Chest Pain

Moises Auron, MD FAAP Assistant Professor of Medicine CCLCM of CWRU August 28, 2009
Chest Pain l April 7, 2010 l 1

Objectives

‡ 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

Chest Pain l April 7, 2010 l 2

CASE # 1

‡ Emergency Room ‡ ‡ ‡ ‡
33 years old male ± stock broker Chest pain Shortness of breath Palpitations (³I feel I have a butterfly in my chest´)

Chest Pain l April 7, 2010 l 3

What information would you want to know?
± ± ± ± ±
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

Chest Pain l April 7, 2010 l 4

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

Chest Pain l April 7, 2010 l 5

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
Chest Pain l April 7, 2010 l 6

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

Chest Pain l April 7, 2010 l 7

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
Chest Pain l April 7, 2010 l 8

http://www.framinghamheartstudy.org/index.html
Chest Pain l April 7, 2010 l 9

Metabolic Syndrome (NCEP/ATP III)

Circulation. 2002;106:3143-3421.
Chest Pain l April 7, 2010 l 10

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
Chest Pain l April 7, 2010 l 11

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
Chest Pain l April 7, 2010 l 12

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

Chest Pain l April 7, 2010 l 13

Cardiac enzymes in Myocardial Infarction

Chest Pain l April 7, 2010 l 14

Cardiac microfibrillary thin filament

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

Chest Pain l April 7, 2010 l 15

Use of Troponin in Acute Chest Pain evaluation

Hamm CW. Circulation. 2000;102:118-122
Chest Pain l April 7, 2010 l 16

Troponin in Unstable Angina: Prognostic implications

Hamm CW. Circulation. 2000;102:118-122
Chest Pain l April 7, 2010 l 17

Troponin I in Acute Coronary Syndromes

N = 1404

N = 855

Antman EM, et al. NEJM. 1996;335:1342-9. Ohman EM, et al. NEJM. 1996;335:1333-41.
Chest Pain l April 7, 2010 l 18

Back to the Case - EKG

Chest Pain l April 7, 2010 l 19

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

Chest Pain l April 7, 2010 l 20

EKG Changes: Ischemia

BMJ. 2002;324(27): 1023-26
Chest Pain l April 7, 2010 l 21

EKG Changes: Lesion

BMJ. 2002;324(27): 1023-26
Chest Pain l April 7, 2010 l 22

Patophysiology of Acute Coronary Syndromes

Ischemic discomfort
ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction. Circulation. 2004;110;e82-e293. Chest Pain l April 7, 2010 l 23

Patophysiology of Acute Coronary Syndromes

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

Chest Pain l April 7, 2010 l 24

Chest Roentgenogram

Chest Pain l April 7, 2010 l 25

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
Chest Pain l April 7, 2010 l 26

CASE # 2

‡ Medical office ‡ 63 year old African-American male ‡ Poor follow-up with a physician ‡ Nausea without emesis for three hours ‡ Has ³heartburn´ unresolved with TUMS ‡ Had an episodes of diaphoresis and ³dizziness´ that
lasted 30 minutes, before coming to the office.

Chest Pain l April 7, 2010 l 27

What information would you want to know?
± 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 ± Severity of pain ± 5/10 ± 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.

Chest Pain l April 7, 2010 l 28

Differential diagnosis

‡ Acute myocardial infarction ‡ GERD ‡ Hiatal hernia ‡ Esophageal spasm

Chest Pain l April 7, 2010 l 29

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

Chest Pain l April 7, 2010 l 30

Family History

Age 49

65, pancreas CA

66, DM, CAD

HTN

60, HTN, DM

Chest Pain l April 7, 2010 l 31

What are the patient risk factors?

‡ Male > 55 years old ‡ ‡ ‡ ‡ ‡ ‡
Smoker Hyperlipidemia Hypertension Overweight Sedentarism Family history (Father passed < 55 y/o)

Chest Pain l April 7, 2010 l 32

Patient symptoms

‡ 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

Chest Pain l April 7, 2010 l 33

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

Chest Pain l April 7, 2010 l 34

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

Chest Pain l April 7, 2010 l 35

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?
Chest Pain l April 7, 2010 l 36

Case continuation«

Chest Pain l April 7, 2010 l 37

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.

Chest Pain l April 7, 2010 l 38

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.)
Chest Pain l April 7, 2010 l 39

Pfisterer M. Right ventricular involvement in myocardial infarction and cardiogenic shock. Lancet 2003; 362: 392 94.
Chest Pain l April 7, 2010 l 40

Where are you going to send the patient?

‡ Home? ‡ Emergency Room? ‡ How would you get him there?

Chest Pain l April 7, 2010 l 41

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

Chest Pain l April 7, 2010 l 42

What is in your differential?
± Panic attack ± Costochondritis ± Pneumothorax ± Pericarditis ± Pleuritis ± Pneumonia ± Pulmonary Embolism ± Angina

Chest Pain l April 7, 2010 l 43

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)
Chest Pain l April 7, 2010 l 44

What would you expect to find on exam?

‡ VS: HR 110, BP 110/70, BMI 25 ‡ General: Rapid speech, tearfulness, ³smoker¶s
fetor´

‡ Neck: no goiter ‡ Cor: Tachycardic, no gallop ‡ Chest: Bilateral expiratory wheezing and
decreased breath sounds

‡ Extremities: no swelling, no tremor, pulses 2+
Chest Pain l April 7, 2010 l 45

What tests (if any) would you do?
± Electrocardiogram ± Chest X-ray ± TSH ± CBC ± Fasting blood sugar ± Lipid panel ± Stress test

Chest Pain l April 7, 2010 l 46

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 Chest Pain l April 7, 2010 l 47

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

Chest Pain l April 7, 2010 l 48

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

Chest Pain l April 7, 2010 l 49

What information would you want to know?
± ± ± ± ±
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

± Severity of pain ± 9/10 ± How long since episodes first began? First time ± How long does the pain last each episode? ± continuous

Chest Pain l April 7, 2010 l 50

What is in your differential?
± Angina pectoris ± Pericarditis ± Aortic dissection ± GERD ± Esophageal spasm

Chest Pain l April 7, 2010 l 51

What other information would you want?

‡ Past medical history: none ‡ Social history:
± No drugs, no cigarettes, no EtOH

‡ Family history: early deaths

Chest Pain l April 7, 2010 l 52

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

Chest Pain l April 7, 2010 l 53

What tests, if any, would you do?
± Electrocardiogram ± Chest x-ray ± CT angiography ± Troponin, CPK ± Echocardiogram ± RPR ± Toxicology screen

Chest Pain l April 7, 2010 l 54

Chest Roentgenogram

Chest Pain l April 7, 2010 l 55

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

Chest Pain l April 7, 2010 l 56

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
Chest Pain l April 7, 2010 l 57

What is your diagnosis?

Tapson VF. Acute Pulmonary Embolism. NEJM. 2008;358:1037-52.
Chest Pain l April 7, 2010 l 58

Risk factors for venous thromboembolism

Tapson VF. Acute Pulmonary Embolism. NEJM. 2008;358:1037-52.
Chest Pain l April 7, 2010 l 59

Wells PS. Ann Intern Med. 2001; 135:98-107
Chest Pain l April 7, 2010 l 60

Would you order a D-dimer?

Tapson VF. Acute Pulmonary Embolism. NEJM. 2008;358:1037-52.
Chest Pain l April 7, 2010 l 61

Chest Roentgenogram

Chest Pain l April 7, 2010 l 62

What study would you order next?

Tapson VF. Acute Pulmonary Embolism. NEJM. 2008;358:1037-52.
Chest Pain l April 7, 2010 l 63

Chest CT scan

Tapson VF. Acute Pulmonary Embolism. NEJM. 2008;358:1037-52.
Chest Pain l April 7, 2010 l 64

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.

Chest Pain l April 7, 2010 l 65

What treatment does she needs?

‡ Oxygen ‡ ‡ ‡ ‡
IV fluids Monitor ± telemetry, BP, SpO2 Anticoagulation Thrombolysis (if hemodynamically stable)

Chest Pain l April 7, 2010 l 66

CASE #6

‡ 40 y/o Male ‡ Previously healthy ‡ Finished 2 weeks of oral levofloxacin for ³acute
sinusitis´

‡ Presents with chest pain ‡ Afebrile

Chest Pain l April 7, 2010 l 67

What information would you want to know?
± 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 ³gasp for air´ after deep inspiration,
cough with deep inspiration

± Where is the pain located? ± right side of the chest ± Severity of pain ± 7/10 ± How long since episodes first began? 3 days ± How long does the pain last each episode? ± intermittent

Chest Pain l April 7, 2010 l 68

What is your differential diagnosis

‡ Pneumonia ‡ ‡ ‡ ‡ ‡ ‡
Pleural Effusion Pleurisy Pneumothorax Pericarditis Atelectasis Pulmonary embolism

Chest Pain l April 7, 2010 l 69

What test do you want to order?

Chest Pain l April 7, 2010 l 70

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

Kass SM, et al. Pleurisy. Am Fam Physician. 2007;75:1357-64.
Chest Pain l April 7, 2010 l 71

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. Chest Pain l April 7, 2010 l 72

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%. 21 3 17%. 1%.

Incidence of fever (>38.0°C): 37 Incidence of fever (>38.5°C): 14

Engoren M. Chest 1995; 107:81-84
Chest Pain l April 7, 2010 l 73

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

Chest Pain l April 7, 2010 l 74

Sign up to vote on this title
UsefulNot useful

Master Your Semester with Scribd & The New York Times

Special offer for students: Only $4.99/month.

Master Your Semester with a Special Offer from Scribd & The New York Times

Cancel anytime.