Presentation on theme: "Evaluation of Chest Pain in the Emergency Department"— Presentation transcript:
1Evaluation of Chest Pain in the Emergency Department Rachel Steinhart, MD, MPHCCRMC Emergency Dept.
2Chest Pain in the EDThere an estimated 4.6 million annual ED visits for “non-traumatic chest pain” by adults ≥25 in the US27.7 visits per 1,000 persons annuallyAcute Cardiac Insufficiency is estimated to account for 11% of these non-traumatic chest pain visits*Burt CW. Am J Emerg Med Oct;17(6):552-9.
3Chest Pain in the EDAt SFGH, 2.5% of all visits in patients >35 were for “non-traumatic chest pain”Of these, 37.6% were hospitalized, 45% of whom received significant diagnoses10.7% MI22.5% UA or Stable CAD11.2% Serious Pulmonary Etiology0.4% Aortic Dissection0.3% Pulmonary EmbolismOverall, approximately 16% of visits with serious etiology(Calculated)Kohn MA, et al. J Emerg Med. 2005;29(4):
4Chest Pain in the ED Litigation Missed myocardial infarction represents approximately 10% of malpractice suits filedMissed myocardial infarction representsapproximately 30% of the dollars paid out in malpractice claimsEmerg Med News. 2006: 28(2); 20-7
5Proportion of final diagnoses in patients presenting with CP Family Practice ;18(6):586-8
8Clear cut alternative diagnosis Patients given a clear-cut alternative non-cardiac diagnosisAt significantly lower risk of revascularization, MI or death in the subsequent 30 daysHOWEVERStill with 4% event rate at 30 daysAcad Emerg Med Mar; 14(3):210-5
9Character of Chest Pain Likelihood ratios for MI based on components of the chest pain historyDescription of pain LR (95%)Descriptions increasing the likelihood of MIRadiation to R arm/shoulder (1.9-12)Radiation to both arms/shoulders ( )Exertional ( )Radiation to L arm ( )Associated with diaphoresis ( )Associated with nausea or vomiting ( )Worse than previous angina or similar 1.8 ( )to previous MIDescribed as pressure ( )Descriptions decreasing the likelihood of MIPleuritic ( )Positional ( )Sharp ( )Reproducible with palpation ( )Inframammary location ( )Nonexertional ( )JAMA 2005; 294:2623.
10Nitroglycerine in ER Chest Pain Annals of Internal Medicine 2003Improvement in chest pain with nitroglycerine proved:35% Sensitive30% SpecificAnn Intern Med. 2003;139:Canadian Journal of Emergency Medicine 2006Improvement in chest pain with nitroglycerine proved:72% Sensitive37% SpecificCan J Emerg Med 2006;8(3):164-9
11Chest Pain: PMH CAD - self or family Hypertension Diabetes Recent surgery, travelSubstance abuse - alcohol, cigarettes, meth/cokeDVT/PE/Aortic dissection - self or familyLupusMarfan’s/connective tissue dz - self or familyMedications - HAART, estrogenLupus - hypercoagulable, steroids, inflammationWomen with SLE have 7-50 fold increased risk of CHD, greatest in young womenPeople with RA have fold increase in risk of CHDHIV on HAART - not all accounted for by induced hyperlipidemiaAnn Rheum Dis 2000;59;N Engl J Med 2007 Apr 26;356(17):
18Post-op Chest Pain and SOB 70 yo man 10 days following CABGDeveloped acute dyspnea and right-sided chest pain on awakeningExam revealed tachypnea, tachycardia, and hypoxemiaNormalRUL pnaR pl eff
19Studies in suspected PE Initial CXR in PE virtually always NORMALWestermark sign - RAREHampton hump – LATE & RAREEKG Evidence:Tachycardia - sinus, afib or aflutterRV StrainS1, Q3, T3Poor R wave prog + TWI V1-4Westermark sign - a dilatation of the pulmonary vessels proximal to an embolism along with collapse of distal vessels - RARESome patients develop atelectasis that may progress to small pl eff and elevated hemidiaphragmAt hours 1/3 of patients develop focal infiltrates indistinguishable from pneumoniaHampton hump, a triangular or rounded pleural-based infiltrate with the apex pointed toward the hilum, frequently located adjacent to the diaphragm – LATE and RAREAtelectasis, small pleural effusion &Elevated hemidiaphragm may develop24-72 hours – focal infiltratesD-Dimer - Only useful to rule outPE in LOW RISK
20Acute Upper Back Pain 49 yo man with long standing hypertension Sudden mid back and interscapular painAssociated with nausea and sweatsUnrelieved by change of positionSome radiation toward the left chestWide mediastinum - Dissection
21Aortic Dissection: clinical presentation Sudden severe pain %Migrating pain 31%Tearing pain 39% (spec. 95%)Hypertension %Diastolic murmur %Pulse deficits or BP differential 31%Focal neurologic deficits %Syncope %ECG criteria for AMI %Klompas et al, JAMA 2002; 287:Nallamothy et al, Am J Med 2002; 113:
22Aortic Dissection: etiology Prevalence of major risk factors:Hypertension %Bicuspid AoV %Marfan syndrome 3-5%
23Radiographic Signs of Thoracic Aortic Dissection Studies suggest up to 90% of patients will have “abnormal” CXR*Widened mediastinum (>8cm on AP film) [50-65%]Left pleural effusion (hemothorax)Ring Sign (displaced intimal calcification >5mm)Blurred aortic knobTracheal deviation to the RightEsophageal deviation to the Right (seen via NGT)Left apical capDepressed Left mainstem bronchusLoss of paratracheal stripe*Hogg K. Sensitivity of a normal chest radiograph in ruling out aortic dissection.Best Evidence Topics. 9 March 2004.
24Aortic Dissection Classification of Aortic Dissection Type - Not all require surgical intervention
25Wrestler with Chest Pain 18 yo high school wrestler develops right-sided chest pain while pinning his opponent.Pneumothorax
26Alcoholic with Chest Pain and Cough 45 yo alcoholic man with fever, chills and productive cough over two daysRUL Pneumonia
27Hyperemesis with Chest Pain 26yo G1P0 at 10wks presents with 4 days refractory emesis and 12 hours progressive, severe substernal chest painPneumomediastinum - Boerhaave’s
28Smoker with Chest Pain68 yo former smoker with persistant, non-exertional, left substernal and left shoulder pain
29Summary Chest pain in the ED differs from chest pain in primary care ACS is not the only cause of potentially life threatening chest painDiagnosis of chest pain in the ED is rarely straight forwardChest pain in the ED is a high-stakes evaluation
30Parting Words Careful history and physical are imperative While history or physical exam can suggest likely alternate diagnoses, none can rule out serious etiologyNeither NTG nor GI cocktail response, nor reproducibility on palpation are diagnosticPost-prandial pain may be ischemicUse caution when diagnosing “non-cardiac” chest pain in patients with CAD or risk for CADAtypical may be typical of something elseObservation can be key