quality of the pain – tearing, sharp

– Associated symptoms – Diaphoresis; nausea

– Where is the pain located? – anterior chest radiated to scapular area


– How long since episodes first began? First time

– How long does the pain last each episode? – continuous



What is in your differential?

– Angina pectoris

– Pericarditis

– Aortic dissection

– GERD

– Esophageal spasm


What other information would you want?

• Past medical history: none

• Social history: – No drugs, no cigarettes, no EtOH

• Family history: early deaths


What are you going to look for on exam?

– Long arms and legs

– Flexible; joint hyperextension

– Very different blood pressures in the two arms (> 30 mmHg)

– Diastolic Aortic murmur


What tests, if any, would you do?

– Electrocardiogram

– Chest x-ray

– CT angiography

– Troponin, CPK

– Echocardiogram

– RPR

– Toxicology screen


Chest Roentgenogram


What would you do with this patient?

– 2 large bore intravenous lines

– Oxygen

– Monitoring of respiratory rate, cardiac rhythm, blood pressure, and urine output

– Beta-blocker to control heart rate and blood pressure

– Thoracic surgeon consult


CASE # 5

• 32 year old female, obese, sedentary

• Smokes 4 ppd

• Uses oral, transdermal and intramuscular contraceptives

• Has livedo reticularis and severe venous insufficiency

• Diagnosed with metastatic colon cancer

• Both her parents and all her 10 siblings have Factor V Leyden

• Patient arrived from a 15 hours non-stop flight from Seoul

• Patient complaints of chest pain, SOB and cough with hemoptysis


What is your diagnosis?

Tapson VF. Acute Pulmonary Embolism. NEJM. 2008;358:1037-52.


Risk factors for venous thromboembolism



Wells PS. Ann Intern Med. 2001; 135:98-107


Would you order a D-dimer?



Chest Roentgenogram


What study would you order next?



Chest CT scan



What do you expect to see in an EKG?

Kline JA, Runyon MS. Pulmonary Embolism and Deep Venous Thrombosis Ch. 87. in: Marx: Rosen's Emergency Medicine: Concepts and Clinical Practice, 6th ed. Mosby. 2006.


What treatment does she needs?

• Oxygen

• IV fluids

• Monitor – telemetry, BP, SpO2

• Anticoagulation

• Thrombolysis (if hemodynamically stable)


CASE #6

• 40 y/o Male

• Previously healthy

• Finished 2 weeks of oral levofloxacin for “acute sinusitis”

• Presents with chest pain

• Afebrile


– What activities precipitate pain? – insidious, worsen with inspiration and lying down

– What alleviates pain? – sitting up and leaning forward; Ibuprofen

– Quality of the pain – sharp

– Associated symptoms – need to “gasp for air” after deep inspiration, cough with deep inspiration

– Where is the pain located? – right side of the chest


– How long since episodes first began? 3 days

– How long does the pain last each episode? – intermittent



What is your differential diagnosis

• Pneumonia

• Pleural Effusion

• Pleurisy

• Pneumothorax

• Pericarditis

• Atelectasis

• Pulmonary embolism


What test do you want to order?


What is the cause of this patient’s chest pain?

Kass SM, et al. Pleurisy. Am Fam Physician. 2007;75:1357-64.


Would you perform a thoracentesis?

• In patients with viral pleuritis it is reasonable to provide conservative management.

• Treatment with NSAIDS (Indomethacin is the only studied)

• Repeat CXR in 1-2 weeks

Kass SM, et al. Pleurisy. Am Fam Physician. 2007;75:1357-64.Sacks PV, Kanarek D. Treatment of acute pleuritic pain. Comparison between indomethacin and a placebo. Am Rev Respir Dis. 1973;108:666-9.Klein RC. Effects of indomethacin on pleural pain. South Med J. 1984;77:1253-4.


Do atelectasis cause fever?

• N = 100 postoperative cardiac surgery

• F/U from day of surgery through Post-op day 2

• Daily portable Chest radiographs

• Continuous bladder thermometry

• Incidence of atelectasis: 43 69 79%.

• Incidence of fever (>38.0°C): 37 21 17%.

• Incidence of fever (>38.5°C): 14 3 1%.

Engoren M. Chest 1995; 107:81-84


Take Home Messages

• Remember to consider dangerous and bad diagnoses

• Remember that patients don’t read textbooks

• Think about what is going on with patients and individualize treatment

Documents

Chest Pain Cases