Approach to the ED Patient with Chest Pain

University of Utah Medical Center

Division of Emergency Medicine

Medical Student Orientation

The Stats

•5.4% of all ED visits–High volume–High risk

•$$$ malpractice claims –Misdiagnosis

–Delay in treatment

•< 1/3 have myocardial ischemia or infarction

Common Etiologies of Life-threatening Chest Pain

1. Acute MI

2. Unstable angina

3. Aortic Dissection

4. Pulmonary Embolism

5. Spontaneous Pneumothorax

6. Esophageal Rupture (Boerhaave’s Syndrome)

Acute MI

Acute MI

• PMHx– Med Hx

• HTN• DM• Cholesterol

– Meds– FHx

• Immediate relatives CAD

– Social Hx• Tobacco• Drugs• Exercise• Stressors

• HPI– Onset– Palliates/Provokes– Quality– Radiation– Severity– Time course– Undo (what have they

done to “undo” their pain)

• Typical Symptoms– Crescendo pain

• Crushing• Pressure• Tightness

– Radiation• Arms• Jaw• Neck

– Associated Symptoms• Nausea• Vomiting• Diaphoresis• Shortness of breath

• Risk Factors– HTN– Diabetes– High cholesterol– Obesity– Male– Family history– Smoker– Sedentary– Post-menopausal

Acute MI

• But don’t be fooled – Atypical symptoms

• Stridor• Tooth pain• Headache/neck pain

– Atypical demographics• Young• Female

– Cocaine use– Dissection

• Aorta• Coronary arteries

Initial Work-up

• ECG/repeat ECG– before you even step foot in the room!

• CXR• Labs

Enzyme Rise Peak Baseline

Myoglobin 1-2 h 4-6 h 24 h

Troponin 3-6 h 12-24 h 7-10 d

CKMB 4-6 h 12-36 h 3-4 d

LDH 12 h 24-48 h 10-14 d

ECG• STEMI

– 1mm ST elevation in 2 limb leads

– 2mm ST elevation in two contiguous anterior leads

– Reciprocal changes

• Ischemia– ST flattening– ST depression

Treatment

• Anti-platelet– ASA– Plavix

• Heparin• Analgesia

– Nitrates– Narcotics

• B-blockade– No longer recommended in STEMI patients

• Oxygen• Thrombolytics vs. Cath Lab

Missed MI

• ~ 2% missed infarction rate– 25% had missed ST

elevation – 15% had Hx of

nitroglycerin use– 25% died or potentially

lethal outcome!

Unstable Angina

Angina vs. MI

• Heart muscle– death in MI– Ischemia in angina

• Stable vs. Unstable Angina

Presentation of Angina

• Angina– Established character,

timing, duration of CP– Transient,

reproducible, predictable

– Easily relieved by rest or SL NTG

– Reduced coronary flow through fixed atherosclerotic plaques

• Unstable Angina– Angina deviating from

normal pattern– Rest angina > 20 min– New-onset angina,

previously undiagnosed– Increasing angina or

change in class

Evaluation

• Detailed history

• Physical

• ECG/repeat ECG

• CXR

• Labs

Risk Stratify

While this is recommended, exactly how to do it is controversial. There are several scoring systems. They each pros and cons. How risk stratification is will vary from institution to institution.

• TIMI score

• GRACE

• Braunwald Risk Stratification

Risk Stratify

• High/Moderate = admission to r/o MI– ASA– SL NTG for pain x3 then paste if pain free– NTG gtt if pain continues– IV heparin – B-blockade

• Low = provocative testing– From department – Low-risk obs pathway

Aortic Dissection

Aortic Dissection

• 25-50% mortality in 24 hours

Aortic Dissection-Typical Symptoms

• Onset• Palliates/provokes• Quality • Radiation • Severity • Time course • Undo

• sudden, chest/back• nothing!• intense ripping, tearing, cutting• chest to back, flank, extremities• 10/10!• Constant• nothing

Aortic dissection-caveat

• Only about 30% present typically

• This can be a great mimicker

• Neurologic sx’s + CP = think about dissection

Aortic Dissection

• Risk Factors– Trauma (high velocity)– HTN– Men 3:1– Congenital abnormal aortic

valve– Coarctation of aorta– Turner’s Syndrome– Cocaine– Pregnancy– Connective tissue d/o

• Marfan’s• Ehlers-Danlos

– Vascular damage• Card cath, CABG, IABP

Aortic Dissection

• Physical Exam– Aortic regurgitation

(diastolic murmur)– Loss/decreased pulse– Sternoclavicular

heave/pulsation– JVD

• tamponade

Aortic Dissection

• Evaluation– CXR– ECG– TEE– MRI– CT

CXR findings

• Dilated ascending aorta

• Dilated aortic knob

• Apical pleural cap

• Depression of L mainstem bronchus

• Displacement of trachea to R

• Widened mediastinum

Sensitivity of 67%

93% Sensitivity 87% Specificity

98% Sensitivity 97% Specificity

97% Sensitivity 77% Specificity

LVH, Infarct, Ischemia

Aortic Dissection

• Initial Management– Control HTN and shear forces = IV infusions

• B-blocker + Nitroprusside• Labetalol

• Cardiothoracic Surgery Consult– For dissections involving the aortic root

Type 1: ascending & descending; Type 2: ascending only; Type 3: Descending only; Type A: Ascending aorta; Type B: Descending aorta

Aortic Dissection

• Suggested reading (IRAD):– “The International Registry of Acute Aortic

Dissection: New Insights Into an Old Disease” JAMA Feb 16, 2000 Vol 283 No 7.

Pulmonary Embolism

To be discussed in another lecture

Spontaneous Pneumothorax

Spontaneous Pneumothorax

• Absence of trauma• Primary = no lung

disease• Secondary =

underlying lung disease

Pneumothorax

• Presentation may vary– Sudden onset

• Sharp, pleuritic pain, radiates to shoulder

– Gradual symptoms• Progressive dyspnea over weeks…

Spontaneous Pneumothorax

• Risk Factors– Smoker:Non-smoker 120:1– COPD/asthma– Malignancy– Infectious

• Abscess

• TB

• PCP

– Pulmonary infarction

– Pneumonoconiosis• Silicosis

• Berylliosis

– Congenital disease• Cystic fibrosis

• Marfan’s

– Diffuse lung disease• Idiopathic Pulm fibrosis

• Eosinophilia granuloma

• Scleroderma

• Rheumatoid

• Sarcoid

• Etc.

Spontaneous Pneumothorax

• Physical exam– Absence or decreased

breath sounds– Tension

pneumothorax• Cyanosis• Tachypnea• Tachycardia• Hypotension• JVD

Spontaneous Pneumothorax

• Imaging– CXR

• Visceral pleural line• +/- Expiratory film

– CT Scan• Help w/size• Cause

Pneumothorax

• Treatment– oxygen– <15% = observation– >15% = chest tube vs. aspiration

Recurrence is common ~ up to 50% in 2-3 yrs.

Esophageal Rupture

Esophageal RuptureBoerhaave’s Syndrome

• Complete tear• Esophageal contents

leak into mediastinum• Mediastinitis• SICK!

Esophageal Rupture

• Presentation– Chest and neck pain– Often recent instrumentation of esophagus– Hx of forceful vomiting

Esophageal Rupture

• Evaluation & Diagnosis– Subcutaneous emphysema– Hammon’s Sound– Pleural effusion

– CXR– CT– Esophagram

Esophageal Rupture

• Management– Surgical!– 80-90% survival if fixed within 24 hours

Chest Pain Summary

• High index of suspicion

• Broad differential

• Risk stratification

• Evidence-based medicine

• Do what is right for your patient