1. Evaluation of Chest Pain William Norcross, M.D.

2. Evaluation of Chest Pain Dictum: With any chief complaint or symptom complex, first rule- out (R/O) life threats. The stopping point in the R/O should be at the point of your conviction and personal satisfaction that the life threat does not exist. The R.O process may be very short and simple, e.g. a directed histroy, but if you're not convinced that the life threat is absent, pursue the R/O as far as necessary.

3. Chest Pain is very common. > 40 recognized entities in differential diagnosis Life threat (practical) Acute coronary syndromes (ACS) Aortic dissection Pulmonary embolus (PE) Pneumothorax Pneumonia Obscure Boerhave’s Syndrome Usually are discovered in W/U of above.

4. Life-Threat Ruled Out Other entities Musculoskeletal/serosal problems e.g. costochondritis, intercostal muscle spasms/strain, pericarditis, pleurisy Treat with NSAID, opiates, acetaminophen, local measures GI pathology Dyspepsia, GE reflux esophageal spasm Some bad abdominal pathology presents as chest pain – e.g. perfodrated viscous, pancreatitis, cholecystitis –Usually apparent by H&P Treat with antacids, antispsmodics, etc.

5. Approach to Non-Life Threats Less urgent Trial & error approach Evaluation H&P, ancillary tests (CRX, EKG, perhaps dimers and cardiac markers)

6. Approach to Non-Life Threats Pneumonia, pneumothorax easy to diagnose Note: the diagnostic modality for tension pneumothorax is an intracostal needle, not a CXR. ACS, PE, aortic dissection: all easy to diagnose if you do the work-up Triggered by suspicions raised by initial evaluation and R/O life threat

7. Bad things to miss High mortality out-of-hospital (if undiagnosed)

8. Pulmonary Embolism Physical exam: tachycardia, tachypnea,  sats, R heart findings, leg findings Ancillary - EKG, CXR, nonspecific d-dimer is usually  (sensitivity > 85%) Assign likelihood of PE (low, high, intermediate) based on clinical gestalt or grading scales (e.g. Well’s Criteria) If low probability and d-dimer is , quit (probably) If intermediate or high, or if low with  d-dimer, further study (V/Q, CT angio, perhaps dopplers)

9. Aortic dissection History triggers; sudden,radiation, ripping/tearing Risk factors: HTN, Marfan’s, coarctation, aortic valve replacement, bicuspid aorta PE: Severe pain, distress (usually), pulses, BP differential, AI murmur, neuro deficits All are insensitive markers, varied specificity Ancillary data CXR: usually abn (90%) wide mediastinum, abn aorta; non-specific, 10% “normal” EKG: may show ST segment elevation

10. Acute Coronary Syndrome Most important due to commonality as well as lethality Top of differential, first inquiry ‘ACS’ against the field of everything else

11. ACS History: Full history Only 4 things are truly predictive of ACS 1. Presence of chest pain 2. Chest pain as chief complaint 3. Radiation to shoulder(s) 4. History of previous MI Risk factors (traditional) are not predictive in ED setting

12. ACS PE: full physical Only 4 things predictive: 1. Hypotension 2. Diaphoresis 3. Rales 4. S3 Markers CKMB | troponin : sensitivity < 50% at 6 hrs Neg markers with unstable angina and often initially neg with MI Neg first set mandates at lest on additional set

13. ACS: EKG Diagnostic of MI (1 mm elevation ST segments in anatomically contiguous leads) about 50% of the time. Non-diagnostic (usually non-specific ST/T waves) in around 50% MI. Normal 5 - 10% MI If ST  as above there is 80% likelihood of AMI If new ST  1 mm with inverted T in anatomically contiguouse leads, 20% chance of AMI, 20 -- 50% change unstable angina (UA). If old ST changes as above and acute chest pain, 5% chance AMI and 20 - 50% UA.

14. Acute Coronary Syndrome If ACS is Ruled In (with EKG or markers) treat and admit. If not, then: If strong suspicion, teat, admit, further R/O If convinced not ACS (or other potentially serious problem) - treat symptoms, outpatient manage If unsure - treat, admit, further R/O

15. ACS Approached with clinical gestalt. More objective decision aids available (ACI - TIPI). Clinical sensitivity of either approach, > 95%. Not good enough: the 5% (approximate) do badly. If in doubt, assume the worst, treat and admit for further evaluation.

16. References 1. Evaluation of the Patient with Acute Chest Pain. Lee. N Engl J Med 2000; 342: 1187-1195. 2. Missed Diagnosis of Acute Cardiac Ischemia in the Emergency Department. Pope and others. N Engl J Med 2000; 342: 1163-70. Editorial N Engl J Med 2000; 342: 1207-1209. 3. Is this Patient Having a Myocardial Infarction? Panju and others. JAMA 1998;280:1256-63. 4. Prediction of the need for intensive care inpatients who came to Emergency Departments with acute chest pain Goldman and others. N Engl J Med 1996; 334:1498-1504. 5. ST-segment Elevation in Conditions other than Acute Myocardial Infarction. Wang and others. N Engl J Med 2003; 349:2128-2135. 6. Triage of patients with Acute Chest Pain and Possible Cardiac Ischemia: The Elusive Search for Diagnostic Perfection. Goldman and others. Ann Int Med 2003; 139: 987-995. 7. Comprehensive strategy for the evaluation and triage of the chest pain patient. Tatum. Ann Emerg Med 1997;29:116-125. 8. A computer protocol to predict myocardial infarction in emergency department patients with chest pain. N Engl J Med 1988; 318:797-803. 9. Prognostic Importance of the Physical Examination for heart failure in non ST elevation Acute Coronary Syndromes: The Enduring value of Killilp Classification. JAMA 2003; 290: 2174. 10. Use of the Acute Cardian Ischemia Time Insensitive Predictive Instrument (ACI-TIPT) to assist with Triage of Patients with Chest Pain. Selker. Ann Int Med 1998; 129:845-855. 11. Impact of a Clinical Decision Role on Hospital Triage of Patients with suspected Cardiac Ischemia in the Emergency Department. Reilly and others. JAMA 2002; 288:342-350.