Gregory Piazza, MD Chief Medical Resident July 5, 2005 Evaluation of Chest Pain and Dyspnea in the Medical Patient: A Stepwise Approach Gregory Piazza, MD Chief Medical Resident July 5, 2005

Objectives By the end of this talk, you should: Be able to recognize an acutely-ill patient with chest pain and/or dyspnea. Be able to formulate a differential diagnosis for a patient presenting with chest pain and/or dyspnea. Be able to integrate the history and physical examination with additional basic studies to establish pretest probabilities for common and life-threatening disorders. Be able to use specific diagnostic studies to focus your differential.

Overview Chest pain and dyspnea are among the most common complaints triggering admission to the hospital and requests for physician evaluation. Effective and thorough assessment of these patients initially focuses on the life-threatening and most treatable causes. Evaluation requires a careful history and physical examination before application of diagnostic tests.

STEP 1: ALWAYS see patients with chest pain and/or dyspnea

STEP 2: Recognize which patients are SICK

STEP 2: Recognize which patients are SICK Recognizing a “sick” patient can be a “gut-feeling” or based on objective findings. If the patient’s nurse is significantly concerned, there is a good chance that the patient is “sick” or about to become so. Look at the vitals: sinus tachycardia, relative or frank hypotension, tachypnea, and hypoxia all suggest the patient is “sick”. Other signs such as diaphoresis, inability to get comfortable, or accessory muscle use are signs that the patient is acutely ill. Is the nurse able to speak in a full sentence?

STEP 3: Know the differential diagnosis Myocardial ischemia Primary arrhythmia Pulmonary embolism Aortic dissection CHF Pneumonia/aspiration COPD/Asthma Pulmonary HTN Pericarditis/tamponade Shingles Thoracic malignancy Gastrointestinal pain Pneumothorax Anxiety “Musculoskeletal pain” Splenic pathology

STEP 4: Perform a history and physical exam A thorough history and physical exam is the backbone of any chest pain/dyspnea evaluation. The history and physical allows one to establish the differential diagnoses. It also helps create pre-test probabilities of some of the common and life-threatening diagnoses.

STEP 4: Perform a history and physical exam Quality/Severity Location/Radiation Setting Modifiers Duration Associated symptoms Has this ever happened before? Do they have a predisposing condition? Physical: Vital signs (including bilateral BP, pulsus if indicated) General appearance Jugular veins Cardiac exam Pulmonary exam Abdominal exam Extremities

STEP 5: Integrate initial basic studies with your clinical data Standard basic laboratory studies: CBC with differential and chemistry panel. Additional basic labs as warranted: liver function tests (including amylase/lipase), cardiac enzymes, coagulation panel, D-dimer ELISA, pro-BNP. ECG and chest X-ray should be standard. Arterial blood gas should be drawn as warranted by the differential diagnosis.

Avoid PITFALLS in the initial evaluation… Troponin in not a synonym for MI: it may be elevated in a variety of disorders including ischemic heart disease, PE, and renal failure. D-dimer ELISA: is non-specific and can be elevated in many conditions especially among inpatients. Although the NPV can be as high as 99%, there is insufficient evidence to stop the work-up for PE in patients with high clinical suspicion and a negative D-dimer. Pro-BNP: is non-specific and can be elevated in acute pulmonary edema, chronic CHF, and causes of right sided volume or pressure overload. ABGs: should not be used in the work-up of PE. J Am Coll Cardiol 2002;40:1475-78

STEP 6: Use specific diagnostic studies to focus your evaluation Once you have focused your differential diagnosis, use specific diagnostic studies to establish the diagnosis or rule out life-threatening or common conditions. Examples include ordering a stress test on a patient with exertional (but not rest) chest pain or ordering a chest CT in a patient with pleuritic chest pain and a known malignancy.

Acute Coronary Syndromes ACC/AHA 2002 Recommendations for Early Risk Stratification (Class I) A determination should be made in all patients with chest discomfort of the likelihood of acute ischemia caused by CAD as high, intermediate, or low. Patients who present with chest discomfort should undergo early risk stratification that focuses on anginal symptoms, physical findings, ECG findings, and biomarkers of cardiac injury. A 12-lead ECG should be obtained immediately (within 10 min) in patients with ongoing chest discomfort and as rapidly as possible in patients who have a history of chest discomfort consistent with ACS but whose discomfort has resolved by the time of evaluation. Biomarkers of cardiac injury should be measured in all patients who present with chest discomfort consistent with ACS. In patients with negative cardiac markers within 6 h of the onset of pain, another sample should be drawn in the 6- to 12-h time frame (e.g., at 9 h after the onset of symptoms). www.acc.org

Acute Coronary Syndromes www.acc.org

Congestive Heart Failure Congestive heart failure may be secondary to systolic and/or diastolic left ventricular dysfunction. It remains a clinical diagnosis based on the history and physical examination. Knowing whether the patient has structural heart disease (such as LVH, low EF, aortic stenosis) along with attention to associated symptoms (such as PND, orthopnea, edema) and possible triggers for CHF (such as dietary indiscretion) help create a clinical probability. The physical examination helps confirm the presence of left and/or right-sided heart failure. Additional studies such as BNP and the chest X-ray may help support the diagnosis but may initially be negative. For example, an elevated BNP does not mean a patient has CHF in the absence of pulmonary edema.

Pulmonary Embolism < 500 ng/ml > 500 ng/ml Stop work-up Suspected PE: Emergency Department patient with low to moderate clinical suspicion Suspected PE: Inpatient or patient with high clinical suspicion D-dimer Chest CT Echo is not part of work-up < 500 ng/ml > 500 ng/ml Stop work-up

Aortic Dissection Aortic dissection is supported by a history of hypertension, vascular disease, and thoracic trauma. In addition, a presentation of “tearing” chest discomfort, radiation to the back or abdomen, along with a differential between the BP in both arms suggest the diagnosis. Laboratory evaluation may reveal renal insufficiency or hematuria if the renal arteries are involved. The ECG may show signs if myocardial ischemia or injury if the dissection extends proximally to involve the coronary arteries (most often the RCA). The chest X-ray may demonstrate a widened mediastinum. Chest CT angiography (contrast) is the most often utilized test but transesophageal echocardiography and MR angiography may also be used (especially if patient cannot get contrast).

Pericardial Tamponade Pericardial tamponade is supported by the history of a known pericardial effusion, malignancy, recent chest trauma or surgery, and recent cardiac procedure. Patients often complain of fatigue and dyspnea. On physical examination, hypotension, tachycardia, tachypnea, and/or hypoxia may be observed. Patients often present with signs of heart failure. An examination for jugular venous distention, failure of the jugular veins to fail with inspiration (Kussmaul’s Venous Sign), and a pulsus paradoxus should be performed. The ECG may demonstrate low voltage or electrical alternans. The chest X-ray may reveal an enlarged cardiac silhouette. Although tamponade is a clinical and hemodynamic diagnosis, transthoracic echocardiography is often used to detect pericardial effusions and findings suggestive of tamponade.

STEP 7: ALWAYS document your evaluation www.medicaltoons.com

REVIEW STEP 1: ALWAYS see patients with chest pain and/or dyspnea STEP 2: Recognize which patients are SICK STEP 3: Know the differential diagnosis STEP 4: Perform a history and physical exam STEP 5: Integrate initial basic studies with your clinical data STEP 6: Use specific diagnostic studies to focus your evaluation STEP 7: Always document your evaluation

The End… Thanks for listening...