approach to chest pain

Approach to Chest PainIntern Bootcamp, 2014Nathan Stehouwer, MDPGY-4, Internal Medicine & Pediatrics

Differential

Pearl: ALWAYS have the patient point to the pain!

Typical vs. Atypical Chest Pain

Typical

Characterized as discomfort/pressure rather than pain

Time duration >2 mins Provoked by activity/exercise Radiation (i.e. arms, jaw) Does not change with

respiration/position Associated with

diaphoresis/nausea Relieved by rest/nitroglycerin

Atypical

Pain that can be localized with one finger

Constant pain lasting for days

Fleeting pains lasting for a few seconds

Pain reproduced by movement/palpation

Typical vs. Atypical Chest Pain

UpToDate 2012

Typical vs. Atypical Chest Pain

Cayley 2005

Case 1

You are the orphan intern on Wearn team at 6PM. You are called by the nurse because Ms. Z has developed chest pain. Ms. Z is a 62 yo F with PMHx of CAD s/p remote PCI to the LAD, COPD and right THA 3 weeks ago who was admitted for a COPD exacerbation.

What would you do next?

Evaluation of Chest Pain

Case 1: Ask nurse for most current set of vital signs Ask nurse to get an EKG Obtain the admission EKG from the paper chart Go see the patient!

Evaluation of Chest Pain

Once at bedside, determine if patient is stable or unstable

Perform focused history and physical exam Read and interpret the EKG. Compare EKG to old

EKG if available If patient looks unstable or has concerning EKG

findings, call your senior resident for help Write a clinical event note!

Evaluation of Chest Pain

focused physical exam for chest pain Vital Signs: tachycardia, hypertension/hypotension or hypoxia General: Sick appearing, actively having chest pain HEENT: JVD, carotid bruits Chest: Rales, wheezes or decreased breath sounds CVS: New murmurs, reproducible chest pain, s3 gallop Abd: Abdominal tenderness, pulsatile mass Ext: Edema, peripheral pulses Skin: Rash on chest wall

Case 1

You go see the patient. She had been feeling better after getting duonebs, but suddenly developed chest pain that is L-sided, 8/10 and worse with breathing. This pain is not like her prior MI.

Vital signs: Afebrile, HR 120, BP 110/70, RR 28, O2 sat 89% on 2L (was 95% on RA this morning)

Physical exam Gen – in distress, using accessory muscles of respiration Lungs – CTAB, no rales/wheezes Heart – tachycardic, nl s1, loud s2, no mumurs Abd – soft, NT/ND, active BS Ext – b/l LEs warm and well perfused

Labs: CBC wnl, RFP wnl, BNP = 520, D-dimer = positive, Troponin = 0.12

Case 1

Case 1

Differential

Modified Wells Criteria

Clinical symptoms of DVT (3 points) Other diagnoses less likely than PE (1 point) Heart Rate >100 (1.5 points) Immobilization >/= 3 days or surgery within 4 weeks (1.5 points) Previous DVT/PE (1.5 points) Hemoptysis (1 point) Malignancy (1 point)

Interpretation: >6: high 2-6: moderate <2: low

Next moves DDIMER: 95% sensitive, VERY nonspecific ABG – Elevated A-a gradient fairly sensitive, highly

nonspecific EKG – most commonly nonspecific changes (ST/T wave

changes, etc) V/Q scan – helpful in patients with HIGH or LOW pretest

probabilities in whom a CTPE cannot be obtained (eg CKD) LE Ultrasound: not sensitive CTPE

Sensitivity 83% Specificity 96% Moderate - high clinical probability and positive CTPE: 92-96%

chance of PE

Pearl

A CT angiogram (important for evaluating for Pulmonary Embolism or Aortic Dissection) requires EITHER:

1) At least a 20G peripheral IV

OR

2) A Power injectable central line

Case 1

Diagnostic approach is simple if you suspect PE…

Probability low: obtain D-DIMER If positive: obtain CTPE If negative: PE excluded

Probability moderate or high: obtain CTPE If positive: treat If negative: PE excluded

Acute Pulmonary Embolism

Stabliize patient oxygen Fluids if hypotensive!

Anticoagulants Preferred: LMWH or Fondaparinux

Enoxaparin 1.5mg/kg daily or 1mg/kg BID Fondaparinux subcutaneous once daily (weight based)

Alternative: UFH (IV or SC) – select high intensity protocol Hemodynamically unstable patients High risk of bleeding (reversible) GFR < 30

Can initiate warfarin on same day IVC filter an alternative in patients with mod-high bleeding

risk

Management

Search “heparin infusion orders”

Pearl: If you have a moderate or high suspicion of PE, you can start anticoagulation while awaiting full diagnostic workup

PE with hypotension

Thrombolysis Administer over short infusion time

Catheter based thrombectomy For failure of thrombolysis or likelihood of shock/death before

thrombolysis can take effect (hours)

Surgical thrombectomy Failure of above therapies

Case 2

You are the long call intern on Hellerstein and get a call to 67121 at 6:58PM. You have a new patient in the ER, being admitted for ACS rule out.

What’s your next move?

Evaluation of Chest Pain

Get report from ED physician about the patient Ask ED physician about patient’s initial presentation Ask for most recent set of vital signs Ask about EKG and CXR results Ask what meds have been started in ER and how

patient responded

Evaluation of Chest Pain

Go to UH Portal and print out an old EKG for comparison

Review prior discharge summaries

Quickly review prior cardiac work up –echo, stress tests and cath reports

Go see the patient!

Case 2

Mr. M is a 67 yo man with PMHx of HTN, DLD, DMT2 and CAD s/p PCI in 2007. He presents with new onset chest pain x 2 hours that is retrosternal, 7/10, associated with nausea and diaphoresis.

Case 2

VS: T 37 HR 108 BP 105/60 RR 20 O2 sat 93% on RA

Physical exam:Gen – actively having chest pain, diaphoretic

Lungs – crackles at bilateral basesHeart – tachycardic, nl s1/s2, no mumurs or rub

Rest of the exam benign Labs: CBC wnl, RFP wnl, Troponin = 0.05

Next Steps

Review EKG Review CXR Troponin SL Nitroglycerin

Case 2

Case 2 Diagnosis: UA/NSTEMI

EKG changes in Acute Coronary Syndromes: ST elevations ST depressions T wave inversions

“pseudonormalization” – inversion of previously inverted T waves when compared with old EKG

New conduction block Q waves

Importance of serial EKG monitoring: sensitivity of single EKG is only 50% sensitive for acute MI

Pearl: Positive Troponin does not equal ACS

Risk Stratification

Unstable Angina/NSTEMI: Initial Management

“Stabilize” plaque Dual antiplatelet therapy

Plavix load 600mg followed by daily 75mg ASA 324mg chewable, then 81 daily

Anticoagulant UF Heparin at low intensity protocol

Statin Atorvastatin 80mg

Optimize Myocardial O2 supply/demand Control HR -> Short acting metoprolol, can titrate quickly to HR <60 if

BP allows. Give 5mg IV, can repeat at 5-15min intervals. Be wary of patients with heart failure!

Supplemental O2 if hypoxemic SL nitroglycerin (0.4mg), repeat every 4-5 minutes Morphine if still having active chest pain

Case 2 continued

You are now the nightfloat intern, and the patient is signed out to you at 10PM. At midnight, you are called for continued chest pain. Improved from admission but still 5/10 severity.

Next steps

Vitals Repeat EKG Repeat SL nitro Assess patient in person Call your senior!

Dose additional morphine start IV nitroglycerin after 3-4 doses of SL nitroglycerin

Start 5 mcg/min Increase by 5mcg/min every 20 minutes Floor maximum: 30mcg/min

Pearl

Inability to ELIMINATE chest pain in a patient with ACS using maximal medical therapy

=Urgent call to cardiology for consideration of

immediate catheterization

Trivia

What typical ACS med should you NOT give this patient?

Pearl: Nitroglycerin contraindicated in inferior MI

Other contraindications to NG: Preload dependent states

Inferior MI Aortic outflow obstruction (HOCM, severe AS)

Likelihood of hemodynamic instability HR <50 or >100 SBP<90mmHg or more than 30mmHg below baseline Use of PGE inhibitors

Case 3

You are called on Hellerstein to admit a 65 yo man for ACS rule out.

Mr Q is a gentleman with a history of DMT2, NASH, remote NSTEMI, and HTN presenting with severe retrosternal chest pain. Pain is different than prior MI but is very severe. Radiates to neck. Began 3 hours ago; has subsided slightly but is still 8/10 in severity.

You take report, quickly review chart, and go to assess the patient in the ER. VS: T37.1, HR110, BP145/80 in R arm, RR16, Pox 98%RA Focused Exam:

GEN: in discomfort but mentating well HEENT mmm, JVP at clavicle CV normal s1/s2, no murmurs PULM ctab, no w/c/r EXTR: cool Bilateral BP: 145/80R, 110/60L

EKG identical to previous EKG which you printed from portal

Thoracic aortic dissection

CT angiography – first line 83-100% sensitive, specificity 87-100%

TEE – second line; good for proximal, cannot visualize descending aorta well

MRI – useful for surveillance

Diagnosis

Images: reference.medscape.comrwjms1.umdnj.eduen.wikipedia.orgen.wikipedia.org

Thoracic aortic dissection

Hypertension Atherosclerosis Preexisting aneurysm (known history in 13% of patients) Inflammatory conditions affecting aorta (Takayasu, Giant Cell

Arteritis, RA, syphilis) Collagen disorders (Marfan, Ehlers-Danlos) Bicuspid aortic valve Aortic coarctation Turner syndrome History of CABG, AVR, Cardiac Cath High intensity weight lifting Cocaine use Trauma

Risk Factors

Type A Type B

Thoracic aortic dissection

Surgery! Do not delay surgery, even

for LHC Beta blockers, titrate to HR

50-60 (labetalol, esmolol) BP control (nitroprusside)

Beta blockers, titrate to HR 50-60 (labetalol, esmolol)

BP control – add nitroprusside or similar agent to SBP goal 100-120mmHg

Surgery for those with end organ damage or those who do not respond to medical therapy

Watch for hypotension – give fluids if needed, consider tamponade, MI, or rupture as complications if hypotensive

Management

Case 4

You are on long call on VA Blue. You are called to admit a 53 yo M from the ED for chest pain and EKG abnormalities

PMHx: HTN Dyslipidemia

You go see the patient and he tells you that he has had this chest pain for ~2 days, but it has progressively gotten worse. His chest pain is worse with breathing. He notes a recent viral URI.

Case 4 VS: T 37.9 HR 104 BP 140/76 RR 20 O2 sat 95% on

RA Physical exam:

Gen – in mild distress due to chest pain, leaning forward while in bed

Lungs – CTAB Chest wall – no visible rash, chest wall NT to palpation Heart – tachycardic, nl s1/s2, no rub Rest of physical exam benign

Labs: WBC = 14, RFP wnl, AMI panel x 1 = negative

CXR = negative

Case 4

EKG on admission:

Case 4 - Pericarditis

Refers to inflammation of pericardial sac

Idiopathic pericarditis typically preceded by viral prodrome, i.e. flu-like symptoms

Typically, patients have sharp, pleuritic chest pain relieved by sitting up or leaning forward

Goyle 2002

Case 4 - Pericarditis

Goyle 2002

Case 4 - Pericarditis

Diagnostic criteria

UpToDate 2012

Case 4 – Pericarditis

Per 2003 ACC guidelines, all patients diagnosed with pericarditis should receive echocardiogram

High risk features: Fever (>38ºC [100.4ºF]) and leukocytosis Evidence suggesting cardiac tamponade A large pericardial effusion (ie, an echo-free space of more than

20 mm) Immunosuppressed state A history of therapy with vitamin K antagonists (eg warfarin) Acute trauma Failure to respond within seven days to NSAID therapy Elevated cardiac troponin, which suggests myopericarditis

Case 4 - Pericarditis Treatment

UpToDate 2012

Case 5

This is a 45 yro M with PMHx of rheumatoid arthritis who presented with progressive sob. He was found to have a R-sided pleural effusion and underwent an US guided thoracentesis with removal of 1.5 liters of pleural fluid. Two hours after his procedure, he develops new onset R-sided chest pain

Case 5

Case 5 - Pneumothorax

Management of Pneumothorax 100% O2 and observation in stable patients for PTX < 3

cm in size Needle aspiration in stable patients for PTX >3 cm Chest tube placement if PTX >3 cm and if needle

aspiration fails Chest tube placement in unstable patients

Pearl

Great EKG Practice Site:http://ecg.bidmc.harvard.edu/maven/mavenmain.asp

References

Kearon C, Akl EA, Comerota AJ, Prandoni P, Bounameaux H, Goldhaber SZ, Nelson ME, Wells PS, Gould MK, Dentali F, Crowther M, Kahn SR. Antithrombotic therapy for VTE disease: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2012 Feb;141(2 Suppl):e419S-94S.Cayley, W.E. Diagnosing the cause of chest pain. (2005). American Family Physician, Vol 72 (10), 2012-21.

Anderson JL et al. 2012 ACCF/AHA Focuse Update of the Guideline for Management of Patients with Unstable Angina/NSTEMI. JACC 60 (7) 2012.

Thrumurthy SG et al. The diagnosis and management of aortic dissection. BMJ 344, 2012. Imazio M, Demichelis B, Parrini I, Giuggia M, Cecchi E, Gaschino G, Demarie D, Ghisio A, Trinchero R. Day-hospital treatment of

acute pericarditis: a management program for outpatient therapy. J Am Coll Cardiol. 2004;43(6):1042. Goyle, K.K. and Walling, A.D. Diagnosing pericarditis. (2002). American Family Physician, Vol 66 (9), 1695-1702. Diagnostic approach to chest pain in adults. (2014). UpToDate. http://www.uptodate.com/contents/diagnostic-

approach-to-chest-pain-in-adults?source=search_result&search=chest+pain&selectedTitle=1%7E150 Differential diagnosis of chest pain in adults. (2014). UpToDate. http://www.uptodate.com/contents/differential-

diagnosis-of-chest-pain-in-adults?source=search_result&search=chest+pain&selectedTitle=3%7E150 Evaluation of chest pain in the emergency department. (2014). UpToDate.

http://www.uptodate.com/contents/evaluation-of-chest-pain-in-the-emergency-department?source=search_result&search=chest+pain&selectedTitle=5%7E150

Clinical presentation and diagnostic evaluation of acute pericarditis. (2014). UpToDate. http://www.uptodate.com/contents/clinical-presentation-and-diagnostic-evaluation-of-acute-pericarditis?source=search_result&search=pericarditis&selectedTitle=1%7E150

Treatment of acute pericarditis. (2014). UpToDate. http://www.uptodate.com/contents/treatment-of-acute-pericarditis?source=search_result&search=pericarditis&selectedTitle=2%7E150

Thanks to Sumit Bose for use of a number of his excellent slides!