Chest Pain

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Chest Pain

• William Beaumont Hospital
• Department of Emergency Medicine
• Shanna Jones, MD

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The Things That Kill

• Acute MI
• Pulmonary Embolus (PE)
• Pneumothorax (PTX)
• Aortic Dissection
• Esophageal Rupture (Boerhaaves)

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Lets dive right in
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Chest Pain What is it?

• 65 y/o male complains of substernal chest
  pressure and tightening that radiates to his left
  arm, shortness of breath, diaphoresis, and nausea
  that started while working in the yard.
• PMHx HTN, high cholesterol
• Soc tobacco
• FHx father died at 62 of MI

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Chest Pain What is it?

• 86 y/o female presents with generalized weakness,
  mental status changes, vomiting, epigastric pain,
  and syncope after her last episode of vomiting.
• There is no other history as the NH did not feel
  it was necessary to send her records.

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Chest Pain What is it?

• 36 y/o obese, diabetic male presents with
  weakness, fatigue. shortness of breath whenever
  he gets off the couch, and just not feeling
  right, doc.
• PMHx diabetes since his teens, HTN, high
  cholesterol
• FHx Mom HTN Dad had a bad heart

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Acute Coronary Syndrome (ACS)

• Includes USA, NSTEMI, STEMI
• Leading cause of death among adults in the US
  (about 1 million, 2006)
• 6 million people present to the ER per year with
  chest pain
• 2 million of these receive the diagnosis of ACS
• Cost of doing business 100-120 billion

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Risk Factors for CAD Typical

• Male
• Older Age
• Tobacco
• HTN
• DM
• High Cholesterol
• FHx
• Cocaine
• Artificial/early menopause

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Risk Factors for CAD Atypical

• DM
• Elderly
• Female
• Nonwhite
• Dementia
• No history of MI
• No history of high cholesterol
• CHF
• CVA

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Unstable Angina (USA) Defined

• New onset angina occurring with minimal exertion
  or at rest, worsening of previous angina,
  increased frequency or duration of attack, and
  resistance to previous treatment
• ECG normal/unchanged, nonspecific ST segment
  changes, or T wave inversions

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Acute Myocardial Infarction (AMI)Definition

• Rise and fall of cardiac biomarkers with the
  following
• Ischemic symptoms (critical vessel stenosis with
  increased myocardial work load or plaque rupture)
• Development of Q waves on ECG
• ST segment elevation or depression (STEMI
  NSTEMI)
• Coronary artery intervention (lytics or cath lab)

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NSTEMI Definition

• Positive cardiac enzymes in the appropriate
  clinical scenario without ST elevation on the ECG
• ECG normal, T wave inversions, ST segment
  depressions

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ECG Findings of ACS

• Hyperacute T waves
• ST segment elevation of 1 mm
• ST segment depression NSTEMI vs reciprocal
  changes
• T wave inversions initial presentation or
  evolving infarct
• Q waves may emerge in the initial hour, but
  usually develop at 8-12 hours
• Normal ECG

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Injury Patterns on the ECG

• Anterior wall MI ST segment elevation V1-V4
• Vessel LAD

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Injury Patterns on the ECG
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Injury Patterns on the ECG

• Lateral Wall MI I, aVL, V5, V6
• Vessel variable perfusion of LAD, RCA, LCx

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Injury Patterns on the ECG

• Anterolateral with reciprocal changes
• Vessels LAD and 1st diagonal branch

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Injury Patterns on the ECG

• Inferior wall MI II, III, aVF
• Vessel 90 RCA, 10 LCx

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Injury Patterns on the ECG

• Posterior Wall MI V1-V3 depression, tall upright
  T, tall wide R wave, R/S ratio greater than 1
• Vessel RCA, PDA, LCx

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Injury Patterns on the ECG

• Inferior Wall MI with Posterior Wall MI V1-V3
  depression, tall upright T, tall wide R wave, R/S
  ratio greater than 1
• Vessel RCA, PDA, LCx

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Moving on

• What do you want to order in addition to an ECG
  for a patient presenting with chest pain,
  suspected ACS?

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Initial Evaluation

• IV, O2, monitor
• Focused HP
• CBC
• Chem 7
• CK-MB, troponin, myoglobin
• CXR
• PT/PTT
• Possible D-dimer
• ? Repeat ECG

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Treatment in the ED STEMI

• Activate the acute MI page and cath lab
• ASA 325mg PO proven to save lives
• NTG SL and gtt reduces preloadgtafterload,
  dilates coronary arteries
• Heparin 60 U/kg bolus then 16 U/kg/hour
• ? Beta Blocker

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Treatment in the ED STEMI

• Morphine for persistent pain or anxiety to
  reduce O2 need, weak sympathetic blocker, preload
  reducer through venous dilation
• Glycoprotein IIb/IIIA inhibitors started in the
  EC or cath lab for those patients undergoing
  mechanical coronary intervention
• Plavix in consultation with the cardiologist as
  it prohibits CABG for 5 days

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Treatment in the ED STEMIReperfusion Therapy

• PCI 90 minute rule
• Most people are eligible
• Decreased risk of bleeding and stroke
• Higher initial reperfusion rates
• Defines coronary vasculature and allows for
  treatment vs. surgical referral
• t-PA when PCI cannot be achieved in 90 minutes
  or is not available
• 0-12 hours after symptom onset

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NTG When to think twice?
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NTG Be cautious

• Bradycardia
• Hypotension
• Inferior or posterior wall MI with RV INFARCT
• Decreased preload will cause sudden hypotension
  and increase infarct size
• These patients need fluids to increase preload
  and help fill the malfunctioning/weakened
  ventricle

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Treatment in the ED USA/NSTEMI

• Basically the same, but without the cath lab or
  fibrinolytics
• IV, O2, monitor
• ASA, heparin, NTG, ? beta blocker, morphine
• Plavix and GIIb/IIIa inhibitors potentially after
  discussion with cardiology
• Admit to a monitored unit

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Chest Pain low risk, but risky enough

• Patients who are low risk with risk factors
  (silly isnt it?), chest pain free, and have a
  normal ECG and enzymes
• Observation unit for serial cardiac enzymes and
  ECG
• Stress test vs. CTA
• Cardiology consult variable

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Chest Pain What is it?

• 38 y/o female presents with sudden onset of chest
  pain and shortness of breath after retrieving her
  bags at the baggage claim from a flight home from
  Hawaii. She states that it is worse when she
  takes a deep breath. She also complains of this
  aching pain in her right leg when walking.

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Chest Pain What is it?

• 80 y/o bedridden patient sent from the NH with
  mental status changes and hemoptysis. She is
  pleasant during the conversation, but has no idea
  why she is here. She is actively coughing and
  appears to have increased work of breathing.
• PMHx positive for almost everything (she is 80)
• Vitals HR 110, BP 90/60, RR 28, sPO2 88 RA
• Lungs bibasilar rales with right mid lung
  rhonchi

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Pulmonary Embolism 2006 Stats

• Approximately 1 in every 500-1000 EC patients has
  a PE
• EM MDs correctly diagnose about 50
• 10 of EC patients with PE die within 30 days
  even when PE is promptly diagnosed and treated

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PE Risk Factors

• Carcinoma
• Immobility
• Trauma or surgery in the last 4 weeks
• Smoking
• Estrogen/OCP
• Pregnancy/PP
• Thrombophilia
• Connective Tissue Dz
• Prior PE or DVT

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PE Signs and Symptoms

• Chest Pain
• Dyspnea
• Hemoptysis
• Splinting
• Syncope
• HR gt 100
• Pulse ox lt 95
• Unilateral arm or leg swelling

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PE Diagnosis

• Basic Labs CBC and Chem 7
• ? Labs CK-MB, troponin, PT/PTT
• D-dimer low risk patients only with low pretest
  probability
• CXR
• Exclude other diagnosis CHF, PNA, PTX
• Unilateral basilar atelectasis increases the
  probability of PE
• Hamptoms hump wedge shaped infarction
• Westermarks sign unilateral lung oligemia

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PE Hamptons Hump
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PE Westermarks Sign
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PE Diagnosis

• ECG
• Again to exclude other diagnosis
• Most common finding is sinus tachycardia
• T wave inversions V1-V4
• McGinn-White Pattern S1Q3T3
• New incomplete or complete RBBB
• Chest CT moderate to high risk patients or
  pre-test probability, positive D-dimer

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PE ECG
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PE ECG
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PE Treatment

• Heparin unfractionated 80 U/kg bolus then 18
  U/kg/hr
• LMWH 1 mg/kg SQ q12 hours
• Coumadin usually started on the floor

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PE Treatment

• IVC filter for pts who failed anticoagulation
  or have contraindications
• Thrombolytics consider in high risk pts such as
  systolic hypotension, persistent hypoxemia,
  elevated troponin or BNP (early shock or shock)
• Surgery large clot burden, refractory
  hypotension, floating emboli in the R heart

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Chest Pain What is it?

• 18 y/o tall, thin healthy male c/o sudden onset L
  sided CP with shortness of breath. The pain
  started while he was inhaling on a marijuana
  cigarette. It hurts more to breathe.
• Vitals HR 110, RR 28, BP 110/70, sPO2 96

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Chest Pain What is it?

• 60 y/o male with a history of severe COPD c/o
  increasing shortness of today that is not
  relieved with his home inhalers.
• Vitals HR 110, RR 28, BP 110/70, sPO2 90
• Heart distant, tachycardic and regular
• Lungs diffuse wheezing, decreased breath sounds
  on the right

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Pneumothorax

• Primary Spontaneous occurs in people without
  clinically apparent lung disease
• More common in men
• Associated factors tall, smoking, changes in
  ambient atmospheric pressure, genetics, MVP,
  Marfans syndrome
• Disruption of the alveolar-pleural barrier is
  thought to occur when a bleb or bulla ruptures
  into the pleural space

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Pneumothorax

• Secondary Spontaneous occur with known
  underlying pulmonary disease
• More common in men
• Associated with any underlying pulmonary disease
  including infection, ILD, neoplasms, COPD,
  asthma, etc
• Weakening of the alveolar-pleural barrier occurs
  secondary to the underlying lung disease either
  from inflammation or development of bullae

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Pneumothorax

• Iatrogenic
• Complication of intubation or aggressive BVM,
  central line placement, or any endoscopic
  procedure involving the trachea or esophagus
• Consider in any stable patient with acute
  deterioration, hypoxia, or increased difficulty
  with ventilation

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Tension Pneumothorax

• Positive intrapleural pressure causes compression
  of the mediastinum and the contralateral lung
• Pressure exceeding 15 to 20 mm Hg impairs venous
  return to the heart
• Leads to cardiovascular collapse if not treated
  immediately ? this is a clinical diagnosis not a
  radiographic one!

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Pneumothorax Symptoms

• Ipsilateral sharp CP
• Dyspnea
• Pleuritic pain
• Cough

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Pneumothorax Signs

• Sinus tachycardia
• Hyperresonance
• Decreased breath sounds
• Unilateral enlargement of the hemithorax
• Splinting
• Hypoxia

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Pneumothorax Diagnosis

• Clinically for tension PTX
• CXR
• Radiolucent band devoid of lung markings
• Inspiratory/expiratory views
• Lateral decubitus views in sick patients
• Supine CXR may have deep sulcus sign
• Thoracic ultrasound
• Chest CT

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Pneumothorax - Tension
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Pneumothorax Deep Sulcus Sign
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Pneumothorax Management

• Tension needle decompression
• Tube thoracostomy ? 20-28 F for air, 32F at least
  if fluid is present
• Observation for PTX lt 20 collapse
• Reabsorption Rate
• 1-2 per day
• 4-8 if on 100 NRB

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Chest Pain What is it?

• 60 y/o male complains of sudden onset tearing
  chest pain that went up into his jaw, through to
  his back, and then down into his abdomen. He
  also vomited once, is diaphoretic, and appears
  very anxious.
• Vitals BP 190/120, HR 110, RR 22, sPO2 95

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Aortic Dissection

• Occurs more often in men older than 40
• HTN is the most common risk factor
• Associated with cardiac surgery, bicuspid aortic
  valve, stimulant use, and trauma
• Agelt40, associated with congenital heart disease,
  Marfan, Ehlers-Danlos, and giant cell arteritis
• 44 of pts with Marfans will develop an aortic
  dissection

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Aortic Dissection

• Type A 62
• Involve the ascending aorta ? more lethal
• Type B 38
• Do not involve the ascending aorta
• Pt more likely to be older, smoke, have chronic
  lung disease, HTN, or atherosclerosis

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Aortic Dissection - Diagnosis

• Labs CBC, chem7, PT/PTT, type cross, CK-MB,
  troponin
• ECG exclude other dx, 15 may have ischemic
  changes ? 3 dissect back and most commonly
  involve the RCA, may have LVH or nonspecific ST
  or T wave changes
• CXR abnormal in 80 but nonspecific findings

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Aortic Dissection - Diagnosis

• CT scan test of choice
• TEE limited by availability and operator
• Aortography no longer the test of choice
• MRI excellent test but limited by availability
  and instability of the patient

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Aortic Dissection - Management

• Opioids decrease pain and sympathetic tone
• Beta blockers esmolol and labetalol
• Decrease BP and HR to decrease shearing forces
• Should be started first unless the pt is
  bradycardic
• Nipride vasodilator, used in conjunction with a
  beta blocker to maintain SBP 100-120

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Aortic Dissection - Management

• Hypotensive pts measure BP in all 4 extremities
  to make sure it is real, IVF, blood, immediately
  to OR
• Type A ? OR (27 mortality if treated surgically
  vs. 56 if treated medically)
• Type B uncomplicated 10 mortality when treated
  medically (32 mortality if complicated)

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Chest Pain What is it?

• 22 y/o healthy male complains of chest and back
  pain after forcing himself to vomit. He states
  he had food stuck in his chest while eating at
  Mongolian BBQ and then forced himself to vomit
  for relief. He now says that his voice is
  hoarse, it hurts to breathe deep, and he is still
  very nauseated. He tried to drink some water,
  but this only intensified the pain.
• Vitals HR 120 BP, 130/90, RR 25, sPO2 97

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Esophageal Rupture Boerhaaves

• 15 are spontaneous with the remainder being
  iatrogenic from endoscopy, NGT, ETT, combitube,
  foreign body
• 90 of spontaneous ruptures occur in the distal
  esophagus
• DX CXR, gastrograffin swallow, CT
• Management
• IV antibiotics
• NPO and likely NGT
• Surgery consult

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Chest Pain What is it?

• 26 y/o male c/o retrosternal, sharp CP,
  difficulty breathing, pain when breathing deeply,
  and worsening dyspnea tonight when he laid down
  to sleep. He states that for the last week he
  has had URI symptoms and low grade fever, but now
  feels that it has moved into his chest with the
  increasing pain and difficulty breathing.
• Vitals HR 110, BP 110/80, RR 24, sPO2 98
• Heart Tachycardic and regular, () pericardial
  rub
• Lungs CTA
• Bedside TTE is negative for effusion

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Pericarditis
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Pericarditis

• Causes infectious, injury/trauma, metabolic,
  systemic (RA), carcinoma, or aortic dissection
• DX clinical suspicion, ECG, echo
• Echo pericardial effusion and tamponade are
  worrisome complications ? pts should be put in
  obs or hospitalized
• Treatment NSAIDS, steroids for pts who cannot
  tolerate NSAIDS

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THE END!