Chest Pain

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Chest Pain

• James Nixon, MD
• Assistant Professor
• Internal Medicine and Pediatrics

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Case 1

• A 65 year old female comes to the emergency room
  after awakening at 700 AM with Chest pain and
  SOB. Her husband is concerned that she might be
  having a heart attack.

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What would be the differential for her chest
pain?
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Chest Pain

• Stable angina pectoris
• 11 percent of chest pain episodes
• Unstable angina or myocardial infarction
• 1.5 percent of chest pain episodes

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What are risk factors you would ask about for
cardiac etiologies for chest pain?

• Smoking
• Family history
• Hyperlipidemia
• Left ventricular hypertrophy
• Hypertension
• Cocaine
• Age
• Past History

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What characteristics of the chest pain might make
you more concerned for cardiac chest pain?

• Location
• Associated Symptoms
• Quality
• Chronology
• Onset

• Duration
• Intensity
• Exacerbating
• Relieving
• Situation

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Any exam findings that might help distinguish
cardiac from non cardiac chest pain?

• General Appearance
• may suggest seriousness of symptoms.
• Vital signs
• marked difference in blood pressure between arms
  suggests aortic dissection
• Palpate the chest wall
• Hyperesthesia may be due to herpes zoster

• Complete cardiac examination
• pericardial rub
• signs of acute AI or AS
• Ischemia may result in MI murmur, S4 or S3
• Determine if breath sounds are symmetric and if
  wheezes, crackles or evidence of consolidation

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Any tests that might help that you can do in the
ER?

• EKG
• ST elevation of gt 1mm or new Q in 2 leads
• Sens 45
• Above ST depression or T-wave inversion
• Sens 79
• False positive rate 17

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Any tests that might help that you can do in the
ER?

• Troponin, CK, myoglobin
• CK-MB 88-90 sensitive at 4-6 hours
• CK-MB 95-100 sensitive 8-12 hours after CP onset
• 2-3 of skeletal muscle is MB fraction
• one study of 710 patients, an increase in CK-MB
  by gt or 1.6 ng/mL at two hours compared to
  baseline for acute infarction
• Sensitivity - 94
• Specificity - 92
• Positive predictive value - 79
• negative predictive value - 98

Fesmire FM Percy RF Bardoner JB Wharton DR
Calhoun FB. Serial creatinine kinase (CK) MB
testing during the emergency department
evaluation of chest pain utility of a 2-hour
delta CK-MB of 1.6ng/ml. Am Heart J 1998
Aug136(2)237-44
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Any tests that might help that you can do in the
ER?

• Chest X-Ray

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Labs

• CK-MB 15.1
• Troponin T 27

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Case 2

• A 57 year old male comes to Clinic complaining
  of substernal chest pain that comes on with
  exertion and goes away with rest.

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What is his pre-test probability for having
coronary artery disease?
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What tests could help determine if this man truly
does have coronary artery disease causing his
symptoms?
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Exercise Stress Test
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Likelihood Ratio Nomogram EST LR 11 LR- 0.23
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Likelihood Ratio Nomogram Exercise Echo LR
7.4 LR- 0.21
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Case 3

• A 57 year old male comes in to the ER with sudden
  onset of tearing chest pain that radiates to
  his back.
• What is your differential?
• What exam findings might you look for?
• What tests could you do and why?
• What are the treatments for the most likely
  diagnoses?

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What is your differential?
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What exam findings might you look for?

• Acute MI
• Hypotension in one extremity
• Aortic murmur
• Neurologic deficits, including paraplegia,
  stroke, or decreased consciousness
• Syncope, tamponade, and sudden death due to
  rupture of the aorta into the pericardial space
• Shock, hemothorax, and exsanguination
• Acute lower extremity ischemia

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• 60 to 80 year-old men with a long history of
  systemic hypertension
• Disorders of collagen (Marfan's syndrome,
  Ehlers-Danlos syndrome,syphilis)
• Bicuspid aortic valve
• Aortic coarctation
• Trauma

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• 96 percent of acute aortic dissections can
  be identified based upon some combination of the
  following three clinical features
• Immediate onset of aortic pain with a tearing
  and/or ripping character
• Mediastinal and/or aortic widening on chest
  radiograph
• Variation in pulse and/or blood pressure between
  the right and left arm

Von kodolitsch Y, Schwartz AG, Nienaber CA.
Clinical prediction of acute aortic dissection.
Archives of Internal Medicine 20001602977.
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What tests could you do and why?

• CXR-sensitivity 63
• CT sensitivity 94, specificity 87
• TEE
• MRI sensitivity 98, specificity 85
• Aortogram sensitivity 88, specificity 94

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What are the treatments for the most likely
diagnoses?
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Case 4

• A 72 year old obese diabetic male complains of
  2-3 month history of progressive fatigue and more
  trouble with his breathing when he is doing
  housecleaning. He also is concerned because for
  the past two weeks he is waking up short of
  breath in the middle of the night.
• What is your prioritized differential?
• (What is most likely and what would concern you
  the most?)
• What questions would help you refine your
  differential?
• What would you look for on physical exam?
• What test would you do to help refine your
  diagnosis?

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What is your prioritized differential? (What is
most likely and what would concern you the most?)
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What questions would help you refine your
differential?
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What would you look for on physical exam?

• S3
• Murmur
• Elevated JVP
• Tachycardia
• Diaphoresis
• Vasoconstriction

• Crackles
• Edema
• Hepatomegaly
• Heave
• Lateral displacement apical impulse

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What test would you do to help refine your
diagnosis?

• CXR
• EKG
• Echocardiogram

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Case 5

• A 65 year old male with known coronary artery
  disease and long history of stable angina
  pectoris after walking 2 blocks presents
  complaining of chest pain occurring with simply
  walking across the room.
• Does he still have stable angina pectoris?
• What are potential causes for his worsening chest
  pain?
• What would you do now?

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