1. Evaluation of Chest Pain In Outpatient Clinic
Crystal Wiley Cené, MD, MPH

2. A Chest Pain Case
A 65 year-old man with a past medical history significant for hypertension and dyslipidemia presents to clinic after 2 episodes of chest pain in past couple days. What do you want to know and do?

3. Clinical classification of chest pain
Typical angina (definite)
Substernal chest discomfort with a characteristic quality & duration that is 2) provoked by exertion or stress and 3) relieved by NTG or rest
Atypical angina (probable)
Meets 2 of above characteristics
Noncardiac chest pain
Meets 1 or none of typical anginal characteristics

4. #1 Goal
EXCLUDE Coronary artery disease and other life-threatening conditions

5. So, what are those? Acute Coronary Syndrome/Myocardial infarction
Pulmonary embolus
Aortic dissection
Tension Pneumothorax
*All of these could lead to sudden death*

6. History “PQRST” Severity Timing
Provocative/palliative factors
Quality: character, duration, frequency, associated sxs
Radiation
Severity
Timing
Risk factors: age, tobacco use, family history, DM/HTN/Lipids, cocaine; other- DVT/PE, Marfans/Pregnancy, ETOH, NSAIDS
PMHx: prior CV w/u & Rx, GI history

7. Provocation and Palliation
Postprandial? GI or cardiac disease
Exertion? Angina or esophageal pain
Cold, emotional stress, sexual intercourse can promote ischemic pain
Worse with swallowing? Esophageal origin
Body position, movement, deep breathing? Musculoskeletal origin
Antacids or food? Gastro-esophageal origin
Sublingual nitro? Esophageal or cardiac
“GI Cocktail” (viscous lidocaine and antacid)? GI or cardiac
Cessation of activity/rest? Ischemic origin
Sitting up and leaning forward? Pericarditis

8. Evaluation Severity: not useful predictor for presence of CAD
Region or location:
Radiation to neck, throat, lower jaw, teeth, upper extremity, or shoulder
Radiation to arms is useful and stronger predictor of acute MI
Between scapulae think aortic dissection
Larger areas of discomfort more likely ischemic etiology
Severity: not useful predictor for presence of CAD
Timing:
Abrupt onset with greatest intensity in beginning: PTX, dissection, acute PE
Gradual with increasing onset over time: ischemic
Crescendo pattern: esophageal disease
Lasts for seconds or constant over weeks ≠ ischemic
Circadian rhythm (morning>afternoon) correlating with increase sympathetic tome- more likely myocardial ischemia

9. Associated Symptoms
Belching, bad taste in mouth, dysphagia or odynaphagia esophageal disease
Vomiting Transmural MI, GI problems
Diaphoresis MI> esphoageal disease
Syncope dissection, PE, critical AS, ruptured AAA
Presyncope myocardia ischemia
Palpitations in setting of new A. Fib + chest pain PE
Fatigue can be presenting complaint of MI esp. in elderly

10. Any exam findings that might help distinguish cardiac from non cardiac chest pain?
General Appearance
may suggest seriousness of symptoms.
Vital signs
marked difference in blood pressure between arms suggests aortic dissection
Palpate the chest wall
Hyperesthesia may be due to herpes zoster
Complete cardiac examination
pericardial rub
signs of acute AI or AS
Ischemia may result in MI murmur, S4 or S3
Determine if breath sounds are symmetric and if wheezes, crackles or evidence of consolidation

11. Ancillary Studies
EKG
“Normal” reduces probability chest pain is due to AMI, but does NOT exclude serious cardiac etiology (i.e. Unstable Angina)
ST elevation, ST depression, or new Q waves- important predictor of Acute Coronary Syndrome (AMI or UA)
“Nonspecific” ST and T wave changes is common- may or may not indicate heart disease
CXR
Useful in acute setting to avoid missing dangerous diagnoses (e.g. PTX, Aortic dissection, Pneumomediastinum)

12. “Likelihood Ratio”
Likelihood ratio expresses the odds that a given level of a diagnostic test result would be expected in a patient with (as opposed to without) the target disorder
Sacket, et al. Clinical Epidemiology

13. Features Increasing Likelihood of AMI
Clinical Feature
Likelihood Ratio (95% CI)
Pain in chest or left arm
2.7
Chest pain radiation
Right Shoulder
2.9 ( )
Left arm
2.3 ( )
Both left and right arm
7.1 ( )
Chest pain most important symptom
2.0
History of MI
Nausea or vomiting
1.9 ( )
Diaphoresis
2.0 ( )
Third heart sound
3.2 ( )
Hypotension (SBP<80)
3.1 ( )
Pulmonary rales on exam
2.1 ( )

14. Features Decreasing Likelihood of AMI
Clinical Feature
Likelihood Ratio (95% CI)
Pleuritic chest pain
0.2 ( )
Chest pain sharp or stabbing
0.3 ( )
Positional chest pain
0.3 ( )
Chest pain reproduced with palpation
Panju, et al. JAMA 1998;280:14:

15. ECG Findings Increasing Likelihood of AMI
Panju, et al. JAMA 1998;280:14:

16. High likelihood of ACS
Worsening frequency, intensity, duration, timing (e.g. nocturnal pain, rest pain) of prior angina
New onset SOB, nausea, sweating, extreme fatigue in patient with known h/o CVD
Onset of typical anginal symptoms in pt without h/o CVD
New murmur (or worsening of previously noted murmur), hypotension, diaphoresis, rales, pulmonary edema
Transient ST deviation (≥ 1mm) or TWI in multiple precordial leads

17. Case
A 57 year old male comes in to the ER with sudden onset of “tearing chest pain” that radiates to his back.
What is your differential?
What exam findings might you look for?
What tests could you do and why?
What are the treatments for the most likely diagnoses?

18. What exam findings might you look for?
Acute MI
Hypotension in one extremity
Aortic murmur
Neurologic deficits, including paraplegia, stroke, or decreased consciousness
Syncope, tamponade, and sudden death due to rupture of the aorta into the pericardial space
Shock, hemothorax, and exsanguination
Acute lower extremity ischemia

19. Wrestler with Chest Pain
18 yo high school wrestler develops right-sided chest pain while pinning his opponent.
Physical exam reveal decreased breath sounds on right

20. Final Thoughts Nitro response is not diagnostic of UA
Post-prandial pain may be ischemic
Discomfort thresholds vary
Patient histrionics may influence you
“Atypical” is typical of something
Value of careful history and physical