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

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. 1999 Oct;17(6):552-9.

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):383-90.

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

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

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)

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

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. 2007 Mar; 14(3):210-5

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 4.7 (1.9-12) Radiation to both arms/shoulders 4.1 (2.5-6.5) Exertional 2.4 (1.5-3.8) Radiation to L arm 2.3 (1.7-3.1) Associated with diaphoresis 2.0 (1.9-2.2) Associated with nausea or vomiting 1.9 (1.7-2.3) Worse than previous angina or similar 1.8 (1.6-2.0) to previous MI Described as pressure 1.3 (1.2-1.5) Descriptions decreasing the likelihood of MI Pleuritic 0.2 (0.1-0.3) Positional 0.3 (0.2-0.5) Sharp 0.3 (0.2-0.5) Reproducible with palpation 0.3 (0.2-0.4) Inframammary location 0.8 (0.7-0.9) Nonexertional 0.8 (0.6-0.9) JAMA 2005; 294:2623.

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;139:979-986 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

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 1.13 - 5.25 fold increase in risk of CHD HIV on HAART - not all accounted for by induced hyperlipidemia Ann Rheum Dis 2000;59;321-325 N Engl J Med 2007 Apr 26;356(17):1723-35

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?

Physical Signs

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

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

Adverse Cardiac Events (12 mo out) Patients discharged with chest pain of unclear origin: Abnormal ECG OR 9.5 (2.0 - 45.8) Preexisting DM OR 7.1 (1.8 - 27.2) Preexisting CAD OR 28.4 (3.5 - 229.0) Ann Emerg Med. 2004 Jan;43(1):59-67

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

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

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 24-72 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

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

Aortic Dissection: clinical presentation 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; 287:2262-2272. Nallamothy et al, Am J Med 2002; 113:468-471.

Aortic Dissection: etiology Prevalence of major risk factors: Hypertension 50-90% Bicuspid AoV 9-13% Marfan syndrome 3-5%

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.

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

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

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

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

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

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

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