Evaluation of Chest Pain In Outpatient Clinic Crystal Wiley Cené, MD, MPH

A Chest Pain Case A 65 year-old man with a past medical history significant for hypertension and dyslipidemia presents to clinic after 2 episodes of chest pain in past couple days. What do you want to know and do?

Clinical classification of chest pain Typical angina (definite) Substernal chest discomfort with a characteristic quality & duration that is 2) provoked by exertion or stress and 3) relieved by NTG or rest Atypical angina (probable) Meets 2 of above characteristics Noncardiac chest pain Meets 1 or none of typical anginal characteristics

#1 Goal EXCLUDE Coronary artery disease and other life-threatening conditions

So, what are those? Acute Coronary Syndrome/Myocardial infarction Pulmonary embolus Aortic dissection Tension Pneumothorax *All of these could lead to sudden death*

History “PQRST” Severity Timing Provocative/palliative factors Quality: character, duration, frequency, associated sxs Radiation Severity Timing Risk factors: age, tobacco use, family history, DM/HTN/Lipids, cocaine; other- DVT/PE, Marfans/Pregnancy, ETOH, NSAIDS PMHx: prior CV w/u & Rx, GI history

Provocation and Palliation Postprandial? GI or cardiac disease Exertion? Angina or esophageal pain Cold, emotional stress, sexual intercourse can promote ischemic pain Worse with swallowing? Esophageal origin Body position, movement, deep breathing? Musculoskeletal origin Antacids or food? Gastro-esophageal origin Sublingual nitro? Esophageal or cardiac “GI Cocktail” (viscous lidocaine and antacid)? GI or cardiac Cessation of activity/rest? Ischemic origin Sitting up and leaning forward? Pericarditis

Evaluation Severity: not useful predictor for presence of CAD Region or location: Radiation to neck, throat, lower jaw, teeth, upper extremity, or shoulder Radiation to arms is useful and stronger predictor of acute MI Between scapulae think aortic dissection Larger areas of discomfort more likely ischemic etiology Severity: not useful predictor for presence of CAD Timing: Abrupt onset with greatest intensity in beginning: PTX, dissection, acute PE Gradual with increasing onset over time: ischemic Crescendo pattern: esophageal disease Lasts for seconds or constant over weeks ≠ ischemic Circadian rhythm (morning>afternoon) correlating with increase sympathetic tome- more likely myocardial ischemia

Associated Symptoms Belching, bad taste in mouth, dysphagia or odynaphagia esophageal disease Vomiting Transmural MI, GI problems Diaphoresis MI> esphoageal disease Syncope dissection, PE, critical AS, ruptured AAA Presyncope myocardia ischemia Palpitations in setting of new A. Fib + chest pain PE Fatigue can be presenting complaint of MI esp. in elderly

Any exam findings that might help distinguish cardiac from non cardiac chest pain? General Appearance may suggest seriousness of symptoms. Vital signs marked difference in blood pressure between arms suggests aortic dissection Palpate the chest wall Hyperesthesia may be due to herpes zoster Complete cardiac examination pericardial rub signs of acute AI or AS Ischemia may result in MI murmur, S4 or S3 Determine if breath sounds are symmetric and if wheezes, crackles or evidence of consolidation

Ancillary Studies EKG “Normal” reduces probability chest pain is due to AMI, but does NOT exclude serious cardiac etiology (i.e. Unstable Angina) ST elevation, ST depression, or new Q waves- important predictor of Acute Coronary Syndrome (AMI or UA) “Nonspecific” ST and T wave changes is common- may or may not indicate heart disease CXR Useful in acute setting to avoid missing dangerous diagnoses (e.g. PTX, Aortic dissection, Pneumomediastinum)

“Likelihood Ratio” Likelihood ratio expresses the odds that a given level of a diagnostic test result would be expected in a patient with (as opposed to without) the target disorder Sacket, et al. Clinical Epidemiology

Features Increasing Likelihood of AMI Clinical Feature Likelihood Ratio (95% CI) Pain in chest or left arm 2.7 Chest pain radiation Right Shoulder 2.9 (1.4-6.0) Left arm 2.3 (1.7-3.1) Both left and right arm 7.1 (3.6-14.2) Chest pain most important symptom 2.0 History of MI 1.5-3.0 Nausea or vomiting 1.9 (1.7-2.3) Diaphoresis 2.0 (1.9-2.2) Third heart sound 3.2 (1.6-6.5) Hypotension (SBP<80) 3.1 (1.8-5.2) Pulmonary rales on exam 2.1 (1.4-3.1)

Features Decreasing Likelihood of AMI Clinical Feature Likelihood Ratio (95% CI) Pleuritic chest pain 0.2 (0.2-0.3) Chest pain sharp or stabbing 0.3 (0.2-0.5) Positional chest pain 0.3 (0.2-0.4) Chest pain reproduced with palpation 0.2-0.4 Panju, et al. JAMA 1998;280:14:1256-1263

ECG Findings Increasing Likelihood of AMI Panju, et al. JAMA 1998;280:14:1256-1263

High likelihood of ACS Worsening frequency, intensity, duration, timing (e.g. nocturnal pain, rest pain) of prior angina New onset SOB, nausea, sweating, extreme fatigue in patient with known h/o CVD Onset of typical anginal symptoms in pt without h/o CVD New murmur (or worsening of previously noted murmur), hypotension, diaphoresis, rales, pulmonary edema Transient ST deviation (≥ 1mm) or TWI in multiple precordial leads

Case A 57 year old male comes in to the ER with sudden onset of “tearing chest pain” that radiates to his back. What is your differential? What exam findings might you look for? What tests could you do and why? What are the treatments for the most likely diagnoses?

What exam findings might you look for? Acute MI Hypotension in one extremity Aortic murmur Neurologic deficits, including paraplegia, stroke, or decreased consciousness Syncope, tamponade, and sudden death due to rupture of the aorta into the pericardial space Shock, hemothorax, and exsanguination Acute lower extremity ischemia

Wrestler with Chest Pain 18 yo high school wrestler develops right-sided chest pain while pinning his opponent. Physical exam reveal decreased breath sounds on right

Final Thoughts Nitro response is not diagnostic of UA Post-prandial pain may be ischemic Discomfort thresholds vary Patient histrionics may influence you “Atypical” is typical of something Value of careful history and physical