~ §)JjL~EkC~ECOURSE 2. 60-year-old woman with chest pain - Ms.

Johnston

May 13,20161:13:19 AM EDT

Learning objectives

differentiate among the patient's symptoms as angina pectoris, atypical angina, or non-cardiac
chest pain.
document and present an appropriately complete medical history that differentiates among the
common etiologies of chest pain.
perform a physical exam that includes identifying the presence of dyspnea and anxiety, obtaining
accurate vital signs, and performing heart, lung, and vascular exams.
obtain a history of a patient with chest pain that: (1) contains information about those clinical
characteristics that are typical of angina pectoris, and (2) includes risk factors of coronary heart
disease.
propose appropriate laboratory and diagnostic studies based on patient demographics and the
most likely etiologies of chest pain.
discuss primary and secondary prevention of ischemic heart disease through the reduction of
cardiovascular risk factors (e.g. controlling hypertension and dyslipidemia, aggressive diabetes
management, avoiding tobacco, and aspirin prophylaxis).
propose appropriate anti-anginal medications when indicated and communicate potential adverse
reactions.

Knowledge

Broad Differential Diagnosis of Chest Pain
Cardiac
Sean Byrnes - sbyrnes@sgu.edu

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Gastrointestinal
Pulmonary
Musculoskeletal
Psychogenic

Hyperlink "L">Cardiac"

Cardiovascular
causes of Chest
Pain

Symptoms

Signs

Vasospastic cause of
Variant Angina

Other abnormalities

Accompanied by transient ST

angina, often younger pt

elevation on EKG.

with few risk factors.

Cocaine

Chest pain after cocaine

Patients may also have burn

Induced Chest

use from infarction or

marks on lips and fingers from Tox screen positive for cocaine.

Pain

intense coronary spasm.

crack pipe.

Aortic
Dissection

Crushing or tearing quality
pain in center of chest,
radiates to back.

Murmur of aortic insufficiency
may be present.

Widened mediastinum on CXR.

Aortic stenosis can result in AS - systolic crescendo
Valvular Heart

angina pain. Mitral prolapse decrescendo murmur, MVP-

Disease

patients often have atypical midsystolic click with possible
chest pain.

late systolic munnur.

Severe retrostemal pain and
Pericarditis

pain alters with body
positioning, often pleuritic or
young patient

Diffuse ST elevation on EKG,
Pericardia! friction rub.

pericardia! effusion on
echocardiogram.

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I

Usually does not manifest
Non-ischemic

as chest pain but rather

Cardiomyopathy dyspnea or other CHF
symptoms.

Cardiac
Syndrome X

Myocarditis

Pulmonary edema, hepatic

Enlarged heart on CXR, elevated b-

congestion, lower ext edema,

type naturetic peptide.

jugular venous distension.

Usually normal EKG, abnormal

Exertional angina-like chest

exercise stress test with normal

pain, more common in

coronaries on angiogram and no

women.

Similar to pericarditis but
can also mimic ischemia.

evidence of coronary spasm.

May manifest as CHF.

Cardiac enzymes may be elevated.

Hyperlink "L">Gastrointestinal"

Gastrointestinal
Causes of
Chest Pain

Symptoms

Signs

Other
Abnormalities

Reflux disease can cause
chest pain usually after meals,
Esophageal
exacerbated by lying down or No reliable signs
Disease
bending over, improved by
antacids.

Biliary
Disease

Usually results in right upper
quadrant pain.

Peptic Uleer
Gnawing, midepigastric pain.
Disease

Murphy's sign - tender palpable
gallbladder with a sudden halt of
Abnormal liver
inspiration with palpation in the
function tests
upper quadrant. Occasional
jaundice
Epigastric tenderness

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Pancreatitis

Moderate to severe
midepigastric pain with
radiation to the back.

Elevated
amylase and
lipase

Epigastric tenderness

Hyperlink "L">Pulmonary"

Pulmonary
Causes of
Chest Pain

Pneumonia

Symptoms

Signs

Other
Abnormalities

Productive
cough, fever

Crackles on lung exam, egophony,
whispered pectoriloquy

lnfi ltrate on
CXR, elevated
WBC

Decreased breath sounds in affected
hemithorax, resonance to percussion,
possible tachycardia distended neck veins
and hypotension

Abnormal CXR

Pleural friction rub heard with lung
auscultation, small tidal volume breathing

Possible
pleural effusion
onCXR

Tachycardia, hypoxemia, possible right
heart strain on EKG

Abnormal CT of
chest, V/Q
scan, elevated
D-dimer

Acute pleuritic
Spontaneous
chest pain and
Pneumothorax
dyspnea

Pleurisy

Pleuritic chest
pain, dyspnea,
possible viral
syndrome

Pulmonary
Embolism

Pleuritic chest
pain associated
with dyspnea

Hyperlink "L">Musculoskeletal"
Museu loskeletal
Causes of
Chest Pain
Symptoms
Sharp anterior chest pain occurring at
Costochond ritis costochondral and costosternal
junctions. Possibly pleuritic

Signs

Other
Abnormalities

Tenderness to
palpation over chest
wall.

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Rib Fracture

Pleuritic chest pain, worsened by
movement, often associated trauma
Widespread pain often with trigger

Tender over
affected rib

Myofascial Pain
points, often associated depression or
Syndromes

Tender over trigger
points to palpation

Museu lar Strain

Chest pain after excessive exercise or
cough

Possible chest wall
tenderness

Herpes Zoster

Pain and possible itching in a
dermatomal pattern

Rash absent initially
then characteristic
of zoster

sleep disorder

I

Rib fractures
seen on X-ray

Hyperlink "L">Psychogenic"
Psychogenic
Causes of
Chest Pain
Symptoms

l

Signs

Panic Disorder

Sudden intense anxiety often
Tachycardia,
associated with palpitations, dyspnea tachypnea,

Hyperventilation

Dyspnea, light-headedness, often
associated with anxiety

Tachypnea

Somatoform
Disorders

Variety of somatic complaints, can
include chest pain. Often history of
psychiatric illness

Subjective complaints
outnumber objective
findings

Other
Abnormalities

ABGshows
low PC02

Typical/Atypical- Stable/Unstable Angina
The Three Criteria for Typical Angina
• Substernal chest discomfort with a characteristic duration and features
• Exertional in nature
• Relief with rest or nitroglycerin

Atypical Angina
Patients who have diabetes, women, and the elderly are more likely to present with atypical
features. Occasionally they will present with only weakness or shortness of breath on exertion.
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Those symptom are considered "anginal equivalents".

Stable vs. Unstable Angina
Angina occurs when myocardial oxygen demand exceeds supply. When angina is thought to be
present it is important to further characterize it as stable angina vs. unstable angina si nee these
two syndromes are managed very differently.
• Stable angina pectoris is a predictable pattern of chest discomfort that usually occurs with
exertion or extreme emotion. It is relieved by rest or nitroglycerin in less than 5-10 minutes.
• Unstable angina is a more serious condition characterized by chest pain that occurs at rest or
with increasingly less exertion. New onset angina (within 4-6 weeks) and angina that has
worsening severity, frequency or duration is also classified as unstable. Unstable angina is
an acute coronary syndrome (along with non-ST segment elevation myocardial infarction
and ST segment elevation myocardial infarction) and requires emergency care.

Risk Factors for Coronary Artery Disease and Atherosclerotic
Cardiovascular Disease
Many risk factors have been independently associated with coronary artery disease. In addition to
age >55, male gender, family history of sudden death or premature CAD, smoking, dyslipidemia,
diabetes mellitus, hypertension, and obesity; other risk factors for coronary artery disease are a
sedentary lifestyle, a personal history of peripheral vascular or cerebrovascular disease, estrogen
use and chronic inflammation.
Most of a person's risk for CVD and for stroke (together called atherosclerotic cardiovascular
disease, or ASCVD) can be determined by a limited set of major risk factors. Other minor risk
factors are only helpful if they adjust a patient's risk category from that determined by the major risk
factors.

Of those listed above, only age, male gender, current smoking, dyslipidemia, diabetes, and
hypertension are considered major traditional risk factors.
American College of Cardiology/American Heart Association (ACC/AHA) guidelines recommend
assessing major ASCVD risk factors every 4 to 6 years in adults 20 to 79 years of age who are free
fromASCVD.
For more required information about risk factors for ASCVD, read the MedU Cholesterol
Guidelines Module {http://www.med-u.org/cholesterol-guidelines) .
Alcohol in moderate quantities is beneficial for ASCVD but usually not recommended in this
country due to the problem of abuse and dependence. Use of greater than one alcoholic beverage
per day in women or two per day in men is not recommended because of other detrimental health
effects of alcohol, including liver disease and direct myocardial injury.
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Prevention of Cardiovascular Disease
Primary prevention of cardiovascular disease (preventing disease in those without known
disease) involves avoiding tobacco, aggressively controlling diabetes mellitus, keeping blood
pressure and cholesterol in the normal range, and regular exercise. USPSTF recommends starting
aspirin at age 55 for women (after balancing the benefit of stroke reduction for women vs Gl
hemorrhage), and recommends starting aspirin at age 45 for men (after balancing the benefit of mi
reduction vs Gl hemorrhage). The patient and practitioner should have a discussion regarding the
benefits and risks (bleeding) of aspirin therapy on a case-by-case basis.

Secondary prevention (preventing further disease in those with known disease) involves
avoidance of risk factors, more aggressive cholesterol lowering, and diabetic control. Certain
cardiovascular medications may be used as well, such as calcium channel blockers (CACBs) and
angiotensin-converting enzyme (ACE) inhibitors.
Several studies have demonstrated that CACBs are effective in the treatment of stable angina. In
2007, the American College of Cardiology/American Heart Association(ACC/AHA) stated their
preference of beta blockers (BB) over CACB based on BBs showing an improved survival rate in
patients with CAD. CACBs should be considered when BBs are contraindicated. The ACC/AHA
recommends patients with stable angina who have normal LV function be treated with ACE
inhibitors, but there is conflicting evidence that they reduce exercise-induced angina. Aspirin
prophylaxis is also an effective secondary prevention strategy.

Use of Fasting Lipid Levels to Further Assess ASCVD Risk and Determine
Appropriate Cholesterol Treatment Plan
The 2013 ACC/AHA Guidelines on Assessment of Cardiovascular Risk indicate that it is
reasonable to use Pooled Cohort Equations that require lipid data to estimate 10-year ASCVD risk
every 4 to 6 years in adults 40 to 79 years of age without clinical ASCVD.
Clinical ASCVD includes acute coronary syndromes, history of Ml, stable or unstable angina,
coronary or other arterial revascularization, stroke, TIA, or peripheral arterial disease presumed to
be of atherosclerotic origin.
To learn more about cholesterol management, see the required MedU Cholesterol Guidelines
Modu Ie (http://www. med·u. orglcholesterol-guidelines).
Therapeutic lifestyle changes (TLC) should always be undertaken with or without concomitant
drug treatments. These lifestyle changes include a diet with saturated fat <7% of calories,
cholesterol intake <200 mg/day and increased soluble fiber intake. Exercise and weight control
are also a part of lifestyle change.
See the associated reference ranges in conventional and Sl units. {http://www.med7/14

u,org/virtua! patient cases/labreferences)

Metabolic Syndrome Criteria
The Metabolic Syndrome is a constellation of risk factors for cardiovascular disease that often
occur in the same individual. Together they increase the risk of cardiovascular disease for any
given LDL level. Metabolic syndrome has several definitions according to various subspecialty
groups; however, all definitions are more alike than they are different. The Adult Treatment Panel
Ill of the National Cholesterol Education Program defines the syndrome as three or more of the
following:
I

I

1

Lab Values:

Conventional:

Sl:

Abdominal
obesity

Waist circumference (men >1 02 em (40 in),
women >89 em (35 in)

TMglyceMdes > 150 mg/dL

1.70 mmoi/L

HDL
cholesterol

men < 40 mg/dL, women < 50 mg/dL

men <1 .04 mmoi/L, women
<1 .30 mmoi/L

Blood
pressure

> 130/85 mmHg

Fasting
glucose

> 110 mg/dL

>6,1 mmoi/L

Stress Testing Indications
When Is Stress Testing Indicated?
American College of Cardiology and American Heart Association table used to assess pre-test
probability of coronary artery disease, (http:Uwww,circ,ahajoumals,org/cgi/contenUfuii/96/1/345/T2)
For more information on exercise testing, link to the ACC/AHA Guidelines for Exercise Testing
{http://www, c irc, ahajou rnals ,org/cgi/contenUfull/96/1 1345)

,

A patient with a high pre-test probability should probably go straight to coronary angiogram,
because a negative stress test will not convince you the patient doesn't have a disease, A patient
with a low pre-test probability should not have a stress test, because it is unlikely to be positive.
Therefore, the best patient for a stress test is one with an intermediate pre-test probability.

Which Stress Test Should You Order?
Determining which stress test is the best is quite controversial at this time, Options include:
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• Treadmill Exercise Stress Testing without additional imaging: Since the patient can
exercise and the EKG is normal this is one option, however some have argued that women
have higher rates of false positives and often cannot exercise to the extent needed for a
diagnostic test.

• Exercise Stress Testing with nuclear or echocardiographic imaging: Imaging increases
the sensitivity and specificity of the test but increases cost too. Nuclear imaging utilizes
technetium 99m sestamibi or thallium-201. Echocardiography can be technically difficult in
the obese patient.

• Pharmacologic Stress with imaging: This is an alternative if the patient cannot exercise to
the degree needed to produce a diagnostic result. Options include dipyridamole or
adenosine with nuclear imaging or dobutamine with echocardiography.

Differential of Intermittent Exertional Chest Pain and Shortness of Breath
Most Likely I Most Important Diagnoses

Angina

GERD

• Some patients report pain from angina as 'burning,' although it is not the classic
descriptor.
• Since women often report atypical symptoms, angina is a reasonable
diagnostic consideration in a woman with atypical symptoms prompted by
exertion.
• In some patients shortness of breath is the only symptom of cardiac ischemia.
This is called an "anginal equivalent."

• Associated chest pain is often described as "burning"
• Not usually associated with exertion

Less Likely Diagnoses

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Aortic
dissection

Myocardial
infarction

• Usually occurs acutely and presents with sudden onset of crushing,
severe chest pain which radiates to the back.
• It is not episodic.

• Can cause chest pain and shortness of breath
• Acute presentation

I
Pulmonary
embolism

Hyperventilation

• Acute

• Usually occurs in younger patients
• Associated with symptoms of anxiety, fearfulness and tingling around
the mouth

Musculoskeletal
pain

• Unlikely without a history of injury or pain worse with position change

Pleurisy or
pneumothorax

• Cause unilateral pleuritic chest pain

I

Ventricular
tachycardia

• MAY present with chest pain, but more commonly the symptoms
are palpitations, lightheadedness and syncope.
• If VT is sustained, it may worsen to ventricular fibrillation --the most
common cause of sudden cardiac death.

Studies

Electrocardiogram
With an electrocardiogram, you can rule out an ST elevation Ml, look for evidence of prior
infarction (pathologic Q waves) and, occasionally, make other diagnoses such as pericarditis.
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Evaluation of Suspected Angina
In addition to an ECG, studies indicated include:

CBC

• anemia can contribute to ischemia by decreasing oxygen carrying capacity

Electrolytes

• can contribute to cardiac disease
• medications can alter electrolytes
BUN and Creatinine

• useful for screening for kidney disease as this can contribute to heart disease
• medications can adversely affect kidney function
Thyroid Stimulating Hormone

• screen for thyroid disease
• hyperthyroidism increases oxygen demand of the heart while hypothyroidism adversely
effects lipids
Fasting Lipid Panel

• to further characterize cardiac risk
ALT

• a baseline measurement of transaminase (ALT) levels should be performed before initiating
statin therapy

Imaging Workup for Suspected Angina
A chest x-ray will screen for some non-cardiac causes of chest pain and may suggest underlying
cardiac disease by demonstrating an enlarged cardiac silhouette.
A chest CT is not a first-line test in the workup of likely angina. If the history were more consistent
with acute-onset chest pain associated with SOB or ripping pain through to the back, a chest CT
would be an appropriate choice to evaluate for pulmonary embolism or aortic dissection.

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Management
Positive Stress Test Follow-up
Because the treadmill stress test is positive, the patient's chances of having true angina have
increased.
You could increase anti anginal medication and follow for symptom relief, or you could also order
cardiac catheterization with intervention to improve symptoms. The angiogram will allow the
cardiologist to directly visualize the coronary anatomy and potentially perform interventions on
stenotic segments.

Angina Treatment
• Beta blockers decrease myocardial oxygen consumption by slowing heart rate and
decreasing blood pressure, and thus reduce angina.
• Calcium channel blockers dilate coronary arteries and increase coronary blood flow while
also decreasing myocardial oxygen consumption.
• Nitrates dilate systemic and coronary arteries but are primarily venodilators. The antiischemic effect of nitrates is due to systemic venodilation that leads to reduced preload and a
decrease in myocardial oxygen demand.

Thrombus Prevention with Elective Percutaneous Intervention
One randomized trial has reported a possible benefit to treating patients with clopidogrel before
they undergo an elective intervention. However, a major risk of this is increased bleeding,
especially in patients who have no coronary artery disease or in those who require early coronary
artery bypass grafting.
Another option for thrombus prevention is a glycoprotein (GP) lib/lila inhibitor. These, too, may be
used with an elective percutaneous intervention. However, while these agents have been shown
to reduce mortality at 30 days, GPIIb/llla inhibitors do not reduce the incidence of angiographic
complications and may cause increased bleeding with the continued use of heparin post
procedure. (The ISAR-REACT trial showed that addition of a GP lib/lila agent did not provide
benefit to patients who received preprocedure clopidogrel.)

Secondary Prevention of Cardiovascular Disease
Among other beneficial effects.losjng wejght will decrease cardiac risk by decreasing abdominal
fat stores and improving hypertension control.
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Exercise and dietary modification will be important in losing the weight but will also have other
advantages. Exercise will increase HDL cholesterol and dietary modification can lower total
cholesterol. decrease LDL cholesterol and decrease triglycerides. Decreasing dietary sodium
content will improve blood pressure control as well. Referral to a nutrition expert may be helpful in
achieving the weight loss and dietary objectives.

Medication Side Effects
Lisinopril (ACE inhibitor)
Hydrochlorothiazide
Metoprolol XL (Beta blocker)
Clopidogrel
Aspirin
Atorvastati n

Hyperlink "L">Lisinopril (ACE inhibitor)"
cough, renal dysfunction, angioedema, hyperkalemia

Hyperlink "L">Hydrochlorothiazide"
dehydration, hyponatremia, hypokalemia, renal dysfunction, increases serum uric acid which may precipitate gouty
attack

Hyperlink "L">Metoprolol XL (Beta blocker)"
hypotension, bradycardia, heart block

Hyperlink "L">Ciopidogrel"
bleeding

Hyperlink "L">Aspirin"
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gastritis, peptic ulcer disease, bleeding {especially when used with clopidogrel)

Hyperlink "L">Atorvastatin"
rare cases of rhabdomyolysis with acute renal failure secondary to myoglobinuria; biochemical
abnormalities of liver function.

References
Goff DC Jr, Lloyd-Jones DM, Bennett G, Coady S, D'Agostino RB, Gibbons R, Greenland P,
Lackland DT, Levy D, O'Donnell CJ, Robinson J, Schwartz JS, Shero ST, Smith SC, Sorlie P,
Stone NJ, Wilson PWF. 2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk: A
Report of the American College of Cardiology/American Heart Association Task Force on Practice
Guidelines. Circulation. 2013 Nov 12.
Stone NJ, Robinson J, Lichtenstein AH, et al. 2013 ACC/AHA Guideline on the Treatment of Blood
Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults: A Report of the American
College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation
2013 Nov 12. [Epub ahead of print]

Hill J, Timmis A. Exercise Tolerance Testing. BMJ. 2002;324(7345):1084-1087.

Steinhubl SR, Berger PB, Mann Ill J, et al. Early and Sustained Dual Oral Anti platelet Therapy
Following Percutaneous Coronary Intervention: A Randomized Controlled Trial. JAMA.
2002;288(19) :2411-2420.
Kastrati A, Mehilli J, SchOhlen H, et al., for the lntracoronary Stenting and Antithrombotic RegimenRapid Early Action for Coronary Treatment (ISAR-REACT) Study Investigators. A Clinical Trial of
Abciximab in Elective Percutaneous Coronary Intervention after Pretreatment with Clopidogrel. N
Eng I J Med 2004; 350:232-238

Miller ER 3rd, Pastor-Barriuso R, Dalal D, et al. Meta-Analysis: High-Dosage Vitamin E
Supplementation May Increase All-Cause Mortality. Ann Intern Med. 2005;142(1):37-46.

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