Evaluation of Chest Pain in the Evaluation of Chest Pain in the Emergency DepartmentEmergency Department

Rachel Steinhart, MD, MPHCCRMC Emergency Dept.5-1-2008

Chest Pain in the EDChest Pain in the ED

There an estimated 4.6 million annual ED visits for “non-traumatic chest pain” by adults ≥25 in the US

27.7 visits per 1,000 persons annually

Acute Cardiac Insufficiency is estimated to account for 11% of these non-traumatic chest pain visits*

Burt CW. Am J Emerg Med. 1999 Oct;17(6):552-9.

Chest Pain in the EDChest Pain in the ED

At SFGH, 2.5% of all visits in patients >35 were for “non-traumatic chest pain”

Of these, 37.6% were hospitalized, 45% of whom received significant diagnoses

• 10.7% MI

• 22.5% UA or Stable CAD

• 11.2% Serious Pulmonary Etiology

• 0.4% Aortic Dissection

• 0.3% Pulmonary Embolism

Kohn MA, et al. J Emerg Med. 2005;29(4):383-90.

Overall, approximately 16% of visits with serious etiology(Calculated)

Chest Pain in the EDChest Pain in the ED

Litigation

Missed myocardial infarction represents approximately 10% of malpractice suits filed

Missed myocardial infarction represents approximately 30% of the dollars paid out in malpractice claims

Emerg Med News. 2006: 28(2); 20-7

Proportion of final diagnoses in patients Proportion of final diagnoses in patients presenting with CPpresenting with CP

Diagnosis

GP (n=320)

Hospital (n=580)

Self (n=161)

Referred (n=369)

EMS (n=48)

Esophageal 4.8 1.9 1.9 1.6 4.2

Peptic/gastritis 5.1 0.7 0.6 0.8 0

Angina/arrhythmia 8.4 13.4 8.1 15.7 12.5

Unstable Angina 12.8 8.7 14.9 10.4

Serious CV* 4.8 28.1 24.2 28.5 39.6

Musculoskeletal 20.6 6.2 8.1 6.2 0

Intercostal neuralgia 8.4 1.0 0.6 1.1 2.1

Heart neurosis 10.0 6.4 12.4 3.8 6.3

Psychopathology 7.1 2.9 3.1 2.2 6.3

Tracheitis/bronchitis 16.1 3.3 5.0 3.0 0

Serious lung dz+ 3.5 8.8 10.6 8.9 2.1

Other 10.0 10.0 11.8 8.9 12.5

Unknown 1.3 4.5 5.0 4.3 4.2

* MI, pericarditis, decompensation cordis & pulmonary embolism + Pneumonia, pleuritis, pneumothorax, lung cancer

Family Practice. 2001;18(6):586-8

Chest Pain: HPIChest Pain: HPI

P: pattern (temporal sequence) A: associated features

• SOB, N/V, diaphoresis• Fever, cough, chills• Neurologic symptoms

I: initiation and improvement N: nature (quality)

Chest Pain: LocationChest Pain: LocationMyocardial ischemiaMyocardial ischemiaIntra-peritoneal fluidIntra-peritoneal fluidPericarditisPericarditisPleurisyPleurisy

Myocardial ischemiaMyocardial ischemiaCervical spineCervical spineThoracic outletThoracic outlet

Pulmonary embolismPulmonary embolismPneumoniaPneumoniaSplenic infarctionSplenic infarctionIntraperitoneal fluidIntraperitoneal fluid

Aortic dissectionAortic dissectionBoorhave’sBoorhave’sMyocardial ischemiaMyocardial ischemiaPulmonary embolismPulmonary embolismPericarditisPericarditis

Myocardial ischemia Myocardial ischemia CHFCHFPancreatitisPancreatitisCholecystitisCholecystitisPeptic diseasePeptic disease

Clear cut alternative diagnosisClear cut alternative diagnosis

Patients given a clear-cut alternative non-cardiac diagnosis At significantly lower risk of

revascularization, MI or death in the subsequent 30 days

HOWEVER

Still with 4% event rate at 30 days

Acad Emerg Med. 2007 Mar; 14(3):210-5

Character of Chest PainCharacter of Chest Pain

Likelihood ratios for myocardial infarction (MI) based on components of the chest pain history

Description of pain LLR (95% CI)

Descriptions increasing the likelihood of MI Radiation to right arm or shoulder 4.7 (1.9-12) Radiation to both arms or shoulders 4.1 (2.5-6.5) Exertional 2.4 (1.5-3.8) Radiation to left arm 2.3 (1.7-3.1) Associated with diaphoresis 2.0 (1.9-2.2) Associated with nausea or vomiting 1.9 (1.7-2.3) Worse than previous angina or similar to previous MI

1.8 (1.6-2.0)

Described as pressure 1.3 (1.2-1.5) Descriptions decreasing the likelihood of MI Pleuritic 0.2 (0.1-0.3) Positional 0.3 (0.2-0.5) Sharp 0.3 (0.2-0.5) Reproducible with palpation 0.3 (0.2-0.4) Inframammary location 0.8 (0.7-0.9) Nonexertional 0.8 (0.6-0.9)

JAMA 2005; 294:2623.

Nitroglycerine in ER Chest PainNitroglycerine in ER Chest Pain

Annals of Internal Medicine 2003Improvement in chest pain with nitroglycerine proved:

35% Sensitive30% Specific

Canadian Journal of Emergency Medicine 2006Improvement in chest pain with nitroglycerine proved:

72% Sensitive37% Specific

Ann Intern Med. 2003;139:979-986

Can J Emerg Med 2006;8(3):164-9

Chest Pain: PMHChest Pain: PMH

CAD - self or family Hypertension Diabetes Recent surgery, travel Substance abuse - alcohol, cigarettes, meth/coke DVT/PE/Aortic dissection - self or family Lupus Marfan’s/connective tissue dz - self or family Medications - HAART, estrogen

Ann Rheum Dis 2000;59;321-325N Engl J Med 2007 Apr 26;356(17):1723-35

Chest Pain: Physical ExamChest Pain: Physical Exam

Vital signs - Hypoxia? Tachycardia? Hypertension? General appearance - Marfanoid? Carotids and JVP, check neck for crepitus Lungs Cardiac exam Thoracic cage - Trauma? Pectus excavatum? Abdominal exam - Hepatomegaly? Periphery - symmetric pulses? edema? Skin - dermatomal rash?

Physical SignsPhysical Signs

Chest Pain: LaboratoryChest Pain: Laboratory

EKG - serial Chest x-ray Blood studies

• CBC• Cardiac enzymes• Liver function• Lipase• D-Dimer• BNP

Imaging: Ultrasound, CT, Nuclear Study

EKG Findings in Adult Patients with Chest EKG Findings in Adult Patients with Chest Pain: Association with Ischemic EventsPain: Association with Ischemic Events

Interpretation MI UA Other Total

Normal 1% 4% 95% 114

Nonspecific ST-T-wave changes 3% 23% 75% 150

Abnormal but non-diagnostic of ischemia 4% 21% 75% 72

Ischemia, strain, or infarct pattern OLD 7% 48% 45% 60

Ischemia or strain not known to be old 25% 43% 32% 114

Probable MI 73% 13% 14% 86

TOTAL Number Patients 104 143 349 596 From Au fiderheide TP, Brady WJ: Electrocardiography in the patient with myocardial ischemia or infarction. In Gilber WB, Aufderheide TP (eds): Emergency cardiac care, St Lou is, 1994, Mosby: adapted from Lee TH, Cook EF, Weisberg M, et al: Arch Intern Med 145:65, 1985

Adverse Cardiac EventsAdverse Cardiac Events (12 mo out)(12 mo out)

Patients discharged with chest pain of unclear origin:Patients discharged with chest pain of unclear origin:

Abnormal ECG OR 9.5 (2.0 - 45.8)

Preexisting DM OR 7.1 (1.8 - 27.2)

Preexisting CAD OR 28.4 (3.5 - 229.0) Ann Emerg Med. 2004 Jan;43(1):59-67

Potential Underlying Causes of ACSPotential Underlying Causes of ACS

TachyarrhythmiasSevere anemia/acute hemorrhageMedication withdrawalStimulant substance abuseHyperthyroidismSepsisHypotension

Post-op Chest Pain and SOBPost-op Chest Pain and SOB

70 yo man 10 days following CABG

Developed acute dyspnea and right-sided chest pain on awakening

Exam revealed tachypnea, tachycardia, and hypoxemia

Normal

RUL pnaR pl eff

Studies in suspected PEStudies in suspected PE

EKG Evidence:Tachycardia - sinus, afib or aflutterRV Strain

S1, Q3, T3Poor R wave prog + TWI V1-4

D-DimerD-Dimer - Only useful to rule outPE in LOW RISKLOW RISK

Initial CXR in PE virtually always NORMAL

Westermark sign - RARE

Atelectasis, small pleural effusion &Elevated hemidiaphragm may develop24-72 hours – focal infiltrates

Hampton hump – LATE & RARE

Acute Upper Back PainAcute Upper Back Pain

49 yo man with long standing hypertension

Sudden mid back and interscapular pain

Associated with nausea and sweats

Unrelieved by change of position

Some radiation toward the left chest

Wide mediastinum - Dissection

Sudden severe pain 90%Migrating pain 31%Tearing pain 39% (spec. 95%)

Hypertension 49%Diastolic murmur 28%Pulse deficits or BP differential 31%Focal neurologic deficits 17%Syncope 13%ECG criteria for AMI 7%

Klompas et al, JAMA 2002; 287:2262-2272.Nallamothy et al, Am J Med 2002; 113:468-471.

Aortic Dissection: clinical presentationAortic Dissection: clinical presentation

Aortic Dissection: etiologyAortic Dissection: etiology

Prevalence of major risk factors: Hypertension 50-90% Bicuspid AoV 9-13% Marfan syndrome 3-5%

Radiographic Signs of Thoracic Radiographic Signs of Thoracic Aortic DissectionAortic Dissection

Studies suggest up to 90% of patients will have “abnormal” CXR* Widened mediastinum (>8cm on AP film) [50-65%] Left pleural effusion (hemothorax) Ring Sign (displaced intimal calcification >5mm) Blurred aortic knob Tracheal deviation to the Right Esophageal deviation to the Right (seen via NGT) Left apical cap Depressed Left mainstem bronchus Loss of paratracheal stripe

*Hogg K. Sensitivity of a normal chest radiograph in ruling out aortic dissection. Best Evidence Topics. 9 March 2004.

Aortic DissectionAortic Dissection

QuickTime™ and a decompressor

are needed to see this picture.

Wrestler with Chest PainWrestler with Chest Pain

18 yo high school wrestler develops right-sided chest pain while pinning his opponent.

Pneumothorax

Alcoholic with Chest Pain and CoughAlcoholic with Chest Pain and Cough

45 yo alcoholic man with fever, chills and productive cough over two days

RUL Pneumonia

Hyperemesis with Chest PainHyperemesis with Chest Pain

26yo G1P0 at 10wks presents with 4 days refractory emesis and 12 hours progressive, severe substernal chest pain

Pneumomediastinum - Boerhaave’s

Smoker with Chest PainSmoker with Chest Pain

68 yo former smoker with persistant, non-exertional, left substernal and left shoulder pain

SummarySummary

Chest pain in the ED differs from chest pain in primary care

Not all serious chest pain is ACS

Diagnosis of chest pain in the ED is rarely straight forward

Chest pain in the ED is a high-stakes evaluation

Parting WordsParting Words

Neither NTG nor GI cocktail response, nor reproducibility on palpation are diagnostic

Post-prandial pain may be ischemic

Use caution when diagnosing “non-cardiac” chest pain in patients with CAD risk

Atypical may be typical of something else

Careful history and physical are imperative

Observation can be key