1. Approach to the ED Patient with Chest Pain
University of Utah Medical Center
Division of Emergency Medicine
Medical Student Orientation

2. The Stats 5.4% of all ED visits
High volume
High risk
$$$ malpractice claims
Misdiagnosis
Delay in treatment
< 1/3 have myocardial ischemia or infarction
Chest pain accounts for over 5% of all ED visits. It is a high volume and high risk presentation, resulting in 20% of malpractice claims in dollars. These are often the result of misdiagnosis (missed MI) and a delay in treatment. Of all the patients who present to the ED with chest pain, less than 1/3 of them actually have myocardial ischemia or infarct. However, there is a broader differential for chest pain which holds significant morbidity and mortality.

3. Common Etiologies of Life-threatening Chest Pain
Acute MI
Unstable angina
Aortic Dissection
Pulmonary Embolism
Spontaneous Pneumothorax
Esophageal Rupture (Boerhaave’s Syndrome)
Ask students to list the differential diagnosis for life threatening causes of chest pain.

4. Acute MI

5. Acute MI HPI Onset Palliates/Provokes Quality Radiation Severity
Time course
Undo (what have they done to “undo” their pain)
PMHx
Med Hx
HTN DM
Cholesterol
Meds
FHx
Immediate relatives CAD
Social Hx
Tobacco
Drugs
Exercise
Stressors
Typical Symptoms
Crescendo pain
Crushing
Pressure
Tightness
Radiation
Arms
Jaw
Neck
Associated Symptoms
Nausea
Vomiting
Diaphoresis
Shortness of breath
Risk Factors
HTN
Diabetes
High cholesterol
Obesity
Male
Family history
Smoker
Sedentary
Post-menopausal
We will talk about the “typical’ signs and symptoms – but remember there are many patients who fall outside of this realm. You must keep your differential open and broad.
(The McDonald’s man is something that showed up on google.com)

6. Acute MI But don’t be fooled Atypical symptoms Atypical demographics
Stridor
Tooth pain
Headache/neck pain
Atypical demographics
Young
Female
Cocaine use
Dissection
Aorta
Coronary arteries
Again, many folks can present with atypical symptoms – especially those that are young and female.
Cocaine use puts you at risk for early atherosclerosis
Not only can the aorta dissect back into the coronary arteries, causing MI, but the coronary arteries themselves can spontaneously dissect, leading to MI.

7. Initial Work-up ECG/repeat ECG CXR Labs
before you even step foot in the room!
CXR
Labs
Get an ECG before you step foot in the room! Remember, this is only a 12 second snapshot of something that is very dynamic. It is important to repeat the ECG during the patients stay, when their symptoms change (i.e. chest pain resolves, pain returns).
CXR is important to help you rule out other etiologies of chest pain, i.e. PTX, PNA, aortic dissection etc.
We now use CKMB (absolute value) and troponin for our labs. Remember, the troponin does not approach 100% sensitivity until 12 hours out from the onset of pain. Enzymes indicated myocardial damage. Could your patient be having unstable angina and not necessarily an MI? Thus, enzymes must be used in the context of the patient presentation. Just because the enzymes are negative, does not mean that the patient is safe for discharge home.
Enzyme
Rise
Peak
Baseline
Myoglobin
1-2 h
4-6 h
24 h
Troponin
3-6 h
12-24 h
7-10 d
CKMB
12-36 h
3-4 d
LDH
12 h
24-48 h
10-14 d

8. ECG STEMI Ischemia 1mm ST elevation in 2 limb leads
2mm ST elevation in two contiguous anterior leads
Reciprocal changes
Ischemia
ST flattening
ST depression

9. Treatment Anti-platelet Heparin Analgesia B-blockade Oxygen
ASA
Plavix
Heparin
Analgesia
Nitrates
Narcotics
B-blockade
No longer recommended in STEMI patients
Oxygen
Thrombolytics vs. Cath Lab
According to the new guidelines, B-blockers are not longer recommended in acute STEMI!
Lytics vs. cath lab depends on the type of facility you are working in. Here, patients will go to the cath lab. If all are busy, lytics will be administered. If you are working in a “sending” hospital, it depends upon the time it will take you to transport the patient to a tertiary care facility with cath ability.

10. Missed MI ~ 2% missed infarction rate 25% had missed ST elevation
15% had Hx of nitroglycerin use
25% died or potentially lethal outcome!
As conservative as we are, we still miss up to 2% of MIs. We discharge them from our EDs.
Of these 2%, a quarter of them had missed ST elevation on their ECG. And 25% had a bad outcome!

11. Unstable Angina

12. Angina vs. MI Heart muscle Stable vs. Unstable Angina death in MI
Ischemia in angina
Stable vs. Unstable Angina

13. Presentation of Angina
Established character, timing, duration of CP
Transient, reproducible, predictable
Easily relieved by rest or SL NTG
Reduced coronary flow through fixed atherosclerotic plaques
Unstable Angina
Angina deviating from normal pattern
Rest angina > 20 min
New-onset angina, previously undiagnosed
Increasing angina or change in class
Discuss difference between stable and unstable angina

14. Evaluation Detailed history Physical ECG/repeat ECG CXR Labs
BP in both arms helps with aortic dissection in the differential; similar w/u to MI as you don’t know if the angina is progressing to MI.

15. Risk Stratify
While this is recommended, exactly how to do it is controversial. There are several scoring systems. They each pros and cons. How risk stratification is will vary from institution to institution.
TIMI score
GRACE
Braunwald Risk Stratification

16. Risk Stratify High/Moderate = admission to r/o MI
ASA
SL NTG for pain x3 then paste if pain free
NTG gtt if pain continues
IV heparin
B-blockade
Low = provocative testing
From department
Low-risk obs pathway
With patients with Angina, we must risk stratify them. First of all, do we think this is cardiac chest pain? Is it MI/angina? If patients are deemed high to moderate risk, they get the full work up and admission; if they are low risk (where we really do not think this is cardiac chest pain, but cannot be sure), we have 2 options here at UMC – admit to ECU as low risk observation pathway (<24 admit for serial cardiac enzymes followed by provocative testing) or provocative testing right from our department (during daylight hours)

17. Aortic Dissection

18. Aortic Dissection 25-50% mortality in 24 hours
Morbidity and mortality can be quite high in these patients – we must keep this in our differential for chest pain!

19. Aortic Dissection-Typical Symptoms
Onset
Palliates/provokes
Quality
Radiation
Severity
Time course
Undo
sudden, chest/back
nothing!
intense ripping, tearing, cutting
chest to back, flank, extremities
10/10!
Constant
nothing
These are the “typical” symptoms. Though I have seen patients present with chest pain relieved by nitrates without radiation to their back, not a severe pain etc. have a dissection. Often it is SUDDEN in onset, this should raise a red flag!

20. Aortic dissection-caveat
Only about 30% present typically
This can be a great mimicker
Neurologic sx’s + CP = think about dissection

21. Aortic Dissection Risk Factors Trauma (high velocity) HTN Men 3:1
Congenital abnormal aortic valve
Coarctation of aorta
Turner’s Syndrome
Cocaine
Pregnancy
Connective tissue d/o
Marfan’s
Ehlers-Danlos
Vascular damage
Card cath, CABG, IABP
There are many risk factors for dissection and you should think of all of these as you evaluate your patient.

22. Aortic Dissection Physical Exam
Aortic regurgitation (diastolic murmur)
Loss/decreased pulse
Sternoclavicular heave/pulsation
JVD
tamponade
On physical exam, you may notice a new diastolic murmur or aortic regurgitation if the dissection involves the root – these patients may present hypotensive and in frank shock. Evaluate BP in both arms, evaluate peripheral pulses, if JVD, think about an aortic root dissection that has dissected into the pericardium, causing tamponade.

23. Aortic Dissection Evaluation CXR ECG TEE MRI CT
Select an image by clicking on the blue button. Continue with slides until you see a blue house button in the lower right hand corner. Click the house and it will return you to this home slide. When you have gone through the imaging, click the button in the lower right hand corner to move you onto the subject, management of aortic dissection.

24. CXR findings Dilated ascending aorta Dilated aortic knob
Apical pleural cap
Depression of L mainstem bronchus
Displacement of trachea to R
Widened mediastinum
Various findings you are looking for on a CXR to evaluate for aortic dissection); 12-20% of those with aortic dissection will have a normal CXR
Sensitivity of 67%

25. Normal mediastinum

26. Review findings of this traumatic dissection: wide mediastinum, loss of aortic knob, L pleural apical cap, trachea deviated to right

27. Impressive aortic knob; aortic aneurysm patient

28. 93% Sensitivity 87% Specificity
CT scan with IV contrast has 93% sensitivity for aortic dissection; depends on technique/timing of contrast.
93% Sensitivity 87% Specificity

30. Here you can see bleeding outside of the calcifications of the aorta.

31. 98% Sensitivity 97% Specificity

32. 97% Sensitivity 77% Specificity

33. Aortic dissections can dissect into the coronary arteries, causing infarction
LVH, Infarct, Ischemia

34. Aortic Dissection Initial Management Cardiothoracic Surgery Consult
Control HTN and shear forces = IV infusions
B-blocker + Nitroprusside
Labetalol
Cardiothoracic Surgery Consult
For dissections involving the aortic root
Start beta blocker first and then add alpha blockade to lower pressure; if you lower pressure first, you will get a reflex tachycardia, which will increase the shear forces across the aortic wall.

35. Stick to Type A (involving ascending aorta) or Type B (descending aorta only);Who has survived an aortic dissection: Dr. Michael E. DeBakey, who devised the surgery to correct aortic dissection (as well as other cardiovascular and vascular techniques). Dr. DeBakey was also noteworthy for being the oldest patient ever to receive his own operation: he was 97 at the time of his surgery on February 9 and 10 of He survived and, though he worked with physical therapists to walk on his own again after suffering muscle deconditioning from prolonged physical inactivity during recovery, retained all of his mental faculties and was back to working nearly a full day until his death of natural causes on July 11, 2008
Type 1: ascending & descending; Type 2: ascending only; Type 3: Descending only; Type A: Ascending aorta; Type B: Descending aorta

36. Aortic Dissection Suggested reading (IRAD):
“The International Registry of Acute Aortic Dissection: New Insights Into an Old Disease” JAMA Feb 16, 2000 Vol 283 No 7.

37. To be discussed in another lecture
Pulmonary Embolism
To be discussed in another lecture
Will be addressed in the dyspnea lecture.

38. Spontaneous Pneumothorax

39. Spontaneous Pneumothorax
Absence of trauma
Primary = no lung disease
Secondary = underlying lung disease
A primary spontaneous ptx occurs in patients without any underlying lung disease.

40. Pneumothorax Presentation may vary Sudden onset Gradual symptoms
Sharp, pleuritic pain, radiates to shoulder
Gradual symptoms
Progressive dyspnea over weeks…

41. Spontaneous Pneumothorax
Risk Factors
Smoker:Non-smoker 120:1
COPD/asthma
Malignancy
Infectious
Abscess TB
PCP
Pulmonary infarction
Pneumonoconiosis
Silicosis
Berylliosis
Congenital disease
Cystic fibrosis
Marfan’s
Diffuse lung disease
Idiopathic Pulm fibrosis
Eosinophilia granuloma
Scleroderma
Rheumatoid
Sarcoid
Etc.

42. Spontaneous Pneumothorax
Physical exam
Absence or decreased breath sounds
Tension pneumothorax
Cyanosis
Tachypnea
Tachycardia
Hypotension
JVD
Watch out for referred sounds from the good lung. It is best to listen in the axillary region.

43. Spontaneous Pneumothorax
Imaging
CXR
Visceral pleural line
+/- Expiratory film
CT Scan
Help w/size
Cause

44. Visceral pleural line

45. R sided PTX, no pulmonary markings present, at all!

46. This patient actually drove himself to the ED from home after having an outpatient CXR for progressive SOB over a month….Actually shows a tension ptx by film with L ptx and shift of mediastinum to the right…but he was stone cold STABLE! Arrow points to collapsed lung parenchyma.

47. s/p chest tube an re-inflation of the lung.

48. L PTX

49. Pneumothorax Treatment oxygen <15% = observation
>15% = chest tube vs. aspiration
Recurrence is common ~ up to 50% in 2-3 yrs.

50. Esophageal Rupture

51. Esophageal Rupture Boerhaave’s Syndrome
Complete tear
Esophageal contents leak into mediastinum
Mediastinitis
SICK!

52. Esophageal Rupture Presentation Chest and neck pain
Often recent instrumentation of esophagus
Hx of forceful vomiting

53. Esophageal Rupture Evaluation & Diagnosis Subcutaneous emphysema
Hammon’s Sound
Pleural effusion
CXR CT
Esophagram

54. Elderly female presented with severe chest and back pain after forceful vomiting. 1. air in mediastinum 2. air in pericardium 3. subcutaneous emphysema.

55. Progressive worsening

56. non=-operative, perimortum CXR of same patient

57. Esophageal Rupture Management Surgical!
80-90% survival if fixed within 24 hours

58. Chest Pain Summary High index of suspicion Broad differential
Risk stratification
Evidence-based medicine
Do what is right for your patient