chest pain epidemiology

Chest PainEpidemiology

• 6 million ED visits/year• 5-7% ED patients• 3.3% AIS evacuations 2002, 3.5% in 2003,

3.6% in 2004, 3.2% in 2005• 3 million patients admitted/year• 70% found not to have acute coronary event• 0.4% - 4.0% acute MI are sent home

Chest PainPathophysiology

• Chest pain syndromes difficult to diagnose• Multiple organ systems of the chest• Share afferent (nerve) pathways• Pathology in any of these systems have

similar pattern of complaints• Most patients have CP with acute coronary

syndrome(ACS), others may present with only SOB, N/V, arm or jaw pain

Differential Diagnosisof Chest Pain

Life-threatening causes • Acute coronary syndrome(ACS)• Aortic dissection• Pulmonary embolism• Tension pneumothorax• Esophageal rupture (Boerhaave’s syndrome)• Pericarditis; myocarditis• Acute chest syndrome(in sickle cell disease)


Non-life-threatening causes• Gastrointestinal

Biliary colic (cholelithiasis, cholecystitis)

Gastroesophageal reflux disease

Peptic ulcer disease• Pulmonary

Pneumonia

Pleurisy


Non-life-threatening causes• Chest wall syndromes

Musculoskeletal pain

Costochondritis

Thoracic radiculopathy• Psychiatric

Anxiety• Shingles

Chest Pain Evaluation

• Problems

• History

• Risk factors

• Physical exam

• Rhythm strip, 9 lead ECG, 12 lead ECG

• Risk stratification based on above factors

The Initial Clinical Examination

• ECG can only help if it shows acute MI

• Initial ECG sensitivity 20% - 60% AMI

• Sensitivity of plasma CK-MB low first 4 hrs

• Can’t detect unstable angina

• Therefore evaluation based on history, physical exam and ECG

History

“The most important difference between a good and indifferent clinician lies in the amount of attention paid to the story of the patient”---Farquhar Buzzard

History

• Helpful to group questions to target the three most common life threats;

Consider ACS questions

Pulmonary embolism(PE) questions

Aortic dissection questions

HistoryCardiac Questions

• 2 most important historical information

age, gender• Advancing age, prevalence and severity of CAD

increases• Can estimate pretest probability of CAD based on

age and gender• Further refine pretest probability by classifying

the chest pain as typical, atypical, or non-anginal

Pretest likelihood of CAD based on age, sex, and symptoms

Asymptomatic non-anginal CP

Age Men Women Men Women

30-39 1.9% 0.3% 5.2% 0.8%

40-49 5.5% 1.0% 14.1% 2.8%

50-59 9.7% 3.2% 21.5% 8.4%

60-69 12.3% 7.5% 28.1% 18.6%

Pretest likelihood of CAD based on age, sex, and symptoms

Atypical angina Typical angina

Age Men Women Men Women

30-39 21.8% 4.2% 69.7% 25.8%

40-49 46.1% 13.3% 87.3% 55.2%

50-59 58.9% 32.4% 92.0% 79.4%

60-69 67.1% 54.4% 94.3% 90.6%

Cardiac Questions

• Example; 35y/o male with non-anginal CP has 5% pretest probability of CAD(1 in 20)

same 35y/o with atypical angina 22% of CAD or (1in 5)

same 35y/o with typical angina 70%(7in10) • If patient has known previous CAD/MI raises risk

of subsequent coronary event 5 times• If patient has cardiac history ask about prior stress

tests, cardiac caths, bypass surgery, stents

Cardiac Questions

• Character of Pain

• Many patients have atypical symptoms

• Ask questions in regard to nature (quality), severity(1-10), duration, modifying factors of the pain, and associated symptoms

• 40% patients with AMI have atypical CP

• 35% patients without AMI have typical CP

Cardiac Questions

• In one study of 721 patients who were diagnosed with AMI, almost ½ presented without CP

• SOB, weakness, dizziness, syncope, abdominal pain

• Typical angina is a deep, poorly localized chest or arm discomfort that is classically exertional and relieved with rest or nitrates

Analysis of Clinical Predictors of AMI

• Clinical features AMI chest pain radiation Odds ratio left arm 1.5 right arm 3.2 both arms 7.7 nausea, vomiting 1.8 diaphoresis 1.4 exertional CP 3.1

Analysis of Clinical Predictors of AMI

• Clinical features AMI

Odds ratio

burning/indigestion pain 4.0

crushing/squeezing pain 2.1

relief with nitroglycerin 0.9

pleuritic pain 0.5

tender chest wall 0.2

sharp/stabbing pain 0.5

Cardiac Questions

• Another study of 251 patients with cardiac CP showed 88% respond to NTG, also 92% of noncardiac CP responded to NTG

• Can you give GI cocktail to R/O cardiac CP?

a study of 97 patients who received GI cocktail showed 8 of 11 patients admitted with possible cardiac ischemia had complete or partial relief of CP

Cardiac Questions

• Risk Factors

• Diabetes, hypertension, smoking, high cholesterol, and family history

• Most CAD patients have at least one

• The absence of risk factors does not exclude acute cardiac ischemia

Aortic DissectionHistory

• Male (75%)

• Seventh decade

• History of hypertension (70%)

• Other risk factors;

Marfan’s syndrome, atherosclerosis, prior dissection, or known aortic aneurysm

Aortic DissectionHistory

• Pain is sudden onset (83%)

• Severe or “worse ever” (90%)

• Sharp (64%) or tearing (50%)

• Location anterior chest (60%), back (53%)

• Migratory (16%), radiating (28%)

• Suspect dissection in patients with clinical changing picture

Aortic Dissection History

• Should address 3 basic concerns regarding a patient’s pain:

quality (sudden and severe)

radiation (especially to the back)

intensity at onset (maximal)

• Aortic dissection and MI can coexist

8% dissection involves coronary arteries

Pulmonary EmbolismHistory

• Clinical diagnosis of PE is difficult• Symptoms are variable and nonspecific• Can range from dyspnea and fatigue to

severe pleuritic CP and syncope• Classic description of pleuritic pain,

dyspnea, and hemoptysis represents embolic pulmonary infarction and is seen most commonly in hospitalized patients


• Ambulatory patients often present with painless dyspnea

• Can have several weeks of intermittent symptoms

• Physical exam is rarely diagnostic

• Reproducible chest wall pain does not exclude diagnosis


• Wide spectrum of pain quality and location• Pain that is peripheral, increases with deep breath,

and not reproducible- suspect PE• Isolated substernal, pleuritic CP less likely PE• Substernal, anginal CP occurs 4% PE• Radiation to arm distinctly unusual • Pleuritic CP and leg pain more commonly PE than

other diagnosis

Pulmonary EmbolismRisk Factors

• Inherited hypercoagulability disorders

• Acquired disorders:

immobilization, pregnancy, BCP

malignancy, age

prior history venous thromboembolism

trauma, obesity

surgery, smoking

Pulmonary EmbolismRisk Factors

• Medical conditions

CHF

MI

stroke

hyperviscosity syndrome (polycythemia vera)

Crohn’s disease

Nephrotic syndrome

Other Conditions

• Boerhaave’s syndrome presents as spontaneous esophageal rupture after vomiting

• Pain on swallowing• Significant number are recently, or acutely

intoxicated• Pericarditis refers pain to neck, shoulder and

worsens with inspiration, swallowing, and lying supine

Physical Examination

• Stable patients with AMI rarely have physical findings on exam

• Vital Signs• Chest pain and hypotension-not good• 8% PE and 15% aortic dissection are hypotensive

on presentation• Patients with CP and hypotension are 3 times

more likely to have AMI than normotensive pts


• Vital Signs

• Fever, consider noncardiac cause, pneumonia, mediastinitis

• Low grade fever occurs 14% PE, only 2% PE pts had fever> 102F

• Tachypnea is most common sign in PE, 15% PE pts had respiratory rate <20/min


• Vital Signs

• Tachycardia is nonspecific sign

• May be only clue to early pericarditis, myocarditis

• Bradycardia, esp. due to conduction defects, may be seen in right coronary occlusions


• Vital Signs

• Fifth vital sign, pulse oximetry

• Hypoxia can occur in many conditions

• Patient with low O2 saturations require supplemental oxygen

• O2 saturation is normal in ¼ of pts with PE

Physical ExaminationHead and Neck

• Check neck for Kussmaul’s sign (a paradoxical increase in jugular venous distension with inspiration)

• Seen in pericardial tamponade, right heart failure or infarction, PE, or tension pneumothorax)

• Subcutaneous air at the root of the neck suggests pneumothorax, or pneumomediastinitis

• Carotids bruits increase likelihood of CAD

Physical ExaminationPulmonary Exam

• Look for respiratory distress:• nasal flaring, intercostal retractions, and

accessory muscle use• Listen for unilateral absence of breath

sounds; consider pneumothorax, or massive pleural effusion

• Percuss the chest for infiltrates, effusions, and pneumothorax

Physical ExaminationPulmonary Exam

• Wheezing and rales are important findings but are not specific for certain diseases

• Asthma, foreign body, CHF, PE all may cause wheezing

• Rales are rare in pts with AMI, but their presence with left heart failure, raises the likelihood of MI by twofold

Physical ExaminationCardiac Exam

• A new murmur may signal papillary muscle rupture

• Murmur of aortic insufficiency is an important finding associated with aortic dissection

• S3 gallop secondary to CHF raises likelihood of MI 3 times

Physical ExaminationCardiac Exam

• Hamman’s crunch- crunching sound of heart beating against mediastinal air

• Pericardial rub(creaking of new leather) seen in pericarditis

• Beck’s triad(distant heart sounds, distended neck veins, and hypotension) seen in pericardial tamponade from proximal aortic dissection

Physical ExaminationChest Wall Exam

• Even with chest wall tenderness, still have to consider life-threatening causes

• Reproducible CP frequently seen in pts with PE and ACS

• Costochondritis is inflammation of the costal cartilages, may result in sharp, dull, or pleuritic CP, rarely has swelling of soft tissues

Physical ExaminationChest Wall Exam

• Tietze’s syndrome- fusiform swelling and pain of only one upper costal cartilage

• Compression of cervical or thoracic nerve may produce dull chest pain mimickings angina (cervico-precordial angina)

• Pain worsens with neck movement, coughing, sneezing, or axial loading of the vertebrae

• Check skin for herpes zoster (shingles); causes unilateral pain over 1-2 dermatones

Physical ExaminationExam of the Extremities

• Look for edema, thrombosis, or pulse deficits• Peripheral edema frequently seen in right-sided

and biventricular failure• Usually absent in acute left heart failure• Unilateral edema or palpable venous

thrombus(cord) suggest DVT or PE• But most pts with PE have normal ext. exams

Physical ExaminationExamination of Pulses

• Exam for symmetry and quality• Pulse deficit is defined as asymmetrical

amplitude between the right and left sides• Pulse deficits most common in type A

dissections(ascending aorta)• Measured BP difference occurs 15%• Differences > 20mmHg between arms was

an independent predictor of dissection

Physical ExaminationNeurologic Exam

• Altered mental status nonspecific finding• Associated with any cause of CP that leads

to BP instability and cerebral hypoperfusion• 17% aortic dissection have focal neurologic

deficits due to occlusion of carotid or spinal arteries

• Distal aortic dissections can cause spinal cord ischemia

Diagnostic Studies

• The ECG is the most important test in the evaluation of CP

• The initial ECG is insensitive in identifying acute coronary syndrome

• Only 20%-60% pts presenting with acute MI have diagnostic changes on initial ECG

Diagnostic StudiesECG

• What diagnostic changes?

at least 1 mm elevation in one or more inferior/lateral leads

or at least 2mm of elevation in one or more anterioseptal leads

• 10% pts with AMI have LVH with repolarization changes

• Tall peaked T waves may be earliest sign of AMI

Acute Anterior MI

Acute Inferior MI

Offshore Case Presentation # 1

• Chief Complaint

chest and arm pain

• History of Present Illness

38 y/o male c/o burning right sided chest and arm pain which began after he stood up from the supper table.

Case Presentation # 1History of Present Illness

• Pain is burning in quality

• Location is substernal and in the right arm

• 5 on (1-10 scale) initially, now 2

• No radiation, duration > 2 hours

• No associated nausea, vomiting, SOB, or diaphoresis

• Pain increased after climbing 3 flights stairs

Case Presentation # 1

• Past History 2 weeks ago dx with acid reflux, had

substernal chest pain. PMD stated ECG was normal, blood test normal, but cholesterol and BP were elevated

Began Nexium, cholesterol, and BP meds, but quit taking them

• No other past medical problems


• Medications- none

• NKA

• Risk Factors

• + HTN, cholesterol, Family hx heart disease, smoker

- diabetes


• Physical Examination• Vital signs: BP-140/88, P-76, RR-20, T-

97.9, O2 sat.-98%; ECG- no acute changes Alert WM in NAD skin warm, and dry Ht -RR&R; Lungs- clear; Chest wall-

nontender; Abd- soft, nontender; Ext- equal pulses


• What should we do now?

Case Presentation # 1Treatment Plan, Physician Orders

• 4 baby ASA chew and swallow

• O2

• IV NS TKO

• NTG SL q3-5min up to 3

• Nitrol paste 1” if BP stable

• MS if needed

• Send in emergently

Case Presentation #1

• Final diagnosis: ACS

Angiogram revealed two 95% blockages, 2 stents placed


• Chief Complaint

chest pain

• History of Present Illness

32y/o male with squeezing, substernal chest pain that began while sitting in chair. Pain is worse with deep breathing and not relieved by drinking carbonated soda.

Case Presentation # 2HPI

• Quality- squeezing

• Location- substernal

• No radiation, duration >1 hour

• Intensity- 5 (1-10) scale

• No associated nausea, vomiting, SOB, diaphoresis

Case # 2

• Past History• Hx of 2 previous episodes of chest pain

while on rig. 1st workup was neg. 2nd revealed aortic valve problem and coronary blockage with stent placement 1998

• Hx of HTN• Medicines- Toprol, Avapro, and ASA qd• NKA

Case # 2

• Risk Factors

• + HTN, smoker, Past Hx of CAD, Family Hx of MI- GF (both sides)

- DM, elevated cholesterol

Case # 2

• Physical Exam• Vital signs- BP 160/80, P-94, RR-16, O2 sat

98%; ECG- no acute changes• Alert WM in NAD skin warm and dry heart- RR&R; Lungs- clear; Chest wall

nontender; Abd- soft, nontender; Ext- equal pulses

Case # 2


Case # 2Treatment Plan, Physician Orders

• O2

• IV NS TKO

• NTG SL q3-5min up to 3

• Nitrol paste 1” if BP stable

• MS if needed

• Send in emergently

Case # 2

• Final diagnosis:

• Work up revealed an ascending aortic aneurysm

• Emergent surgical repair, resection

Case # 3

• Chief complaint Shortness of breath• History of Present Illness 53y/o awoke from sleep with SOB. Patient

denies CP, nausea, vomiting, or diaphoresis. No hx of previous episodes in past. Denies cold, but did have coughing episode prior to SOB.

Case # 3

• Past Medical History

negative

• Medicine- none

• NKA

• Risk Factors

+ smoker

- HTN, DM, cholesterol, Family Hx CAD

Case # 3

• Physical Exam• Vital signs- BP-130/90, P-104, RR-30, T-97.4,

O2 sat- 95%; ECG- sinus tach, no acute changes• Alert WM in mild distress, not SOB now

skin warm and dry

Heart- RR&R; lungs- clear, no wheezes; Abd- nontender; Ext- no swelling, equal pulses

Case # 3


Case # 3Treatment Plan, Physician Orders

• O2

• IV NS TKO

• Cardiac Monitor

• Emergent evacuation

Case # 3

• Final Diagnosis

Pulmonary Embolism

Questions???

chest pain epidemiology

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