1. Chest Pain Epidemiology
6 million ED visits/year
5-7% ED patients
3.3% AIS evacuations 2002, 3.5% in 2003, % in 2004, 3.2% in 2005
3 million patients admitted/year
70% found not to have acute coronary event
0.4% - 4.0% acute MI are sent home

2. Chest Pain Pathophysiology
Chest pain syndromes difficult to diagnose
Multiple organ systems of the chest
Share afferent (nerve) pathways
Pathology in any of these systems have similar pattern of complaints
Most patients have CP with acute coronary syndrome(ACS), others may present with only SOB, N/V, arm or jaw pain

3. Differential Diagnosis of Chest Pain
Life-threatening causes
Acute coronary syndrome(ACS)
Aortic dissection
Pulmonary embolism
Tension pneumothorax
Esophageal rupture (Boerhaave’s syndrome)
Pericarditis; myocarditis
Acute chest syndrome(in sickle cell disease)
Myocarditis is the most common cause of sudden death in the young. Acute chest syndrome is the most common cause of death in sickle cell patients. Sickle cell patients presenting with chest pain should be presumed to have acute chest syndrome until proven otherwise. Progressive hypoxia, multilobar pneumonia, on chest x-ray, and falling hemoglobin levels are the most common clinical findings.

4. Differential Diagnosis of Chest Pain
Non-life-threatening causes
Gastrointestinal
Biliary colic (cholelithiasis, cholecystitis)
Gastroesophageal reflux disease
Peptic ulcer disease
Pulmonary
Pneumonia
Pleurisy

5. Differential Diagnosis of Chest Pain
Non-life-threatening causes
Chest wall syndromes
Musculoskeletal pain
Costochondritis
Thoracic radiculopathy
Psychiatric
Anxiety
Shingles

6. Chest Pain Evaluation Problems History Risk factors Physical exam
Rhythm strip, 9 lead ECG, 12 lead ECG
Risk stratification based on above factors
Do modified 9 lead by placing unit in the diagnostic mode.

7. The Initial Clinical Examination
ECG can only help if it shows acute MI
Initial ECG sensitivity 20% - 60% AMI
Sensitivity of plasma CK-MB low first 4 hrs
Can’t detect unstable angina
Therefore evaluation based on history, physical exam and ECG

8. History
“The most important difference between a good and indifferent clinician lies in the amount of attention paid to the story of the patient”---Farquhar Buzzard

9. History
Helpful to group questions to target the three most common life threats;
Consider ACS questions
Pulmonary embolism(PE) questions
Aortic dissection questions

10. History Cardiac Questions
2 most important historical information
age, gender
Advancing age, prevalence and severity of CAD increases
Can estimate pretest probability of CAD based on age and gender
Further refine pretest probability by classifying the chest pain as typical, atypical, or non-anginal
CAD(coronary artery disease). A combination of autopsy data and large angiography studies allows us to estimate the pretest probability of CAD in patients based on age and gender alone.

11. Pretest likelihood of CAD based on age, sex, and symptoms
Asymptomatic non-anginal CP
Age Men Women Men Women
% % % %
% % % %
% % % %
% % % %

12. Pretest likelihood of CAD based on age, sex, and symptoms
Atypical angina Typical angina
Age Men Women Men Women
% % % %
% % % %
% % % %
% % % %
Atypical(variant) angina or Prinzmetal angina primarily occurs at rest and without provocation. The current thought is that variant angina is due to vasospasm of the coronary vessels. When studies are performed by angiogram, about 1/3 have no or insignificant atherosclerosis and about 2/3 have CAD in addition to spasm.

13. Cardiac Questions
Example; 35y/o male with non-anginal CP has 5% pretest probability of CAD(1 in 20)
same 35y/o with atypical angina 22% of CAD or (1in 5)
same 35y/o with typical angina 70%(7in10)
If patient has known previous CAD/MI raises risk of subsequent coronary event 5 times
If patient has cardiac history ask about prior stress tests, cardiac caths, bypass surgery, stents

14. Cardiac Questions Character of Pain
Many patients have atypical symptoms
Ask questions in regard to nature (quality), severity(1-10), duration, modifying factors of the pain, and associated symptoms
40% patients with AMI have atypical CP
35% patients without AMI have typical CP

15. Cardiac Questions
In one study of 721 patients who were diagnosed with AMI, almost ½ presented without CP
SOB, weakness, dizziness, syncope, abdominal pain
Typical angina is a deep, poorly localized chest or arm discomfort that is classically exertional and relieved with rest or nitrates

16. Analysis of Clinical Predictors of AMI
Clinical features AMI
chest pain radiation Odds ratio
left arm
right arm
both arms
nausea, vomiting
diaphoresis
exertional CP

17. Analysis of Clinical Predictors of AMI
Clinical features AMI
Odds ratio
burning/indigestion pain
crushing/squeezing pain
relief with nitroglycerin
pleuritic pain
tender chest wall
sharp/stabbing pain

18. Cardiac Questions
Another study of 251 patients with cardiac CP showed 88% respond to NTG, also 92% of noncardiac CP responded to NTG
Can you give GI cocktail to R/O cardiac CP?
a study of 97 patients who received GI cocktail showed 8 of 11 patients admitted with possible cardiac ischemia had complete or partial relief of CP

19. Cardiac Questions Risk Factors
Diabetes, hypertension, smoking, high cholesterol, and family history
Most CAD patients have at least one
The absence of risk factors does not exclude acute cardiac ischemia

20. Aortic Dissection History
Male (75%)
Seventh decade
History of hypertension (70%)
Other risk factors;
Marfan’s syndrome, atherosclerosis, prior dissection, or known aortic aneurysm
Marfan”s syndrome is a generalized disorder of connective tissue with skeletal, ocular, and cardiac manifestations. The extremities are long and thin. The eyes show subluxation of the lens. Severe myopia and spontaneous retinal detachment are common. Cardiovascular defects include disruption and loss of elastic fibers in the media of the aorta. The lack of elasticity results in progressive diffuse dilatation of the proximal segment of the ascending aorta and severe aortic regurgitation. Heart failure and rupture of the aorta from dissecting aneurysm are the most common cause of death.

21. Aortic Dissection History
Pain is sudden onset (83%)
Severe or “worse ever” (90%)
Sharp (64%) or tearing (50%)
Location anterior chest (60%), back (53%)
Migratory (16%), radiating (28%)
Suspect dissection in patients with clinical changing picture
Patients who complain of chest pain along with a neurologic deficit may have a dissection occluding a cerebral or spinal artery.

22. Aortic Dissection History
Should address 3 basic concerns regarding a patient’s pain:
quality (sudden and severe)
radiation (especially to the back)
intensity at onset (maximal)
Aortic dissection and MI can coexist
8% dissection involves coronary arteries
One retrospective study showed that when all three questions were asked, physicians correctly diagnosed thoracic aortic dissection in 30 of 33 patients(91%); if one or more of these aspects were omitted, the correct diagnosis was suspected in fewer than half of all patients.
EKG changes such as acute ST and T wave abnormalities are present in half of all patients with aortic dissection--- often confounding the initial diagnosis.

23. Pulmonary Embolism History
Clinical diagnosis of PE is difficult
Symptoms are variable and nonspecific
Can range from dyspnea and fatigue to severe pleuritic CP and syncope
Classic description of pleuritic pain, dyspnea, and hemoptysis represents embolic pulmonary infarction and is seen most commonly in hospitalized patients

24. Pulmonary Embolism History
Ambulatory patients often present with painless dyspnea
Can have several weeks of intermittent symptoms
Physical exam is rarely diagnostic
Reproducible chest wall pain does not exclude diagnosis

25. Pulmonary Embolism History
Wide spectrum of pain quality and location
Pain that is peripheral, increases with deep breath, and not reproducible- suspect PE
Isolated substernal, pleuritic CP less likely PE
Substernal, anginal CP occurs 4% PE
Radiation to arm distinctly unusual
Pleuritic CP and leg pain more commonly PE than other diagnosis

26. Pulmonary Embolism Risk Factors
Inherited hypercoagulability disorders
Acquired disorders:
immobilization, pregnancy, BCP
malignancy, age
prior history venous thromboembolism
trauma, obesity
surgery, smoking

27. Pulmonary Embolism Risk Factors
Medical conditions
CHF MI
stroke
hyperviscosity syndrome (polycythemia vera)
Crohn’s disease
Nephrotic syndrome

28. Other Conditions
Boerhaave’s syndrome presents as spontaneous esophageal rupture after vomiting
Pain on swallowing
Significant number are recently, or acutely intoxicated
Pericarditis refers pain to neck, shoulder and worsens with inspiration, swallowing, and lying supine

29. Physical Examination
Stable patients with AMI rarely have physical findings on exam
Vital Signs
Chest pain and hypotension-not good
8% PE and 15% aortic dissection are hypotensive on presentation
Patients with CP and hypotension are 3 times more likely to have AMI than normotensive pts

30. Physical Examination Vital Signs
Fever, consider noncardiac cause, pneumonia, mediastinitis
Low grade fever occurs 14% PE, only % PE pts had fever> 102F
Tachypnea is most common sign in PE, 15% PE pts had respiratory rate <20/min

31. Physical Examination Vital Signs Tachycardia is nonspecific sign
May be only clue to early pericarditis, myocarditis
Bradycardia, esp. due to conduction defects, may be seen in right coronary occlusions

32. Physical Examination Vital Signs Fifth vital sign, pulse oximetry
Hypoxia can occur in many conditions
Patient with low O2 saturations require supplemental oxygen
O2 saturation is normal in ¼ of pts with PE

33. Physical Examination Head and Neck
Check neck for Kussmaul’s sign (a paradoxical increase in jugular venous distension with inspiration)
Seen in pericardial tamponade, right heart failure or infarction, PE, or tension pneumothorax)
Subcutaneous air at the root of the neck suggests pneumothorax, or pneumomediastinitis
Carotids bruits increase likelihood of CAD

34. Physical Examination Pulmonary Exam
Look for respiratory distress:
nasal flaring, intercostal retractions, and accessory muscle use
Listen for unilateral absence of breath sounds; consider pneumothorax, or massive pleural effusion
Percuss the chest for infiltrates, effusions, and pneumothorax

35. Physical Examination Pulmonary Exam
Wheezing and rales are important findings but are not specific for certain diseases
Asthma, foreign body, CHF, PE all may cause wheezing
Rales are rare in pts with AMI, but their presence with left heart failure, raises the likelihood of MI by twofold

36. Physical Examination Cardiac Exam
A new murmur may signal papillary muscle rupture
Murmur of aortic insufficiency is an important finding associated with aortic dissection
S3 gallop secondary to CHF raises likelihood of MI 3 times

37. Physical Examination Cardiac Exam
Hamman’s crunch- crunching sound of heart beating against mediastinal air
Pericardial rub(creaking of new leather) seen in pericarditis
Beck’s triad(distant heart sounds, distended neck veins, and hypotension) seen in pericardial tamponade from proximal aortic dissection

38. Physical Examination Chest Wall Exam
Even with chest wall tenderness, still have to consider life-threatening causes
Reproducible CP frequently seen in pts with PE and ACS
Costochondritis is inflammation of the costal cartilages, may result in sharp, dull, or pleuritic CP, rarely has swelling of soft tissues

39. Physical Examination Chest Wall Exam
Tietze’s syndrome- fusiform swelling and pain of only one upper costal cartilage
Compression of cervical or thoracic nerve may produce dull chest pain mimickings angina (cervico-precordial angina)
Pain worsens with neck movement, coughing, sneezing, or axial loading of the vertebrae
Check skin for herpes zoster (shingles); causes unilateral pain over 1-2 dermatones

40. Physical Examination Exam of the Extremities
Look for edema, thrombosis, or pulse deficits
Peripheral edema frequently seen in right-sided and biventricular failure
Usually absent in acute left heart failure
Unilateral edema or palpable venous thrombus(cord) suggest DVT or PE
But most pts with PE have normal ext. exams

41. Physical Examination Examination of Pulses
Exam for symmetry and quality
Pulse deficit is defined as asymmetrical amplitude between the right and left sides
Pulse deficits most common in type A dissections(ascending aorta)
Measured BP difference occurs 15%
Differences > 20mmHg between arms was an independent predictor of dissection

42. Physical Examination Neurologic Exam
Altered mental status nonspecific finding
Associated with any cause of CP that leads to BP instability and cerebral hypoperfusion
17% aortic dissection have focal neurologic deficits due to occlusion of carotid or spinal arteries
Distal aortic dissections can cause spinal cord ischemia

43. Diagnostic Studies
The ECG is the most important test in the evaluation of CP
The initial ECG is insensitive in identifying acute coronary syndrome
Only 20%-60% pts presenting with acute MI have diagnostic changes on initial ECG

44. Diagnostic Studies ECG
What diagnostic changes?
at least 1 mm elevation in one or more inferior/lateral leads
or at least 2mm of elevation in one or more anterioseptal leads
10% pts with AMI have LVH with repolarization changes
Tall peaked T waves may be earliest sign of AMI

45. Acute Anterior MI

46. Acute Inferior MI

47. Offshore Case Presentation # 1
Chief Complaint
chest and arm pain
History of Present Illness
38 y/o male c/o burning right sided chest and arm pain which began after he stood up from the supper table.

48. Case Presentation # 1 History of Present Illness
Pain is burning in quality
Location is substernal and in the right arm
5 on (1-10 scale) initially, now 2
No radiation, duration > 2 hours
No associated nausea, vomiting, SOB, or diaphoresis
Pain increased after climbing 3 flights stairs

49. Case Presentation # 1 Past History
2 weeks ago dx with acid reflux, had substernal chest pain. PMD stated ECG was normal, blood test normal, but cholesterol and BP were elevated
Began Nexium, cholesterol, and BP meds, but quit taking them
No other past medical problems

50. Case Presentation # 1 Medications- none NKA Risk Factors
+ HTN, cholesterol, Family hx heart disease, smoker
- diabetes

51. Case Presentation # 1 Physical Examination
Vital signs: BP-140/88, P-76, RR-20, T-97.9, O2 sat.-98%; ECG- no acute changes
Alert WM in NAD
skin warm, and dry
Ht -RR&R; Lungs- clear; Chest wall- nontender; Abd- soft, nontender; Ext- equal pulses

52. Case Presentation # 1
What should we do now?

53. Case Presentation # 1 Treatment Plan, Physician Orders
4 baby ASA chew and swallow O2
IV NS TKO
NTG SL q3-5min up to 3
Nitrol paste 1” if BP stable
MS if needed
Send in emergently

54. Case Presentation #1 Final diagnosis: ACS
Angiogram revealed two 95% blockages, 2 stents placed

55. Case Presentation # 2 Chief Complaint chest pain
History of Present Illness
32y/o male with squeezing, substernal chest pain that began while sitting in chair. Pain is worse with deep breathing and not relieved by drinking carbonated soda.

56. Case Presentation # 2 HPI
Quality- squeezing
Location- substernal
No radiation, duration >1 hour
Intensity- 5 (1-10) scale
No associated nausea, vomiting, SOB, diaphoresis

57. Case # 2
Past History
Hx of 2 previous episodes of chest pain while on rig. 1st workup was neg. 2nd revealed aortic valve problem and coronary blockage with stent placement 1998
Hx of HTN
Medicines- Toprol, Avapro, and ASA qd
NKA

58. Case # 2
Risk Factors
+ HTN, smoker, Past Hx of CAD, Family Hx of MI- GF (both sides)
- DM, elevated cholesterol

59. Case # 2
Physical Exam
Vital signs- BP 160/80, P-94, RR-16, O2 sat 98%; ECG- no acute changes
Alert WM in NAD
skin warm and dry
heart- RR&R; Lungs- clear; Chest wall nontender; Abd- soft, nontender; Ext- equal pulses

60. Case # 2
What should we do now?

61. Case # 2 Treatment Plan, Physician Orders
IV NS TKO
NTG SL q3-5min up to 3
Nitrol paste 1” if BP stable
MS if needed
Send in emergently

62. Case # 2 Final diagnosis:
Work up revealed an ascending aortic aneurysm
Emergent surgical repair, resection

63. Case # 3 Chief complaint Shortness of breath
History of Present Illness
53y/o awoke from sleep with SOB. Patient denies CP, nausea, vomiting, or diaphoresis. No hx of previous episodes in past. Denies cold, but did have coughing episode prior to SOB.

64. Case # 3 Past Medical History negative Medicine- none NKA Risk Factors
+ smoker
- HTN, DM, cholesterol, Family Hx CAD

65. Case # 3
Physical Exam
Vital signs- BP-130/90, P-104, RR-30, T-97.4, O2 sat- 95%; ECG- sinus tach, no acute changes
Alert WM in mild distress, not SOB now
skin warm and dry
Heart- RR&R; lungs- clear, no wheezes; Abd- nontender; Ext- no swelling, equal pulses

66. Case # 3
What should we do now?

67. Case # 3 Treatment Plan, Physician Orders
IV NS TKO
Cardiac Monitor
Emergent evacuation

68. Case # 3
Final Diagnosis
Pulmonary Embolism

69. Questions???