1. Sorting out chest pain in the office setting
Anthony J. Viera, MD, MPH, FAHA
Professor and Chair

2. Primary objectives
Discuss the common causes of CP and incorporate epidemiology of CP into development of differential diagnosis
Present an approach to evaluation of CP in the office setting
Use principles of clinical epidemiology to understand when a stress test is and is not going to be helpful in evaluation of CP

3. Epidemiology of chest pain in family medicine settings
Musculoskeletal
36 %
19 %
Gastrointestinal
16 %
“Nonspecific”
11 %
Stable angina
“Psychosocial”
7 %
5 %
Pulmonary
4 %
Non-ischemic cardiac
Acute cardiac ischemia
2 %

4. The biggies 54 Acute coronary syndrome (AMI, USA)
Pulmonary embolus (history, Wells)
Aortic emergency
In the ER setting, ___% of CP is due to serious cardiovascular etiology (AMI, USA, PE, CHF) 54

5. Other causes Pericarditis Arrhythmia Valve disease Pneumonia
Pneumothorax
Neoplasm
Others?

6. Approach First order of business
Assess for any acute life, threatening condition or other serious cardiovascular etiology
Rapid history, exam (VS, overall appearance, heart & lungs) +/- ECG
If one of the “biggies” is a legitimate consideration, then needs to be evaluated in the emergency department

7. Rational clinical exam…
Which of the following has the strongest association with acute myocardial infarction?
Pain radiating down left arm
Pain radiating down right arm
Pain radiating down both arms

8. Rational clinical exam…
Which of the following has the strongest association with acute myocardial infarction?
Pain radiating down left arm LR+ 2.3
Pain radiating down right arm LR+ 2.9
Pain radiating down both arms LR+ 7.1

9. Steps 1 & 2
History
Electrocardiogram
Acute MI? Acute ischemia?

10. 46 y/o man with chest pain now
Sinus bradycardia
ST & T wave abnormalities
suggesting myocardial injury 1

11. 58 y/o man with epigastric discomfort last night
Sinus tachycardia
LAD
Inf Q wave MI
ST elev II, III, avF 7

12. 52 y/o woman with substernal CP
Sinus tachycardia
Acute (anteroseptal Q wave) MI
ST & T wave abnormalities
suggesting myocardial ischemia
suggesting myocardial injury 13

13. 24 y/o man with brief sharp pain in chest two weeks ago
Sinus bradycardia
Early repolarization 25

14. 59 y/o man with several days of CP and cough
Sinus rhythm
Diffuse ST elevation
Peaked T’s inferiorly
Findings suggest acute pericarditis 27

16. If not an emergency, is CAD (i.e., stable angina) a consideration?
No (not really)
Consider diagnoses:
Musculoskeletal
GERD/esoph spasm
Panic disorder
Somatoform sensations and worries

17. Musculoskeletal
What is the pretest probability that someone coming to clinic with chest pain has a musculoskeletal etiology?
History
Exam
Reproducible: LR LR-0.78
Caution

18. GERD/esophageal spasm
About one out of 5 clinic CP patients
History
Exam not helpful
Empiric trial may be your best “test”

19. Panic attack
“In the past 6 months, did you ever have a spell or attack when all of a sudden you felt frightened, anxious, or very uneasy?”
“In the past 6 months, did you ever have a spell or attack when for no reason your heart suddenly began to race, you felt faint, or you could not catch your breath?”

20. Panic attack “No” to both questions is helpful Others
Lowers from about 8% pretest to about 1% posttest
Others
Fear of “going crazy”
Feeling of “unreality” (derealization)
Feeling of “being outside of oneself” (depersonalization)

21. A perception among clinicians (and patients): A normal test result is enough to reassure a patient that nothing is wrong
Is it?

22. McDonald IG, et al. Opening Pandora’s box: the unpredictability of reassurance by normal test result. BMJ 1996:313:
6 university cardiologists recruited 40 patients to exclude heart disease
30 asymptomatic w/ systolic murmur heard, 10 w/ palpitations
Anxiety level before and after (asap and 9-12 mos) echocardiogram
Echo normal in 37; only 1 had significant abnormality
30/38 had pretest anxiety (all 10 w/sxs)
55 % of the asymptomatic pts had residual anxiety
_______of symptomatic pts had residual anxiety
100 %

23. If not an emergency, is CAD (i.e., stable angina) a consideration?
No (not really)
Consider diagnoses:
Musculoskeletal
GERD/esoph spasm
Panic disorder
Somatoform sensations and worries
Yes
Consider stress test
Assign a pretest probability
Determine if a stress test (and which type) will “move” that probability in any meaningful way

24. Pretest probability Kind of chest pain Age Sex
Typical = SS, brought on by exertion, relieved by rest
Atypical = 2 out of 3
Nonanginal = 1 out of 3
Age
Sex

25. Diamond and Forrester

26. Test / treat threshold
Test
Treat 0%
100% ?
Test
Treat

27. Test / treat threshold <10% = don’t test (& don’t treat)
10-90 = testing zone
>90% = don’t test, just treat (with cath)

28. ETT
Sensitivity ~68%
Specificity ~77%

29. Sample patient
38 y/o man with diffuse (left and right) CP while running on treadmill
Relieved after about 15 minutes once run stopped
Typical, atypical, or nonanginal?

30. Diamond and Forrester

31. Specificity * (1-pretest)
Using a 2 X 2 table
Positive disease
Negative disease
Positive test
Negative test
Sensitivity * pretest
Specificity * (1-pretest) 22 78
100
Pretest probability of having disease
Hypothetical sample of people

32. Using a 2 X 2 table Positive disease Negative disease Positive test
Negative test
0.68*22 = 15 18 33
0.77*78 = 60 7 67 22 78
100
Pretest probability of having disease
Hypothetical sample of people

33. Deriving post-test probability
If positive ETT, the post-test probability = 15/33 = 45%
If negative ETT, the post-test probability of having disease is 7/67 = 10%

34. How much does the ETT help?
After a positive test (45%)
After a negative test (10%)
What now?
Before the test (22%)

35. Bottom-line Very low or low – not going to help much
Intermediate – most helpful
But might need further testing (serial testing)
High – not going to help all that much (if it’s negative, are you going to believe it?)

36. A brief ETT primer

37. Examples of ETT findings
Patient 1
54 y/o man with a family history of CAD
No chest pain

38. Pretest probability

47. Cath report

48. Patient 2
57 y/o man w/ episodes of sudden onset of heavy breathing & discomfort in the center of his chest with exertion
Episodes last 10 minutes
No h/o CAD, HTN, DM
Remote history of smoking

49. Pretest probability

59. Duke treadmill score
-18 estimates an annual cardiovascular mortality of 7% and a five year survival of 64%
Using the Duke Score there is a high probability of severe angiographic coronary disease

60. Same day cath

61. 2 days later

62. Don’t order a regular ETT if…
Pt cannot walk on treadmill (for 6 minutes)
Severe obesity – consider PET
Pt has LBBB or enough baseline ST segment abnormality that will make it difficult to interpret (e.g., LVH with “strain”)
Pt on digitalis

63. Summary
The epidemiology of CP in the office setting is different than in the ER setting
First step is still to assess for one of the biggies
After that, use history and (to lesser extent) exam to guide you
Consider pretest probability before ordering a stress test

64. Thank you for your attention!