1. Chest Pain
Sumit Bose, MD
PGY-3

2. Objectives Overview of chest pain Differential diagnosis of chest pain
Typical vs. atypical chest pain
Evaluation of chest pain
Review patient cases

3. Overview
Chest pain accounts for 6 million annual visits to the EDs in the United States
Chest pain is the second most common ED complaint
Patients with chest pain present with a wide spectrum of signs and symptoms
It is up to the clinician to recognize the life-threatening causes of chest pain

4. Overview
Cayley 2005

5. POSITIVE TROPONIN ≠ ACS
Pearl 1
CHEST PAIN ≠ ACS
POSITIVE TROPONIN ≠ ACS

6. Life-threatening causes of chest pain
Acute coronary syndrome (unstable angina, NSTEMI, STEMI)
Aortic dissection
Pulmonary embolism
Pneumothorax
Tension pneumothorax
Pericardial tamponade
Mediastinitis (e.g. esophageal rupture)

7. Differential diagnosis
UpToDate 2012

8. Typical vs. Atypical Chest Pain
Characterized as discomfort/pressure rather than pain
Time duration >2 mins
Provoked by activity/exercise
Radiation (i.e. arms, jaw)
Does not change with respiration/position
Associated with diaphoresis/nausea
Relieved by rest/nitroglycerin
Pain that can be localized with one finger
Constant pain lasting for days
Fleeting pains lasting for a few seconds
Pain reproduced by movement/palpation

9. Typical vs. Atypical Chest Pain
UpToDate 2012

10. Typical vs. Atypical Chest Pain
Cayley 2005

11. Evaluation of Chest Pain
Scenario 1 - It’s 2:00 AM and you are the VA NF intern. The nurse pages you and tells you that Mr. S, a 67 yro M with known hx of CAD, who is admitted for ARF is having chest pain after he walked back from the bathroom. What would you do next?

12. Evaluation of Chest Pain
Scenario 1:
Ask nurse for most current set of vital signs
Ask nurse to get an EKG
Ask nurse to have the admission EKG at bedside if available
Go see the patient!

13. Evaluation of Chest Pain
Once at bedside, determine if patient is stable or unstable
Read and interpret the EKG. Compare EKG to old EKG if available
If patient looks unstable or has concerning EKG findings, call your senior resident for help

14. Evaluation of Chest Pain
If patient is stable:
Perform a focused history
Does patient have known CAD or other cardiac risk factors?
Is the pain typical/atypical?
Is the pain similar to prior MI?
Perform a focused physical exam
Look for tachycardia, hypertension/hypotension or hypoxia on vital signs
General: Sick appearing, actively having chest pain
HEENT: JVD, carotid bruits
Chest: Rales, wheezes or decreased breath sounds
CVS: New murmurs, reproducible chest pain, s3 gallop
Abd: Abdominal tenderness, pulsatile mass
Ext: Edema, peripheral pulses
Skin: Rash on chest wall

15. Evaluation of Chest Pain
Labs/imaging/disposition
CXR
Cardiac biomarkers
ABG?
Telemetry/ICU
Write a clinical event note!

16. Evaluation of Chest Pain
Scenario 2 - You are the orphan intern and you get a page from and the DACR informs you that you have a 45 yro female in the ED who is being admitted to the Hellerstein service for r/o ACS. How would you approach this patient?

17. Evaluation of Chest Pain
Scenario 2:
Get report from ED physician about the patient
Ask ED physician about patient’s initial presentation
Get last set of vital signs
Ask ED physician to order EKG and CXR

18. Evaluation of Chest Pain
Go to UH Portal and print out an old EKG for comparison
Review prior discharge summaries
Quickly review prior cardiac work up –echo, stress tests and cath reports
Review any labs/imaging from current ED visit

19. CASES

20. Case 1
You are on the Wearn team and the nurse calls you and tells you that Ms. Z suddenly started having chest pain and her O2 sat went from 94% on room air to 88% on 2L via NC

21. Case 1
Ms. Z is a 62 yro F with PMHx of CAD s/p remote PCI to the LAD, COPD and right THA 3 weeks ago who was admitted for a COPD exacerbation
EKG on admission:

22. Case 1
You go see the patient. The patient tells you that she was feeling better after getting duonebs during this admission, but suddenly developed chest pain that is L-sided, 8/10 and worse with breathing. She has never experienced pain like this in the past
Vital signs: Afebrile, HR 120, BP 110/70, RR 28, O2 sat 89% on 2L
Physical exam
Gen – in distress, using accessory muscles of respiration
Lungs – CTAB, no rales/wheezes
Heart – tachycardic, nl s1, loud s2, no mumurs
Abd – soft, NT/ND, active BS
Ext – b/l LEs warm and well perfused
Labs:
CBC wnl, RFP wnl, BNP = 520, D-dimer = positive, Troponin = 0.12

23. Case 1

24. Case 1

25. Case 1

26. Case 1 - Pulmonary Embolism
Cayley 2005

27. Case 1 - Pulmonary Embolism
Diagnostic testing
Pulmonary angiography (Gold standard)
Spiral CT (CT-PE protocol)
V/Q scan (helpful for detecting chronic VTE)
D-dimer (<500ng/ml helps exclude PE in patient with low/moderate pre-test probability)

28. Case 1 - Pulmonary Embolism
Treatment of PE
Anticoagulant therapy is primary therapy for PE
Unfractionated heparin
LMWH
For unstable patients, catheter embolectomy or surgical embolectomy are options
For patients at risk for bleeding, IVC filter is an alternative

29. Case 2
24 yro M is being admitted to you from the ED for chest pain and EKG abnormalities
PMHx:
SLE
Asthma
You go see the patient and he tells you that he has had this chest pain for ~2 days, but it has progressively gotten worse. His chest pain is worse with breathing. He does report getting over a recent URI few days ago

30. Case 2 VS: T 38.1 HR 104 BP 140/76 RR 20 O2 sat 95% on RA
Physical exam:
Gen – in mild distress due to chest pain, leaning forward while in bed
Lungs – CTAB
Chest wall – no visible rash, chest wall NT to palpation
Heart – tachycardic, nl s1/s2, no rub
Rest of physical exam benign
Labs:
WBC = 14, RFP wnl, AMI panel x 1 = negative
CXR = negative

31. Case 2
EKG on admission:

32. Case 2 - Pericarditis Refers to inflammation of pericardial sac
Preceded by viral prodrome, i.e. flu-like symptoms
Typically, patients have sharp, pleuritic chest pain relieved by sitting up or leaning forward

33. Case 2 - Pericarditis
Goyle 2002

34. Case 2 - Pericarditis
Goyle 2002

35. Case 2 - Pericarditis
Diagnostic criteria
UpToDate 2012

36. Case 2 - Pericarditis
Treatment
UpToDate 2012

37. Case 3
You are evaluating a patient on the Carpenter team with chest pain
Patient is a 67 yro M with PMHx of HTN, HLD, DM-2 and CAD s/p PCI to the LCx in 2007 who is admitted for L leg cellulitis. He develops new onset chest pain that is retrosternal, 7/10, associated with nausea and diaphoresis. Says pain is radiating to his L jaw and is similar to the chest pain he had during his last MI

38. Case 3 VS: T 37 HR 108 BP 105/60 RR 20 O2 sat 93% on RA Physical exam:
Gen – actively having chest pain, diaphoretic
Lungs – rales at bilateral bases
Heart – tachycardic, nl s1/s2, no mumurs or rub
Rest of the exam benign
Labs: CBC wnl, RFP wnl, Troponin = 3.2, CKMB = 9, CK = 345

39. Case 3

40. Case 3 - NSTEMI
Risk stratification?

41. Case 3 - NSTEMI Management of UA/NSTEMI Aspirin
Inhibits platelet aggregation
HR control with beta-blocker
Titrate to goal HR ~ 60 beats/min
Statin
Nitroglycerin SL
Use if patient having active chest pain
DO NOT USE if patient is hypotensive and concern for RV infarct

42. Case 3 - NSTEMI Management of UA/NSTEMI Plavix Anticoagulation Oxygen
P2Y12 receptor blocker
Inhibits platelet aggregation
Anticoagulation
Heparin/LMWH
Inhibits thrombus formation
Oxygen
For O2 sat <90%
Morphine
For refractory chest pain, unrelieved by NTG SL

43. USE THE CHEST PAIN ORDER SET!
Pearl 2
USE THE CHEST PAIN ORDER SET!

44. Order Set

45. QUICK CASES

46. Case 4

47. Case 4
You find out the patient is having crushing chest pain radiating to the back. His BP in the R arm = 193/112 and in the L arm = 160/99
What diagnosis is on top of your differential?

48. Case 4 - Aortic Dissection
Stanford Classification
Type A – Involves ascending aorta
Type B – Involves any other part of aorta
Diagnostic Imaging
CXR
CT chest with contrast
MRI chest
TEE

49. Case 4 - Aortic Dissection
Management of Aortic Dissection
Type A dissection – Surgical
Type B dissection – Medical
Mainstay of medical therapy
Pain control
HR and BP control
Goal HR = 60 beats/min, goal SBP = mmHg
Use IV beta-blockers (i.e. Labetalol, Esmolol)
Can also use Nitroprusside for BP control
AVOID Hydralazine

50. Case 5
This is a 45 yro M with PMHx of rheumatoid arthritis who presented with progressive sob. He was found to have a R-sided pleural effusion and underwent an US guided thoracentesis with removal of 1.5 liters of pleural fluid. Two hours after his procedure, he develops new onset R-sided chest pain

51. Case 5

52. Case 5 - Pneumothorax Management of Pneumothorax
Supplemental O2 and observation in stable patients for PTX < 3 cm in size
Needle aspiration in stable patients for PTX >3 cm
Chest tube placement if PTX >3 cm and if needle aspiration fails
Chest tube placement in unstable patients

53. Pearl 3
ECG Wave-Maven

54. Summary
Chest pain is a very common complaint but has a broad differential
Always try to rule out the life-threatening causes of chest pain
It is important to remember that troponin elevation DOES NOT always mean ACS
Use the history, physical exam, labs, EKG and imaging to commit to a diagnosis
Whenever you are stuck, ask for help. Your seniors are here to help you!

55. References
Cayley, W.E. Diagnosing the cause of chest pain. (2005). American Family Physician, Vol 72 (10),
Goyle, K.K. and Walling, A.D. Diagnosing pericarditis. (2002). American Family Physician, Vol 66 (9),
Diagnostic approach to chest pain in adults. (2012). UpToDate.
Differential diagnosis of chest pain in adults. (2012). UpToDate.
Evaluation of chest pain in the emergency department. (2012). UpToDate.
Clinical presentation and diagnostic evaluation of acute pericarditis. (2012). UpToDate.
Treatment of acute pericarditis. (2012). UpToDate.