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Evaluation of Chest Pain in the Emergency Department Rachel Steinhart, MD, MPH CCRMC Emergency Dept. 5-1-2008.

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Presentation on theme: "Evaluation of Chest Pain in the Emergency Department Rachel Steinhart, MD, MPH CCRMC Emergency Dept. 5-1-2008."— Presentation transcript:

1 Evaluation of Chest Pain in the Emergency Department Rachel Steinhart, MD, MPH CCRMC Emergency Dept

2 Chest Pain in the ED There an estimated 4.6 million annual ED visits for non-traumatic chest pain by adults 25 in the US 27.7 visits per 1,000 persons annually Acute 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.

3 Chest Pain in the ED At 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 diagnoses 10.7%MI 22.5%UA or Stable CAD 11.2%Serious Pulmonary Etiology 0.4%Aortic Dissection 0.3%Pulmonary Embolism Kohn MA, et al. J Emerg Med. 2005;29(4): Overall, approximately 16% of visits with serious etiology (Calculated)

4 Chest Pain in the ED Litigation Missed myocardial infarction represents approximately 10% of malpractice suits filed Missed myocardial infarction represents approximately 30% of the dollars paid out in malpractice claims Emerg Med News. 2006: 28(2); 20-7

5 Proportion of final diagnoses in patients presenting with CP Family Practice. 2001;18(6):586-8

6 Chest Pain: HPI P: pattern (temporal sequence) A: associated features SOB, N/V, diaphoresis Fever, cough, chills Neurologic symptoms I: initiation and improvement N: nature (quality)

7 Chest Pain: Location Myocardial ischemia Intra-peritoneal fluid PericarditisPleurisy Myocardial ischemia Cervical spine Thoracic outlet Pulmonary embolism Pneumonia Myocardial ischemia Splenic infarction Intraperitoneal fluid Peptic disease Aortic dissection Boorhaves Myocardial ischemia Pulmonary embolism Pericarditis Myocardial ischemia CHFPancreatitisCholecystitis Peptic disease

8 Clear cut alternative diagnosis Patients given a clear-cut alternative non- cardiac diagnosis At significantly lower risk of revascularization, MI or death in the subsequent 30 days HOWEVER Still with 4% event rate at 30 days Acad Emerg Med Mar; 14(3):210-5

9 Character of Chest Pain JAMA 2005; 294:2623. Likelihood ratios for MI based on components of the chest pain history Description of painLR (95%) Descriptions increasing the likelihood of MI Radiation to R arm/shoulder4.7 (1.9-12) Radiation to both arms/shoulders4.1 ( ) Exertional2.4 ( ) Radiation to L arm2.3 ( ) Associated with diaphoresis2.0 ( ) Associated with nausea or vomiting1.9 ( ) Worse than previous angina or similar1.8 ( ) to previous MI Described as pressure1.3 ( ) Descriptions decreasing the likelihood of MI Pleuritic0.2 ( ) Positional0.3 ( ) Sharp0.3 ( ) Reproducible with palpation0.3 ( ) Inframammary location0.8 ( ) Nonexertional0.8 ( )

10 Nitroglycerine in ER Chest Pain Annals of Internal Medicine 2003 Improvement in chest pain with nitroglycerine proved: 35% Sensitive 30% Specific Canadian Journal of Emergency Medicine 2006 Improvement in chest pain with nitroglycerine proved: 72% Sensitive 37% Specific Ann Intern Med. 2003;139: Can J Emerg Med 2006;8(3):164-9

11 Chest Pain: PMH CAD - self or family Hypertension Diabetes Recent surgery, travel Substance abuse - alcohol, cigarettes, meth/coke DVT/PE/Aortic dissection - self or family Lupus Marfans/connective tissue dz - self or family Medications - HAART, estrogen Ann Rheum Dis 2000;59; N Engl J Med 2007 Apr 26;356(17):

12 Chest Pain: Physical Exam Vital signs - Hypoxia? Tachycardia? Hypertension? General appearance - Marfanoid? Carotids and JVP, check neck for crepitus Lungs Cardiac exam Thoracic cage - Trauma? Pectus excavatum? Abdominal exam - Hepatomegaly? Periphery - symmetric pulses? edema? Skin - dermatomal rash?

13 Physical Signs

14 Chest Pain: Laboratory EKG - serial Chest x-ray Blood studies CBC Cardiac enzymes Liver function Lipase D-Dimer BNP Imaging: Ultrasound, CT, Nuclear Study

15 EKG Findings in Adult Patients with Chest Pain: Association with Ischemic Events

16 Adverse Cardiac Events (12 mo out) Patients discharged with chest pain of unclear origin: Abnormal ECG OR 9.5 ( ) Preexisting DM OR 7.1 ( ) Preexisting CADOR 28.4 ( ) Ann Emerg Med Jan;43(1):59-67

17 Potential Underlying Causes of ACS Tachyarrhythmias Severe anemia/acute hemorrhage Medication withdrawal Stimulant substance abuse Hyperthyroidism Sepsis Hypotension

18 Post-op Chest Pain and SOB 70 yo man 10 days following CABG Developed acute dyspnea and right- sided chest pain on awakening Exam revealed tachypnea, tachycardia, and hypoxemia Normal RUL pna R pl eff

19 Studies in suspected PE EKG Evidence : Tachycardia - sinus, afib or aflutter RV Strain S1, Q3, T3 Poor R wave prog + TWI V1-4 D-Dimer D-Dimer - Only useful to rule out LOW RISK PE in LOW RISK Initial CXR in PE virtually always NORMAL Westermark sign - RARE Atelectasis, small pleural effusion & Elevated hemidiaphragm may develop hours – focal infiltrates Hampton hump – LATE & RARE

20 Acute Upper Back Pain 49 yo man with long standing hypertension Sudden mid back and interscapular pain Associated with nausea and sweats Unrelieved by change of position Some radiation toward the left chest Wide mediastinum - Dissection

21 Sudden severe pain 90% Migrating pain 31% Tearing pain 39% (spec. 95%) Hypertension 49% Diastolic murmur 28% Pulse deficits or BP differential 31% Focal neurologic deficits 17% Syncope 13% ECG criteria for AMI 7% Klompas et al, JAMA 2002; 287: Nallamothy et al, Am J Med 2002; 113: Aortic Dissection: clinical presentation

22 Aortic Dissection: etiology Prevalence of major risk factors: Hypertension50-90% Bicuspid AoV9-13% Marfan syndrome3-5%

23 Radiographic 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 knob Tracheal deviation to the Right Esophageal deviation to the Right (seen via NGT) Left apical cap Depressed Left mainstem bronchus Loss of paratracheal stripe *Hogg K. Sensitivity of a normal chest radiograph in ruling out aortic dissection. Best Evidence Topics. 9 March 2004.

24 Aortic Dissection Classification of Aortic Dissection Type - Not all require surgical intervention

25 Wrestler with Chest Pain 18 yo high school wrestler develops right-sided chest pain while pinning his opponent. Pneumothorax

26 Alcoholic with Chest Pain and Cough 45 yo alcoholic man with fever, chills and productive cough over two days RUL Pneumonia

27 Hyperemesis with Chest Pain 26yo G1P0 at 10wks presents with 4 days refractory emesis and 12 hours progressive, severe substernal chest pain Pneumomediastinum - Boerhaaves

28 Smoker with Chest Pain 68 yo former smoker with persistant, non- exertional, left substernal and left shoulder pain

29 Summary Chest pain in the ED differs from chest pain in primary care ACS is not the only cause of potentially life threatening chest pain Diagnosis of chest pain in the ED is rarely straight forward Chest pain in the ED is a high-stakes evaluation

30 Parting Words Careful history and physical are imperative While history or physical exam can suggest likely alternate diagnoses, none can rule out serious etiology Neither NTG nor GI cocktail response, nor reproducibility on palpation are diagnostic Post-prandial pain may be ischemic Use caution when diagnosing non-cardiac chest pain in patients with CAD or risk for CAD Atypical may be typical of something else Observation can be key

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