1. James Ignatius Nicole Qaqish 7/19/2010
Chest Pain
James Ignatius
Nicole Qaqish
7/19/2010

2. Classification Cardiac Vs Non-Cardiac causes
Cardiac: Ischemic Vs Non-ischemic pathology
Ischemic: Angina, Myocardial Infarction
Non-Ischemic: Pericarditis
Non Cardiac: G.I (GERD, PUD), Pulmonary (PE, Pneumothorax, Pneumonia, Pleurisy, and Pul. HTN)

3. Chest Pain Questions “LIQUOR’D” mnemonic
L = location, (retro, substernal…
I Intensity (1 -10)
Q Quality (Sharp, Pressure, dull…)
U Upsetting/Aggravating Factors
O Onset
R Releiving factors + Radiation
D Duration

4. Angina
Chest pain that occurs when the coronary arteries do not deliver an adequate amount of oxygen-rich blood to the heart
Categorized as stable, unstable, and Variant (Prinzmetal’s )

5. Stable Angina Clinical findings of stable angina:
Substernal , high pressure/heavy feeling
Duration from 1 – 5 minutes
Instigated by physical exertion
Relieved with rest or nitrates

6. Unstable Angina Clinical findings of Unstable Angina:
Occurs even at rest
unexpected
More severe and lasts longer than stable angina, maybe as long as 30 minutes
May not disappear with rest or use of nitrates

7. Variant Angina
Transient coronary vasospasm that is associated with a fixed atherosclerotic lesion (75%)
Pt tends to be younger and in seemingly good health
Occurs at rest and and associated with ventrcular dysrhythmias
Nitrates and CCB’s are often effective

8. Diagnosis
Resting EKG – normal in pts with Stable Angina, ST/T wave changes in unstable Angina and Variant Angina
Stress Echo-detect ischemia, asses LV function and valve disease

9. Treatment Lifestyle changes
Pharmacotherapy – Aspirin, Beta, Blockers, CCB, Nitrates
Revascularization (CABG)

10. Myocardial Infarction
Interruption of blood supply which causes necrosis of the myocardium.
Atheromatous plaque ruptures into lumen and thrombus forms on top of the lesion causing occlusion
MI has a 30% mortality rate.

11. Myocardial Infarction
Clinical Features:
Crushing substernal chest pain(usually >30 minutes)
Radiation to arms, neck, jaw, back (Left side)
Diaphoresis, Nausea, Vomiting, Dyspnea, Syncope

12. Diagnosis EKG changes:
ST elevation – transmural injury and can be diagnostic of acute infarct
ST depression – Sunbendocardial injury
Q wave – evidence for necrosis, usually indicative of an old MI. Not seen acutely

13. Diagnosis

14. Diagnosis Cardiac enzymes – Gold Standard. 3 sets q8 in 24 hours
CKMB – increases within 4-8 hours, peaks at 24hrs, and returns to normal hrs later
Trop I – More specific/sensitive than CKMB.
TropI falsely increased in Renal failure

15. Treatment
Admit pt to CCU, Insert IV, , administer oxygen, nitrates, morphine
Aspirin, b-blockers, ACE Inhibitors reduce mortality
Lovenox can slow progression of thrombosis.
Cardiac Rehab- exercise + lifestyle changes post MI

16. Pericarditis Inflammation of fibrous sac which covers the heart
Causes: Viral Infection (Coxsackie B, Echovirus, Hep. A/B) MI, Uremia,
Pts usually recover in 1-3 weeks

17. Pericarditis Clinical Features:
Pleuritic chest pain that is positional(worsened by lying down, inspiration). Pain is releived by sitting up + leaning forward
Friction Rub – scratching, high-pitched sound caused by rubbing of visceral and parietal pleura

18. Pericarditis Diagnosis
EKG – ST elevation and PR depression , then ST returns to normal, Twave inverts, then returns to normal.
Treatment: Treat underlying cause and offer NSAIDS for pain

19. GERD
Inaappropriate relaxing of LES causes backwards flow of stomach contents into esophagus.
Contributing factors: ETOH, coffee, fatty food intake, increased age, and Hiatal Hernia

20. GERD Clinical Features: Burning, retrosternal pain after meals
Cough, nausea, vomiting
Hoarseness , sore throat
Reflex saliva hypersecretion

21. GERD
Diagnosis:
Endoscopy w/ Biopsy- Can detect cancer complication or GERD
24 hr pH monitoring of LE – Gold Standard. Highly specific/sensitive

22. GERD Treatment: Phase I- diet changes + antacids
Phase II – Add H2 blocker (Ranitidine)
Phase III – Switch to PPI if symptoms don’t resolve
Phase IV – Add pro – GI motility Agent (bethanechol/metoclopramide)
Phase V – combo (H2 or PPI) + BTH/MET

23. Peptic Ulcer Disease
A peptic ulcer is erosion in the lining of the duodenum.
Causes: H. pylori infection, NSAID, Zollinger-Ellison syndrome, Smoking, Stress
Clinical Features:
Epigastric pain that is achy
Nausea, vomiting, weight loss, Upper GI bleed

24. Diagnosis Endoscopy is most accurate test
Histological evaluation of endoscope biopsy – Gold Standard for H. pylori infection
Urease Breath Test – Shows active infection, and efficacy of antibiotic therapy
Serum gastrin- specific test for ZE Syndrome

25. Treatment
Lifestyle mods(Reduce smoking,stress, ETOH, NSAID) No food before bedtime!
If H. pylori is present use Triple or Quadruple therapy
Triple ( PPI + 2 antibiotics)
Quadruple (PPI + Peptobismol + 2 Antibiotics)

26. Treatment H2 blockers help with ulcer healing
Surgical intervention need for complications of PUD like bleeding, perforation

27. Case Study
A 30 year old woman comes to the clinic complaining of chest pain. For the last 2 years, she has had intermittent nocturnal chest pain that lasts up to 10 minutes. The pain is substernal and radiates to her throat. It is 6/10 and wakes her up from sleeping. She has mild nausea and a clammy feeling. In the past, she has used antacids and PPI which did NOT help. Aerobic exercise sometimes instigates this pain.

28. Case Study
She reports being quite healthy except for having Raynauds phenomenon in winter and migraines treated with sumatriptan. Social history is remarkable for cocaine use. Vital signs and physical exam are unremarkable. Holter monitor study is arranged. What findings would be most likely evident during an episode of her chest pain?

29. Case Study A) PR segment depression
B) Normal electrocardiographic tracing
C) Prolonged QT interval with increased duration at night
D) Transient St elevation in inferior Leads

30. Answer
D) This patient has a classic presentation of Variant Angina, which is caused by coronary vasospasm that induces transient ischemia and ST elevations. Patients are usually young women w/o classic CVS risk factors. It usually occurs at night and can be worsened by cocaine and serotonergic agents like sumatriptan.

31. Answer
Vasospams can occur in any distribution but tend to favor the right coronary artery which supplies the inferior portion of the heart
A = Pr depression is indicative of pericardits. Viral infection in Hx would have been a clue and leaning forward in bed would have produced relief.

32. Answer
B= ST elevations and T wave changes are associated with variant angina. EKG can not be normal
C= There is no reason to suspect QT interval prolongation. Pts who have syncopal episodes may have QT prolongation and it would not worsen at night.

33. Respiratory Induced Chest Pain
By Nicole Qaqish
7/19/2010

34. Clinical Presentations
Shortness of breath
Cough
Pleuritic chest pain
Non specific

35. Initial Approach to Chest Pain
Ensure adequate A,B,C’s, asses vital signs, Detailed history on the chest pain
Rule out Life threatening Lung/ Cardiac conditions.
Categorize the chest pain
Pleuritic ( Pain upon inspiration)
Visceral ( Dull, Tightness, that is poorly localized)
Chest wall pain

36. Approach to Chest Pain
Many Respiratory induced chest pain have similar symptoms.
Evaluate any risk factors the patient might have.
Pulmonary embolism ( Hypercougable states, H/O DVT’s, recent immobilization)
Pneumothorax ( trauma, recent ventilation)
Pnuemonia ( age >65, Immune deficient, Hospitalization causing noscomial pneumonia

37. The Physical Exam Inspection – rate and pattern of breathing
Palpation – Focal tenderness, rib fractures
Percussion – Determine Resonance within the lung tissue
Hyperresonance (pneumothorax) vs dull percussion (pneumonia)
Auscultation – the quality and intensity of breath sounds. Adventitious sounds such as rales, rhonchi, friction rubs can also be heard and be diagnostic for specific lung conditions.
I-increased work of breathing. Asymmetric expansion of the chest is usually due to an asymmetric process affecting the lungs, such as endobronchial obstruction of a large airway, unilateral parenchymal or pleural disease, or unilateral phrenic nerve paralysis. Visible abnormalities of the thoracic cage include kyphoscoliosis and ankylosing spondylitis, either of which can alter compliance of the thorax, increase the work of breathing, and cause dyspnea.
A- ronchophony andwhispered pectoriloquy, respectively, are present. The sound of a spoken E becomes more like an A, although with a nasal or bleating quality, a finding that is termed egophony.
Crackles are the discontinuous, typically inspiratory sound created when alveoli and small airways open and close with respiration. They are often associated with interstitial lung disease, microatelectasis, or filling of alveoli by liquid. Wheezes, which are generally more prominent during expiration than inspiration, reflect the oscillation of airway walls that occurs when there is airflow limitation, as may be produced by bronchospasm, airway edema or collapse, or intraluminal obstruction by neoplasm or secretions. Rhonchi is the term applied to the sounds created when there is free liquid or mucus in the airway lumen; the viscous interaction between the free liquid and the moving air creates a low-pitched vibratory sound. Other adventitious sounds include pleural friction rubs and stridor. The gritty sound of a pleural friction rubindicates inflamed pleural surfaces rubbing against each other, often during both inspiratory and expiratory phases of the respiratory cycl

38. Imagining Chest –Xray Further diagnostic imaging
initial diagnostic imaging performed
Can show consolidation, air/ fluid, opacification
Further diagnostic imaging
CT scan
V/Q scan- to observe the perfusion and ventilation throughout the pulmonary vasculature.

39. Most Common Causes of Respiratory induced chest pain
Pulmonary Embolism
Pneumothorax
Pleurisy
Pneumonia
Pulmonary Hypertension

40. Pulmonary Embolism
Thrombosis from the venous system that embolizes in the pulmonary vasculature
Clinical Manifestations
Dyspnea (73%)
Pleuritic chest pain (66%)
Cough (37%)
Hemptopysis (13%)
Acute Cor Pulmonale
Physical Exam
Tachypnea
Tachycardia
Rales
Cyanosis
Pleura friction rub

41. Pulmonary Embolism Imaging: CXR- normal
V/Q scan- Diagnostic imaging in PE
distribution of blood flow (perfusion scan) and the distribution of alveolar ventilation (ventilation scan) are obtained following the inhalation of a radioactive gas and the IV injection of labeled albumin.

43. Pneumothorax
Presence of air between the two layers of pleura, resulting in partial or complete collapse of the lung.
Clinical Manifestations:
Sudden onset of shortness of breath
Unilateral sharp chest pain
Physical Exam:
Tachycardia
Unilateral Hyperresonance
Decreased breath sounds

44. Pneumothorax
Chest X-Ray- Diagnostic
Air Filled in the Lung space

45. Pleuritis Pleura membrane inflammation. Clinical Manifestations:
Sharp chest pain with inhalation
Shortness of breath
Fever/ Chills
Physical Exam:
Pluritic friction rub upon auscultation

46. Diagnosis
CXR-It may show air or fluid in the pleural space. It also may show what's causing the pleurisy –for example, pneumonia, a or a lung tumor.
CT- may show pockets of fluid, lung abscess or pneumonia
Blood tests can show bacterial or viral infectious process
Thoracocentesis and biopsy can be used to determine the specific cause

47. Pneumonia
Inflammation of the parenchyma of the lung due to an infectious process.
Clinical Manifestation:
Fever/ Chills
Shortness of Breath
Pleuritic chest pain
Dry cough
Physical Exam:
Pulse- temperature dissociation ( normal pulse with high fever)
Dull Percussion
Rales/Rhonchi and decreased breath sounds upon auscultation

48. Pneumonia Chest X-ray can be Diagnostic. RUL consolidation
Blood and mucus tests. You may have a blood test to measure your white cell count and look for the presence of viruses, bacteria or other organisms. Your doctor also may examine a sample of your mucus or your blood to help identify the particular microorganism that's causing your illness.

49. Pulmonary Hypertension
Increase blood pressure in lung vasculature; Mean arterial pressure <25mmHg at rest or <30 mmhg during exercise.
Clinical Manifestations:
Shortness of Breath
Fatigue
Non productive cough
Angina
Cyanosis
Peripheral edema
Syncope
Physical Exam:
JVD
Parasternal lift due to RV dilation
Wide Split S2 and loud P2 in pulmonic area upon Auscultation

50. Pulmonary Hypertension
ECG- right axis deviation (RVH)
CXR- Dilated pulmonary vessels with right ventricle enlargement.
Echocardiogram- Dilated pulmonary Artery, Dilation of RA/RV, right heart catherization reveals increased pulmonary artery pressure

51. Chest x ray of PAH
Pulmonary artery dilation plus rvh

52. Treatment Treat Diagnosed condition: Pulmonary Embolism :
O2 to correct hypoxia
Anticouglation therapy heparin to prevent another PE and oral warfarin for long term treatment
Thrombolytics
Surgical removal if large enough
IVC filter if long h/o if DVTs/ PE
Pneumothorax:
Primary Pneumothorax – small , observe should resolve by 10 days; Large administer O2 and insert chest tube to allow lung expansion
Secondary pneumothorax- chest tube drainage

53. Continued Treatment Pleurisy Pneumonia Treat underlying cause
NSAIDS for symptomatic pain
Pneumonia
Antimicrobial Therapy
Pulmonary hypertension
Pulmonary vasodilators ( IV prostacylines) and CCB
Anticougulation due to venous stasis

54. Musculoskelatal Induced Chest Pain
Costochondritis-
Inflammation of cartilage that conncets rib to sternum
localized sharp or dull pain
Tenderness on palpation
Herpes Zoster-
Viral infection that causes painful rash
Intense unilateral pain along dermatome
Anxiety-
Causes a chest tightness, sweating, hyperventilation

55. Questions
A 24 year old smoking male presents to you with a 2 hour history of right sided chest pain. He claims that he was walking and suddenly felt chest pain. He denied any diaphoresis or radiation of pain. He has no other medical problems. His father died at the age of 67 from MI. On examination the individual is a tall male with a thin chest wall. The best method to make your diagnosis is:
Cardiac enzymes every 8 hours
CT scan of the chest
ECG
Chest X-ray
Ultrasound of the chest

56. Answer
D. Spontaneous pneumothorax has no provoking factors. It usually occurs in tall males who smoke. The diagnosis can easily be made by a chest x-ray.

57. 2. A 65 year old female underwent hip replacement surgery 2 days ago
2. A 65 year old female underwent hip replacement surgery 2 days ago. On the third postoperative day, she suddenly became anxious, dyspneic and tachycardic. She has a history of anxiety and takes lorazepam for it. Her vital signs are BP-100/50, Pulse- 120/min RR- 36/min, O2 sat is 86% on 6 LNC and afebrile. Lung examination is unremarkable.Chest Xray did not show any abnormalities. The next step of management is:
Obtain a ABG
Intubate
Venogram
V/Q scan
Give IV Lorazapam

58. Answer
D. When PE is suspected Chest X-ray is usually normal. The initial symptoms are a sudden onset of hypoxia, tachycardia and tachypnea. The patient is at high risk for PE due to bed rest and surgery. The Ventilation Perfusion scan is the next step in evaluation the patient. If chest x-ray is negative that rules out pneumonia, atelectasis, and pulmonary edema. The next step is to rule out PE

59. References
David A. Lipson, Steven E. Weinberger “Harrisons” Chapter 245. Approach to the Patient with Disease of the Respiratory System
Steven S. Agabegi, Elizabeth D. Agabegi. “Step up to Medicine”
Marc S. Sabetine. “ Pocket Medicine Third Edition”
Mayo Clinic.com