APPROACH TO CHEST PAIN MOHAMMAD GARAKYARAGHI ASSOCIATE PROFESSOR OF CARDIOLOGY ISFAHAN UNIVERSITY OF MEDICAL SCIENCES

Chest Pain 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

Chest Pain 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.

As a general rule any chest pain is ischemic in origin until proven otherwise!

Chest Pain 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

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

Chest Pain History Change in pain pattern Associated symptoms: DOE, SOB, diaphoresis, vomiting, heart burn, food intolerance PHx Social history FHx

Chest Pain 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)

Chest Pain Physical Exam Neck: JVD, crepitence, bruits Abdomen Extremities: swelling, pulses, tenderness, Homan’s

Differential Diagnoses Cardiovascular Acute myocardial infarction, Acute coronary ischemia, Aortic dissection, Cardiac tamponade, Unstable angina, Coronary spasm, Prinzmetal's angina, Cocaine induced, Pericarditis, Myocarditis, Valvular heart disease, Aortic stenosis, Mitral valve prolapse, Hypertrophic cardiomyopathy Pulmonary Pulmonary embolus, Tension pneumothorax, Pneumothorax, Mediastinitis, Pneumonia, Pleuritis, Tumor, Pneumomediastinum Gastrointestinal Esophageal rupture (Boerhaave), Esophageal tear (Mallory-Weiss), Cholecystitis, Pancreatitis, Esophageal spasm, Esophageal reflux, Peptic ulcer, Biliary colic Musculoskeletal Muscle strain, Rib fracture, Arthritis, Tumor, Costochondritis, Nonspecific chest wall pain Neurologic Spinal root compression, Thoracic outlet, Herpes zoster, Postherpetic neuralgia Other Psychologic, Hyperventilation

Clinical Classification of Chest Pain

Pretest Likelihood of CAD in Symptomatic Patients According to Age and Sex* (Combined Diamond/Forrester and CASS Data) *Each value represents the percent with significant CAD on catheterization.

Implementing NICE Guidance

Life Threatening causes of Chest Pain Acute coronary syndrome Aortic dissection Pulmonary embolism Tension pneumothorax Pericardial tamponade Mediastinitis (eg, Esophageal rupture)

Ischemic Heart Diseases Stable Angina Pectoris UA/NSTEMI STEMI

Acute Coronary Syndromes (ACS) Unstable Angina (UA) Non-ST Elevation Myocardial Infarction (Non-STEMI) ST Elevation Myocardial Infarction (STEMI)

Evaluation of Chest Pain Systematic approach needed! Description of chest pain –Quality of the pain –Region/location of pain –Radiation –Temporal elements –Provocation –Palliation –Severity Associated symptoms Risk factors Physical examination Investigations –ECG –Chest X-ray –Blood work –Other

Cardiac Risk Factors Hypertension –>140/90 or treated Diabetes –More than doubles cardiac risk Hyperlipidemia –LDL > 3.5 mmol/L or treated Tobacco use –current or within 5 yrs, > 40 pack-years ++ significant Family History –1 st degree male or female relative < 60 yrs

Algorithm for diagnosis… (Adapted from: Diagnostic approach to chest pain in adults. UpToDate Online 19.2) Step 1 (Evaluate need for emergent care) –Consider potentially life-threatening causes of chest pain –If acute coronary syndrome suspected start emergent care –If emergent and not ACS, start appropriate emergent care

Emergent Care Initial Steps... GET HELP! Have staff physician or more senior team member called/paged Don’t forget nurses and RTs

Emergent Care Initial Steps... Airway, Breathing, and Circulation assessed 12-lead ECG obtained Resuscitation equipment brought nearby Cardiac monitor attached Oxygen given IV access and blood work obtained Aspirin 160 to 325 mg given Nitrates and morphine given (unless contraindicated)

ACS Emergent Care M orphine –2 – 4 mg IV q5-15 min O xygen N itro –0.4 mg SL q5min x 3 A spirin – mg chewed

Algorithm for diagnosis… (Adapted from: Diagnostic approach to chest pain in adults. UpToDate Online 19.2) Step 2 (Emergent care not needed) — –If cardiac cause likely based on symptoms that are suggestive of angina and/or a history of cardiac risk factors, proceed to Step 3 –Otherwise, proceed to Step 4 Step 3 (Symptoms consistent with stable angina) — –Evaluate the patient for cardiac disease and consider starting outpatient management (aspirin, beta blockers, nitroglycerin, and education ) –If the results of the evaluation do not demonstrate cardiac disease, proceed to Step 4 Step 4 (Evaluation for cardiac disease was negative) –Evaluate the patient for other causes of chest pain –gastrointestinal disease, respiratory disease, musculoskeletal disease, psychogenic disease

Important points on history… Worsening in the frequency, intensity, duration, and timing (eg, nocturnal pain, rest pain) of prior anginal or anginal equivalent symptoms New onset symptoms of shortness of breath, nausea, sweating, extreme fatigue in a patient with a known history of cardiovascular disease Onset of typical anginal symptoms in a patient without a history of cardiovascular disease Age greater than 70 years Diabetes mellitus Women Extracardiac vascular disease (PVD, PAD, CVA)

Arguments against cardiac pain… Pain less than 30 seconds or lasting weeks If the pain can be localized with one finger If the pain is immediately severe with no crescendo pattern If the pain occurs only at rest

Investigations 12 Lead ECG –Findings depend on Duration — hyperacute/acute versus evolving/chronic Size — amount of myocardium affected Localization –Lateral = Leads I, AVL, V5, & V6 –Inferior = Leads II, III, & AVF –Anterior = Leads V1-4 –Posterior = Leads V4R, V8, V9 (need 15 lead ECG)

ECG Possible findings in ACS –ST segment elevation or depression –Q-waves –New conduction defect –T-wave inversion

NORMAL ECG!

T-wave inversion

Inferior myocardial infarction (Q waves and ST elevations) Anterior ischemia (ST depressions in leads V2 and V3)

Points to remember for ECGs Initial ECG is often NOT diagnostic in patients with ACS –In patients who ended up with an MI, initial ECG was nondiagnostic in 45 percent and normal in 20 percent Don’t assume a normal ECG obtained while patient having chest rules out ACS

Investigations Chest x-ray –Usually non-diagnostic in ACS –Helps to identify other important conditions Congestive heart failure Pnuemonia Pnuemothorax Pleural effusion Widened mediastinum (aortic dissection)

Normal CXR!

Left lower lobe pneumonia

Investigations Blood work –Standard sets of blood work will be done in ER –In other locations, you may have to decide –Troponin-T LHSC) and CK most important for myocardial infarction –Other hospitals may use Troponin-I

Cardiac Enzymes Cardiac Troponins –Blood levels rise after 3-6 hours (can be negative at initial assessment!) –Peak at hours Creatine Kinase (CK) –May rise earlier than troponin, but less specific for cardiac muscle ALWAYS repeat in 6-8 hours if suspicious for acute cardiac event (ie, non-STEMI)

Chest Pain Aortic Dissection - Pathophysiology Intimal tear of the aorta leads to dissection of the layers of the aorta creating a false lumen

Aortic Dissection Blood violates aortic intimal and adventitial layers False lumen is created Dissection may extend proximally, distally, or in both directions

Chest Pain Aortic Dissection - Diagnosis Tearing chest pain radiating to the back Risk Factors: HTN, connective tissue disease Exam: HTN, pulse differentials, neuro deficits Radiology: Wide mediastinum on CXR, CT angio chest, echo

Chest Pain

Aortic Dissection - Classification De Bakey system: Type I dissection involves both the ascending and descending thoracic aorta. Type II dissection is confined to the ascending aorta. Type III dissection is confined to the descending aorta. The Daily system classifies dissections that involve the ascending aorta as type A, regardless of the site of the primary intimal tear, and all other dissections as type B.

Chest Pain Aortic Dissection - Treatment Patients with uncomplicated aortic dissections confined to the descending thoracic aorta (Daily type B or De Bakey type III) are best treated with medical therapy. Medical Therapy: Goal to decrease the blood pressure and the velocity of left ventricular contraction, both of which will decrease aortic shear stress and minimize the tendency to further dissection. Acute ascending aortic dissections (Daily type A or De Bakey type I or type II) should be treated surgically whenever possible since these patients are a high risk for a life-threatening complication such as aortic regurgitation, cardiac tamponade, or myocardial infarction.

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

Pericarditis Diagnostic criteria UpToDate 2012

EKG on admission: PERICARDITIS

Pericarditis Goyle 2002

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