Chest Pain

LSU Medical Student Clerkship, New Orleans, LA

Chest Pain

Goals

Review the pathophysiology, diagnosis and treatment of life threatening causes of chest pain.

Chest Pain

Epidemiolog

5% of all ED visits  Approximately 5 million visits per year

Chest Pain

!isceral Pain

Visceral fi ers enter the spinal cord at several levels leading to poorly locali!ed, poorly characteri!ed pain. "discomfort, heaviness, dull, aching# $eart, lood vessels, esophagus and visceral pleura are innervated y visceral fi ers %ecause of dorsal fi ers can overlap three levels a ove or elow, disease of thoracic origin can produce pain anywhere from the &aw to the epigastrum

Chest Pain

Parietal Pain
 'arietal

pain, in contrast to visceral pain, is descri ed as sharp and can e locali!ed to the dermatome superficial to the site of the painful stimulus.  (he dermis and parietal pleura are innervated y parietal fi ers.

Chest Pain

"nitial Approach
A%)*s first, always "loo+ for conditions re,uiring immediate intervention#  Aspirin for potential A) E./  )ardiac and vital sign monitoring  'ain relief  %ecause of the wide differential, $0' will guide the diagnostic wor+up

Chest Pain

#istor
 12

onset  '2provocation 3palliation  42 ,uality3,uantity  R2 region3radiation  -2 severity3scale  (2 timing3time of onset

Chest Pain #istor
 )hange

in pain pattern  Associated symptoms5 D1E, -1%, diaphoresis, vomiting, heart urn, food intolerance  '$x  -ocial history  6$x

Chest Pain

Ph sical E$am
 

/eneral Appearance and Vitals "sic+ vs not sic+# )hest exam 27nspection "scars, heaves, tachypnea, wor+ of reathing# 2Auscultation "murmurs, ru s, gallops, reath sounds# 2'ercussion "dullness# 2'alpation "tenderness, '87#

Chest Pain Ph sical E$am
 9ec+5

:VD, crepitence, ruits  A domen  Extremities5 swelling, pulses, tenderness, $oman*s

Chest Pain

%i&&erential %iagnoses
)ardiovascular 'ulmonary /astrointestinal 8usculos+eletal 9eurologic 1ther
Acute myocardial infarction, Acute coronary ischemia, Aortic dissection, )ardiac tamponade, ;nsta le angina, )oronary spasm, 'rin!metal<s angina, )ocaine induced, 'ericarditis, 8yocarditis, Valvular heart disease, Aortic stenosis, 8itral valve prolapse, $ypertrophic cardiomyopathy 'ulmonary em olus, (ension pneumothorax, 'neumothorax, 8ediastinitis, 'neumonia, 'leuritis, (umor, 'neumomediastinum Esophageal rupture "%oerhaave#, Esophageal tear "8allory2 =eiss#, )holecystitis, 'ancreatitis, Esophageal spasm, Esophageal reflux, 'eptic ulcer, %iliary colic 8uscle strain, Ri fracture, Arthritis, (umor, )ostochondritis, 9onspecific chest wall pain -pinal root compression, (horacic outlet, $erpes !oster, 'ostherpetic neuralgia

'sychologic, $yperventilation

Chest Pain

Li&e 'hreatening Causes o& Chest Pain
Acute )oronary -yndromes  'ulmonary Em olus  (ension 'neumothorax  Aortic Dissection  Esophageal Rupture  'ericarditis with (amponade

Chest Pain

Acute Coronar S ndromes ( Epidemiolog
 7n

a typical ED population of adults over the age of >? presenting with visceral2type chest pain, a out @5 percent will have A87 and A5 to >? percent will have ;A

Chest Pain

Acute Coronar S ndromes ( #istor
 B(ypicalC

)hest 'ain -tory "'ressure2li+e, s,uee!ing, crushing pain, worse with exertion, -1%, diaphoresis, radiates to arm or &aw# (he ma&ority of patients with A)- D1 91( present with these symptomsD  )ardiac Ris+ 6actors "Age, D8, $(9, 6$, smo+ing, hypercholesterolemia, cocaine a use#

Chest Pain

Acute Coronar S ndromes ) E*G +indings
 -(E87

2 -( segment elevation "E@ mm# in contiguous leadsF new G%%%  ( wave inversion or -( segment depression in contiguous leads suggests su endocardial ischemia  5% of patients with A87 have completely normal E./s

Chest Pain

Chest Pain

Chest Pain
Acute Coronar S ndromes ) Cardiac Markers
8ar+er (roponin ).28% GD$ 8yoglo in 7nitial Rise A2H hr >2H hr @? hr @2A hr 'ea+ @? 2AH hr @?2AH hr AH 2JA hr H 2K hr Return to normal 5 2@? days A I H days @H days AH hours Very sensitive, powerful negative predictive value %enefits -ensitive and specific ;naffected y renal failure

Chest Pain

Acute Coronar S ndromes ) Cardiac Markers

Chest Pain Echocardiogram
 =all

a normalities occur within minutes  =ill detect a normalities in K?% of A87  9ormal resting echo in setting of chest pain gives low pro a ility  Early screen for A87 complications5 aneurysms, valve a normalities, other structural destruction

Chest Pain Echo

Chest Pain

Acute Coronar S ndromes ( 'reatment
 Aspirin  9itroglycerin  1xygen  Analgesia

Chest Pain

Acute Coronar S ndromes ( 'reatment
 Aspirin  9itroglycerin  1xygen  Analgesia

Chest Pain 'reatment
 %eta2%loc+ers  Anticoagulation  Anti2'latelet

Agents  (hrom olysis  'ercutaneous )oronary 7nterventions "')7#

Chest Pain Stress echocardiograms
 -ensitivity

L?2M?%  -pecificity J5% N  -hould e employed with moderate to high ris+ stratification  Gimitations of reader, image ,uality, and previous functional impairment  9egative test has time limited value

Chest Pain

Acute Coronar S ndromes ( 'reatment
 -(E87

"A-A, %2 loc+er, 9(/, anti2platelet, anticoagulation, throm olysis, ')7# "A-A, %2 loc+er, 9(/, anti2platelet, anticoagulation, ')7# le Angina "A-A, %2 loc+er, 9(/, anticoagulation, ris+ stratification#

 9-(E87

 ;nsta

Chest Pain

Acute Coronar S ndromes ( %isposition
 8ortality

is twice as high for missed 87  8issed 87 is the most successfully litigated claim against E'<s. E'*s miss >25% 16 A87, this accounts for A5% of malpractice costs against E'*s

Chest Pain

Acute Coronar S ndromes ( %isposition
A

single set of cardiac en!ymes is rarely of use  Ris+ -tratification5 goal is to predict the li+elihood of an adverse cardiovascular event  )om ination of $0', E./, %iomar+ers  9o single glo ally accepted algorithm  8athematical models such as (787, /RA)E, ';R-;7(, and $EAR( can e helpful ut are no su stitute for clinical &udgment

Chest Pain

Pulmonar Em,olism ( Pathoph siolog
 (hrom

osis of a pulmonary artery  EM?% arise from DV(  )lot from a DV( travels through the venous system and lodges in the pulmonary vasculature creating a ventilation3perfusion mismatch

Chest Pain

Pulmonar Em,olism ) #istor
 Dyspnea

is the most common symptom, present in M?% of patients diagnosed with 'E  -harp pleuritic chest pain, syncope,  'rolonged immo ili!ation, neoplasm, +nown hypercoagula le disorder

Chest Pain

Pulmonar Em,olism ) Ph sical E$am
 (achycardia,

tachypnea, diaphoresis, hypotension, hypoxia, low grade fever, anxiety, cardiovascular collapse, right ventricular heave

Chest Pain

Pulmonar Em,olism ) %iagnostic 'esting
 -inus

(achycardia is the most fre,uent E./ finding  )lassic -@,4>,(> finding is seen in less than A?%  A%/ plays no role in ruling out 'E  D2Dimer in a low ris+ patient can e used to rule out 'E

Chest Pain

Pulmonar Em,olism ) -ells Criteria
      

Clinical Signs and S mptoms o& %!'. /es 01 PE is 23 %iagnosis, or E4uall Likel . /es 01 #eart 5ate 6 377. /es 0389 "mmo,ili:ation at least 1 da s, or Surger in the Pre;ious < weeks. /es 0389 Pre;ious, o,=ecti;el diagnosed PE or %!'. /es 0389 #emopt sis. /es 03 Malignanc w> 'reatment within ? mo, or palliati;e. /es 03 @A B Low risk, A89(? B moderate risk, 6? B high risk

Chest Pain
Pulmonar Em,olism ) %iagnostic "maging Algorithm

Chest Pain

Pulmonar Em,olism ) 'reatment>%isposition

;nfractionated heparin vs low molecular weight heparin "some studies suggest superiority of G8=$#  (hrom olysis "for cardiovascular collapse#  6loor vs 7);

Chest Pain PE CC5

Chest Pain

Chest Pain

Chest Pain

Chest Pain

Chest Pain

Chest Pain

Aortic %issection ( Pathoph siolog

7ntimal tear of the aorta leads to dissection of the layers of the aorta creating a false lumen

Chest Pain

Aortic %issection ( %iagnosis
(earing chest pain radiating to the ac+  Ris+ 6actors5 $(9, connective tissue disease  Exam5 $(9, pulse differentials, neuro deficits  Radiology5 =ide mediastinum on )OR, )( angio chest, echo

Chest Pain

Chest Pain

Aortic %issection ( Classi&ication

De %a+ey system5 (ype 7 dissection involves oth the ascending and descending thoracic aorta. (ype 77 dissection is confined to the ascending aorta. (ype 777 dissection is confined to the descending aorta. (he Daily system classifies dissections that involve the ascending aorta as type A, regardless of the site of the primary intimal tear, and all other dissections as type %.

Chest Pain

Chest Pain

Aortic %issection ( 'reatment

'atients with uncomplicated aortic dissections confined to the descending thoracic aorta "Daily type % or De %a+ey type 777# are est treated with medical therapy. 8edical (herapy5 /oal to decrease the lood pressure and the velocity of left ventricular contraction, oth of which will decrease aortic shear stress and minimi!e the tendency to further dissection. Acute ascending aortic dissections "Daily type A or De %a+ey type 7 or type 77# should e treated surgically whenever possi le since these patients are a high ris+ for a life2threatening complication such as aortic regurgitation, cardiac tamponade, or myocardial infarction.

Chest Pain

'ension Pneumothora$ ( Pathoph siolog
 )ollection

of air in the pleural space causes collapse of the ipsilateral lung and then cardiovascular collapse as intrathoracic pressures increase.

Chest Pain

'ension Pneumothora$ ( %iagnosis
Ris+ factors5 )1'DF connective tissue disease, trauma, recent instrumentation, positive pressure ventilation  A sent reath sounds unilaterally, hypotension, distended nec+ veins, tracheal deviation

Chest Pain

Chest Pain

'ension Pneumothora$ ( 'reatment
 9eedle

decompression  (u e thoracostomy

Chest Pain

Esophageal 5upture ( Pathoph siolog
 (ear

in the esophagus leads to lea+ing of gastrointestinal contents into the mediastinum  7nflammation followed y infection cause rapid deterioration, sepsis and death

Chest Pain

Esophageal 5upture ( %iagnosis
 Rare

ut devastating  Ris+ 6actors5 7atrogenic, heavy retching, trauma, foreign odies, toxic ingestion  Radiology5 8ediastinal air on plain films or )( scan

Chest Pain

Su,tle

Not so su,tle

Chest Pain "maging

Chest Pain

Esophageal 5upture ( 'reatment
 Anti

iotics  -upportive )are  -mall tears with minimal extraesophageal involvement can e managed conservatively  -urgical consult for all regardless of si!e

Chest Pain

'ake #ome Points
 A%)*s

first  $istory is +ey  $ave a low threshold for missed 87