Garik Misenar, MD, FACEP

 Understand differential diagnosis of chest pain  Learn key points in the evaluation of chest pain  Know the key findings associated with chest pain  Discuss disposition of potentially cardiac chest pain

 Nearly 6 million ED patients annually  5% of all ED visits

 Afferent fibers from heart, lungs, great vessels, and esophagus enter same thoracic dorsal ganglia  Visceral fibers produce indistinct quality of pain  Dorsal segments overlap three segments above and below  Pain anywhere from jaw to epigastrium

 Cardiovascular  Pulmonary  Gastrointestinal  Musculoskeletal  Neurologic  Psychogenic

 Vital signs  EKG within 10 minutes  Chest x-ray

 Acute MI  Esophageal rupture  Thoracic aortic aneurysm  Pulmonary embolus  Pneumothorax

 Description  Activity at onset  Location  Radiation  Duration  Aggravating/alleviating

 Similar episodes in past  Misdiagnosis or misattribution  Risk factors  Important for populations

 Syncope/Near syncope  Dyspnea  Hemoptysis  Nausea/vomiting  Diaphoresis

 Respiratory distress  Diaphoresis  Vital signs  Heart sounds  Lung sounds  Abdominal exam  Extremity exam

 New injury  Acute MI  Aortic dissection  New ischemic pattern  Ischemia  Coronary spasm  Diffuse elevation  Pericarditis

 Pneumothorax  Simple vs. Tension  Esophageal rupture  Widened mediastinum  Aortic Dissection  Effusion  Esophageal rupture  Enlarged cardiac silhouette  Pericarditis  Pneumomediastinum  Esophageal rupture

 D-dimer?  Marker of fibrinolysis  Negative rules out if low risk for PE  Positive test does NOT mean PE/DVT ▪ Acute Coronary Syndrome, Aortic dissection, Atrial fibrillation, DIC/VICC, Infection, Malignancy, Pre- eclampsia, Sickle cell, Stroke, Trauma  False positive: ▪ Elderly, pregnancy, post-op, smokers, African- Americans, decreased mobility

 Troponin I and T  Identify patients with highest risk of adverse outcome  Sensitivity at 4 hours is 60%, nearly 100% at 12 hours  CK-MB  Sensitivity at 4 hours is 80%; 93% at 6 hours  Secondary role to troponin currently

 Elevated troponin  New ST depression  Recurrent ischemia  Heart failure with ischemia  Hemodynamic instability  PCI in last 6 months  Previous CABG

 Observation vs. Intervention

 Chest pain resolved  Possible ischemic changes  Normal cardiac markers

 Observation vs. early intervention

 Chest pain resolved  Nondiagnostic EKG  Normal cardiac markers

 Observation  Repeat EKG and cardiac markers  Provocative testing  If all normal, discharge

 There are numerous diagnoses which can cause chest pain  Rapidly assess and treat imminent life threats  Look for key points on the history and physical  Use additional studies to help differentiate among diagnoses  Additional testing required for potentially cardiac chest pain