Chest Pain

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Chest Pain
LSU Medical Student Clerkship, New Orleans, LA
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• Goals
• Review the pathophysiology, diagnosis and
  treatment of life threatening causes of chest
  pain.

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• Epidemiology
• 5 of all ED visits
• Approximately 5 million visits per year

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• Visceral Pain
• Visceral fibers enter the spinal cord at several
  levels leading to poorly localized, poorly
  characterized pain. (discomfort, heaviness, dull,
  aching)
• Heart, blood vessels, esophagus and visceral
  pleura are innervated by visceral fibers
• Because of dorsal fibers can overlap three levels
  above or below, disease of thoracic origin can
  produce pain anywhere from the jaw to the
  epigastrum

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• Parietal Pain
• Parietal pain, in contrast to visceral pain, is
  described as sharp and can be localized to the
  dermatome superficial to the site of the painful
  stimulus.
• The dermis and parietal pleura are innervated by
  parietal fibers.

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• Initial Approach
• ABCs first, always (look for conditions
  requiring immediate intervention)
• Aspirin for potential ACS
• EKG
• Cardiac and vital sign monitoring
• Because of the wide differential, HP will guide
  the diagnostic workup

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• History
• O- onset
• P-provocation /palliation
• Q- quality/quantity
• R- region/radiation
• S- severity/scale
• T- timing/time of onset

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• Physical Exam
• General Appearance and Vitals (sick vs not sick)
• Chest exam-Inspection (scars, heaves, tachypnea,
  work of breathing)-Auscultation (murmurs, rubs,
  gallops, breath sounds)-Percussion
  (dullness)-Palpation (tenderness, PMI)

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Differential Diagnoses
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• Life Threatening Causes of Chest Pain
• Acute Coronary Syndromes
• Pulmonary Embolus
• Tension Pneumothorax
• Aortic Dissection
• Esophageal Rupture
• Pericarditis with Tamponade

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• Acute Coronary Syndromes - Epidemiology
• In a typical ED population of adults over the age
  of 30 presenting with visceral-type chest pain,
  about 15 percent will have AMI and 25 to 30
  percent will have UA

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• Acute Coronary Syndromes - History
• Typical Chest Pain Story (Pressure-like,
  squeezing, crushing pain, worse with exertion,
  SOB, diaphoresis, radiates to arm or jaw) The
  majority of patients with ACS DO NOT present with
  these symptoms!
• Cardiac Risk Factors (Age, DM, HTN, FH, smoking,
  hypercholesterolemia, cocaine abuse)

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• Acute Coronary Syndromes EKG Findings
• STEMI - ST segment elevation (gt1 mm) in
  contiguous leads new LBBB
• T wave inversion or ST segment depression in
  contiguous leads suggests subendocardial ischemia
• 5 of patients with AMI have completely normal
  EKGs

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Acute Coronary Syndromes Cardiac Markers
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• Acute Coronary Syndromes Cardiac Markers

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• Acute Coronary Syndromes - Treatment
• Aspirin
• Nitroglycerin
• Oxygen
• Beta-Blockers
• Anticoagulation
• Anti-Platelet Agents
• Thrombolysis
• Percutaneous Coronary Interventions (PCI)

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• Acute Coronary Syndromes - Treatment
• STEMI (ASA, B-blocker, NTG, anti-platelet,
  anticoagulation, thrombolysis, PCI)
• NSTEMI (ASA, B-blocker, NTG, anti-platelet,
  anticoagulation, PCI)
• Unstable Angina (ASA, B-blocker, NTG,
  anticoagulation, risk stratification)

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• Acute Coronary Syndromes - Disposition
• Mortality is twice as high for missed MI
• Missed MI is the most successfully litigated
  claim against EP's. EPs miss 3-5 OF AMI, this
  accounts for 25 of malpractice costs against EPs

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• Acute Coronary Syndromes - Disposition
• A single set of cardiac enzymes is rarely of use
• Risk Stratification goal is to predict the
  likelihood of an adverse cardiovascular event
• Combination of HP, EKG, Biomarkers
• No single globally accepted algorithm
• Mathematical models such as TIMI, GRACE, and
  PURSUIT can be helpful but are no substitute for
  clinical judgment

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• Pulmonary Embolism - Pathophysiology
• Thrombosis of a pulmonary artery
• gt90 arise from DVT
• Clot from a DVT travels through the venous system
  and lodges in the pulmonary vasculature creating
  a ventilation/perfusion mismatch

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• Pulmonary Embolism History
• Dyspnea is the most common symptom, present in
  90 of patients diagnosed with PE
• Sharp pleuritic chest pain, syncope,
• Prolonged immobilization, neoplasm, known
  hypercoagulable disorder

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• Pulmonary Embolism Physical Exam
• Tachycardia, tachypnea, diaphoresis, hypotension,
  hypoxia, low grade fever, anxiety, cardiovascular
  collapse, right ventricular heave

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• Pulmonary Embolism Diagnostic Testing
• Sinus Tachycardia is the most frequent EKG
  finding
• Classic S1,Q3,T3 finding is seen in less than 20
• ABG plays no role in ruling out PE
• D-Dimer in a low risk patient can be used to rule
  out PE

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• Pulmonary Embolism Wells Criteria
• Clinical Signs and Symptoms of DVT? Yes 3
• PE is 1 Diagnosis, or Equally Likely? Yes 3
• Heart Rate gt 100? Yes 1.5
• Immobilization at least 3 days, or Surgery in the
  Previous 4 weeks? Yes 1.5
• Previous, objectively diagnosed PE or
  DVT? Yes 1.5
• Hemoptysis? Yes 1
• Malignancy w/ Treatment within 6 mo, or
  palliative? Yes 1
• lt2 Low risk, 2.5-6 moderate risk, gt6 high
  risk

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• Pulmonary Embolism Diagnostic Imaging Algorithm

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• Pulmonary Embolism Treatment/Disposition
• Unfractionated heparin vs low molecular weight
  heparin (some studies suggest superiority of
  LMWH)
• Thrombolysis (for cardiovascular collapse)
• Floor vs ICU

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• Aortic Dissection - Pathophysiology
• Intimal tear of the aorta leads to dissection of
  the layers of the aorta creating a false lumen

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• Aortic Dissection - Diagnosis
• Tearing chest pain radiating to the back
• Risk Factors HTN, connective tissue disease
• Exam HTN, pulse differentials, neuro deficits
• Radiology Wide mediastinum on CXR, CT angio
  chest, echo

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• Aortic Dissection - Classification
• De Bakey system Type I dissection involves both
  the ascending and descending thoracic aorta. Type
  II dissection is confined to the ascending aorta.
  Type III dissection is confined to the descending
  aorta.
• The 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 B.

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• Aortic Dissection - Treatment
• Patients with uncomplicated aortic dissections
  confined to the descending thoracic aorta (Daily
  type B or De Bakey type III) are best treated
  with medical therapy.
• Medical Therapy Goal to decrease the blood
  pressure and the velocity of left ventricular
  contraction, both of which will decrease aortic
  shear stress and minimize the tendency to further
  dissection.
• Acute ascending aortic dissections (Daily type A
  or De Bakey type I or type II) should be treated
  surgically whenever possible since these patients
  are a high risk for a life-threatening
  complication such as aortic regurgitation,
  cardiac tamponade, or myocardial infarction.

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• Tension Pneumothorax - Pathophysiology
• Collection of air in the pleural space causes
  collapse of the ipsilateral lung and then
  cardiovascular collapse as intrathoracic
  pressures increase.

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• Tension Pneumothorax - Diagnosis
•  Risk factors COPD connective tissue disease,
  trauma, recent instrumentation, positive pressure
  ventilation
• Absent breath sounds unilaterally, hypotension,
  distended neck veins, tracheal deviation

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• Tension Pneumothorax - Treatment
• Needle decompression
• Tube thoracostomy

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• Esophageal Rupture - Pathophysiology
• Tear in the esophagus leads to leaking of
  gastrointestinal contents into the mediastinum
• Inflammation followed by infection cause rapid
  deterioration, sepsis and death

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• Esophageal Rupture - Diagnosis
• Rare but devastating
• Risk Factors Iatrogenic, heavy retching, trauma,
  foreign bodies, toxic ingestion
• Radiology Mediastinal air on plain films or CT
  scan

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• Esophageal Rupture - Treatment
• Antibiotics
• Supportive Care
• Small tears with minimal extraesophageal
  involvement can be managed conservatively
• Surgical consult for all regardless of size

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• Take Home Points
• ABCs first
• History is key
• Have a low threshold for missed MI