Approach To Chest Pain

Chest Pain TABLE 1-2 DIFFERENTIAL DIAGNOSIS OF EPISODIC CHEST PAIN RESEMBLING ANGINA PECTORIS DURATION QUALITY PROVOCATION RELIEF LOCATION COMMENT Effort angina 5-15 minutes Visceral (pres- During effort or Rest, nitroglyc- Substernal, radi- First episode sure) emotion erin ates vivid Rest angina 5-15 minutes Visceral (pres- Spontaneous (? Nitroglycerin Substernal, radi- Often nocturnal sure) with exercise) ates Mitral prolapse Minutes to Superficial Spontaneous (no Time Left anterior No pattern, vari- hours (rarely visceral) pattern able character Esophageal re- 10 minutes to 1 Visceral Recumbency, Food, antacid Substernal, epi- Rarely radiates flux hour lack of food gastric Esophageal 5-60 minutes Visceral Spontaneous, Nitroglycerin Substernal, Mimics angina spasm cold liquids, ex- radiates ercise Peptic ulcer Hours Visceral, burning Lack of food, Foods, antacids Epigastric, substernal ‘‘acid’’ foods Biliary disease Hours Visceral (waxes Spontaneous, Time, analgesia Epigastric, ? Colic and wanes) food radiates Cervical disc Variable (gradu- Superficial Head and neck Time, analgesia Arm, neck Not relieved by ally subsides movement, pal- rest pation Hyperventilation 2-3 minutes Visceral Emotion, tachy- Stimulus removal Substernal Facial paresthe- pnea sia Musculoskeletal Variable Superficial Movement, Time, analgesia Multiple Tenderness palpation Pulmonary 30 minutes + Visceral (pres- Often spontane- Rest, time, bron- Substernal Dyspneic sure) ous chodilator Reproduced with permission from Christie, L.G., Jr., and Conti, C.R.: Systematic approach to the evaluation of angina-like chest pain. Am. Heart J. 1027, 1981.

Chest Pain TABLE 1-3 SOME FEATURES DIFFERENTIATING CARDIAC FROM NONCARDIAC CHEST PAIN FAVORING ISCHEMIC ORIGIN AGAINST ISCHEMIC ORIGIN Character of Pain Constricting Squeezing ‘‘Knife-like,’’ sharp, stabbing Burning ‘‘Jabs’’ aggravated by respiration ‘‘Heaviness,’’ ‘‘heavy feeling’’ Location of Pain Substernal In the left submammary area Across mid-thorax, anteriorly In the left hemithorax In both arms, shoulders In the neck, cheeks, teeth In the forearms, fingers In the interscapular region Factors Provoking Pain Exercise Pain after completion of exercise Excitement Provoked by a specific body motion Other forms of stress Cold weather After meals From Selzer, A.: Principles and Practice of Clinical Cardiology. 2nd ed. Philadelphia, W.B. Saunders Company, 1983, p. 17.

Patterns of Pain

Differential Dx by Location

Chest Pain Physical Exam Vital Signs Febrile- Endocarditis, Dressler’s, Demand Ischemia BP- Hypertensive, Ischemia, Aortic Dissection, CHF (diastolic dysfxn) Hypotensive, Cardiogenic Shock, CHF (systolic dysfxn, AS) HR- arrhythmia, afib, v-tach, heart block RR/SaO2- CHF, PE

Chest Pain Physical Exam Mental Status- alertness (shock), anxiety HEENT: Mucous Membranes, Carotid Upstrokes (AS, AI, Bisferiens, Alternans), Bruits, Thyroid (CHF, Angina), Cx Tenderness, JVP- CHF,valve disease, Cannon a-waves Lungs: RR, Rales, Wheezing (Bronchoconstriction or CHF), Pleural Effusion Extrem: Equal BP’s, pulses (dissection, PVD), femoral/abdominal bruits, perfusion (cool, clammy, shock), Edema-CHF

Chest Pain Cardiac Exam Rate/Rhythm- arrhythmia (Afib, V-Tach, Bradycardia), heart block PMI- displaced, sustained (CHF), palpable S3, S4 Heart Sounds: S1 Loud (MS), Soft (MR, AVB) Variable(Afib), OS(MS), Mid Sys Click (MVP) Split S2 (BBB, PE, PA HTN, AS, LV Ischemia, Severe MR) Murmurs- (Separate topic) AS, AI(esp acute), Ischemic MR S3- CHF, S4-LV Non compliance (Ischemia, HTN)

ST Elevation Myocardial Infarction (STEMI) Admit, O2 ASA SL NTG, +/- IV NTG (SBP>100) MSO4 2-4mg, (MONA) Heparin (UFH or LMW) Beta-blocker Candidate for Thrombolytics

Definite Indications for PTCA/Thrombolytic Therapy Consistent clinical syndrome Chest pain, new arrhythmia, unexplained hypotension, pulmonary edema Diagnostic EKG >1mm ST elevation in >2 contiguous leads New LBBB Less than 12 hours since onset of pain

Relative Indications for PTCA/Thrombolytic Therapy Consistent Clinical Syndrome Chest pain, new arrhythmia, unexplained hypotension or pulmonary edema Nondiagnostic ECG Left bundle-branch block of unknown duration

Absolute Contraindications for Thrombolytic Therapy History of hemorrhagic stroke Stroke or CVA within 1 year Allergy to the agent Surgery or trauma in past 2 wks Known intracranial neoplasm Suspected aortic dissection Active internal bleeding (except menstruation)

Relative Contraindications for Thrombolytic Therapy Severe uncontrolled hypertension (>180/110 mm Hg) History of chronic severe hypertension CVA or intracerebral pathology > 1 yr ago Current anticoagulant use Recent trauma (within 2-4 weeks) Allergy or prior exposure to streptokinase

Relative Contraindications for Thrombolytic Therapy Active peptic ulcer disease Significant hepatic dysfunction Recent (2-4 weeks) internal bleeding Bleeding diathesis Noncompressible arterial or central venous puncture Pregnancy

PTCA vs. Thrombolysis PAMI Trial Demonstrated Superiority of PTCA over Thrombolysis Hospital Mortality 6.5% with Thrombolysis vs 2.6% with PTCA ICH 2% with Thrombolysis vs 0.2% with PTCA 90 min Door to Balloon Time Experienced Operators

Non-ST Elevation MI (NSTEMI)

NSTEMI, Early Invasive Strategy

Chest Pain Uncertain Etiology EKG with Symptoms 4% of MI’s normal EKG Non Invasive Imaging :Resting Nuclear Imaging/Echo/Contrast During Symptoms, CT Angio, EBCT, MRI Hyperenhancement Cardiac Enzymes Stress Testing Cardiac Catheterization

Bayes Theroem

Predictive Value

Predictive Value ETT

ETT in Women

Cardiac Stress Testing Nuclear TABLE 9-4 SENSITIVITY AND SPECIFICITY FOR DETECTION OF CORONARY ARTERY DISEASE BY 201Tl SINGLE-PHOTON EMISSION COMPUTERIZED TOMOGRAPHY NUMBER OF AUTHOR PATIENTS SENSITIVITY (%) SPECIFICITY Tamaki et al. 104 91 92 De Pasquale et al. 210 95 71 Borges-Neto et al. 100 92 69 Maddahi et al. 110 96 56 Fintel et al. 112 91 90 Iskandrian et al. 164 88 62 Go et al. 202 76 80 Mahmarian et al. 360 93 87 van Train et al. 242 95 56 Total 1901 91 73

Stress Echo

Contraindications to ETT

ETT High Risk Features TABLE 5-4 EXERCISE PARAMETERS ASSOCIATED WITH AN ADVERSE PROGNOSIS AND MULTIVESSEL CORONARY ARTERY DISEASE Duration of symptom-limiting exercise (< 6 METs) Failure to increase systolic blood pressure ³120 mm Hg, or a sustained decrease ³10 mm Hg, or below rest levels, during progressive exercise ST segment depression ³2 mm, downsloping ST segment, starting at < 6 METs, involving ³5 leads, persisting ³5 min- utes into recovery Exercise-induced ST segment elevation (a Vr excluded) Angina pectoris during exercise Reproducible sustained (> 30 sec) or symptomatic ventricular tachycardia

EBCT

Multislice CT Leber et al., JACC July 2005 Sensitivity Specificity Segment <50% >50% >75% Mid/Prox 80 75 88 97 Distal 76 67 60 All 79 73 Leber et al., JACC July 2005

Diagnostic Accuracy CTA Leshka et.al. Eur Heart Journal 2005

CTA Exclusions BMI>30 Afib Coronary Calcium Previous Stent HR>75 Hemodynamic Instability, inability to take beta-blockers Renal Insufficiency, Contrast allergy Coronary Size <3mm

Coronary Angiography

Cardiac Catheterization Remains the “Gold Standard” High risk patients Non diagnostic non-invasive tests Hemodynamic, Anatomical, Physiological Assessment FFR, IVUS Immediate Intervention if Needed