1. Chest Pain Dr.Muhammad Al-Johani Er CONSULTANT SBEM_ABEM

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

5. Visceral Pain Visceral fibers enter the spinal cord at several levels leading to poorly localized, poorly characterized pain. (discomfort, heaviness, dull, aching) Heart, blood vessels, esophagus and visceral pleura are innervated by visceral fibers Because of dorsal fibers can overlap three levels above or below, disease of thoracic origin can produce pain anywhere from the jaw to the epigastrum

6. Parietal Pain Parietal pain, in contrast to visceral pain, is described as sharp and can be localized to the dermatome superficial to the site of the painful stimulus. The dermis and parietal pleura are innervated by parietal fibers.

7. Initial Approach ABC’s first, always (look for conditions requiring immediate intervention) Aspirin for potential ACS EKG Cardiac and vital sign monitoring Pain relief Because of the wide differential, H+P will guide the diagnostic workup

8. History O- onset P-provocation /palliation Q- quality/quantity R- region/radiation S- severity/scale T- timing/time of onset

9. Physical Exam General Appearance and Vitals (sick vs not sick) Chest exam -Inspection (scars, heaves, tachypnea, work of breathing) -Auscultation (murmurs, rubs, gallops, breath sounds) -Percussion (dullness) -Palpation (tenderness, PMI)

10. Overview Cayley 2005

11. 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)

12. Differential diagnosis UpToDate 2012

13. Typical vs. Atypical Chest Pain Typical 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 Atypical 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

14. Typical vs. Atypical Chest Pain UpToDate 2012

15. Evaluation of Chest Pain Scenario 1 - It’s 2:00 AM and you are the intern. The nurse pages you and tells you that Mr. S, a 67 yr 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?

16. 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!

17. 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

18. 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

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

20. CASES

21. 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

22. 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:

23. Case 1 You go see the patient. The patient tells you that she was feeling better after getting NEBS 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 – EAE, 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, BNP = 520, D-dimer = positive, Troponin = 0.12

24. Case 1

27. Case 1 - Pulmonary Embolism Cayley 2005

28. 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)

29. 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

30. 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

31. 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 – EAE 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, AMI panel x 1 = negative CXR = negative

32. Case 2 EKG on admission:

33. 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

34. Case 2 - Pericarditis Goyle 2002

35. Case 2 - Pericarditis Goyle 2002

36. Case 2 - Pericarditis

37. UpToDate 2016

38. Case 3 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

39. 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, Troponin = 3.2, CKMB = 9, CK = 345

40. Case 3

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 P2Y12 receptor blocker Inhibits platelet aggregation Anticoagulation Heparin/LMWH Inhibits thrombus formation Oxygen For O 2 sat <90% Morphine For refractory chest pain, unrelieved by NTG SL

43. Case 4

44. 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?

45. 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

46. 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 = 100-120 mmHg Use IV beta-blockers (i.e. Labetalol, Esmolol) Can also use Nitroprusside for BP control AVOID Hydralazine

47. 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

48. Case 5

49. Case 5 - Pneumothorax Management of Pneumothorax Supplemental O 2 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

50. 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!