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
Overall, approximately 16% of visits with serious etiology
(Calculated)
Kohn MA, et al. J Emerg Med. 2005;29(4):

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 ;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
Pericarditis
Pleurisy
Aortic dissection Boorhave’s
Myocardial ischemia
Pulmonary embolism
Pericarditis
Myocardial ischemia
Cervical spine
Thoracic outlet
Myocardial ischemia
CHF
Pancreatitis
Cholecystitis
Peptic disease
Pulmonary embolism
Pneumonia
Myocardial ischemia
Splenic infarction
Intraperitoneal fluid
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
Likelihood ratios for MI based on components of the chest pain history
Description of pain LR (95%)
Descriptions increasing the likelihood of MI
Radiation 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 MI
Described as pressure ( )
Descriptions decreasing the likelihood of MI
Pleuritic ( )
Positional ( )
Sharp ( )
Reproducible with palpation ( )
Inframammary location ( )
Nonexertional ( )
JAMA 2005; 294:2623.

10. Nitroglycerine in ER Chest Pain
Annals of Internal Medicine 2003
Improvement in chest pain with nitroglycerine proved:
35% Sensitive
30% Specific
Ann Intern Med. 2003;139:
Canadian Journal of Emergency Medicine 2006
Improvement in chest pain with nitroglycerine proved:
72% Sensitive
37% Specific
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
Marfan’s/connective tissue dz - self or family
Medications - HAART, estrogen
Lupus - hypercoagulable, steroids, inflammation
Women with SLE have 7-50 fold increased risk of CHD, greatest in young women
People with RA have fold increase in risk of CHD
HIV on HAART - not all accounted for by induced hyperlipidemia
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 CAD OR 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
Initial CXR in PE virtually always NORMAL
Westermark sign - RARE
Hampton hump – LATE & RARE
EKG Evidence:
Tachycardia - sinus, afib or aflutter
RV Strain
S1, Q3, T3
Poor R wave prog + TWI V1-4
Westermark sign - a dilatation of the pulmonary vessels proximal to an embolism along with collapse of distal vessels - RARE
Some patients develop atelectasis that may progress to small pl eff and elevated hemidiaphragm
At hours 1/3 of patients develop focal infiltrates indistinguishable from pneumonia
Hampton hump, a triangular or rounded pleural-based infiltrate with the apex pointed toward the hilum, frequently located adjacent to the diaphragm – LATE and RARE
Atelectasis, small pleural effusion &
Elevated hemidiaphragm may develop
24-72 hours – focal infiltrates
D-Dimer - Only useful to rule out
PE in LOW RISK

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. Aortic 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:

22. Aortic Dissection: etiology
Prevalence of major risk factors:
Hypertension %
Bicuspid AoV %
Marfan syndrome 3-5%

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 - Boerhaave’s

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