1. Approach to Chest Pain Intern Bootcamp, 2014 Nathan Stehouwer, MD
In keeping with this being intern bootcamp, I’m going to focus on common scenarios you’ll encounter in hospitalized patients
I’ll try to keep this relevant, with some lessions I’ve learned along the way MI PE
Dissection (20G IV!)
Costocondiritis/musculoskeletal
Esophageal Spasm
Acute Chest
PNA
pericarditis
Pleuritis
Heartburn
RUQ pathology
Panic attack
Cocaine chest pain
Aortic Stenosis
Myocarditis
Eosinophilic Esophagitis
Esophageal Rupture/Perforation
Asthma/COPD
Pneumothorax
Pearls:
don’t accept “chest pain” – could be abdominal, patients haven’t read the anatomy books! (story of kidney stones)
Need 20G IV or power injectable central line for contrast – important for PE and TAA
MI: continued chest pain on floor in NSTEMI
TPA in PE
Intern Bootcamp, 2014
Nathan Stehouwer, MD
PGY-4, Internal Medicine & Pediatrics

2. Differential Cardiac Chest wall Esophagus Pulmonary Pleura
Dissection MI
Perforated ulcer
Pericarditis
Chest wall
Myocarditis
Costocondiritis/musculoskeletal
Aortic Stenosis
Esophagus
Pulmonary
Esophageal Spasm PE
Eosinophilic Esophagitis
PNA
Esophageal Rupture/Perforation
Asthma/COPD
Acute Chest Syndrome
GERD
Pleura
Mediastinitis
Pleuritis
RUQ pathology
Pneumothorax
Panic attack
Aorta

4. Pearl: ALWAYS have the patient point to the pain!
(just because the ER says it is chest pain doesn’t mean it’s not abdominal pain)
If the patient can localize pain with 1 finger, less likely to be ACS
Many patients will indicate abdomen but say “chest.”

5. Typical vs. Atypical Chest Pain
Characterized as discomfort/pressure rather than pain
Time duration >2 mins
Provoked by activity/exercise
Radiation (i.e. arms, jaw)
Does not change with respiration/position
Associated with diaphoresis/nausea
Relieved by rest/nitroglycerin
Pain that can be localized with one finger
Constant pain lasting for days
Fleeting pains lasting for a few seconds
Pain reproduced by movement/palpation

6. Typical vs. Atypical Chest Pain
UpToDate 2012

7. Typical vs. Atypical Chest Pain
Cayley 2005

8. Case 1
You are the orphan intern on Wearn team at 6PM. You are called by the nurse because Ms. Z has developed chest pain. Ms. Z is a 62 yo F with PMHx of CAD s/p remote PCI to the LAD, COPD and right THA 3 weeks ago who was admitted for a COPD exacerbation.
What would you do next?

9. Evaluation of Chest Pain
Case 1:
Ask nurse for most current set of vital signs
Ask nurse to get an EKG
Obtain the admission EKG from the paper chart
Go see the patient!

10. Evaluation of Chest Pain
Once at bedside, determine if patient is stable or unstable
Perform focused history and physical exam
Read and interpret the EKG. Compare EKG to old EKG if available
If patient looks unstable or has concerning EKG findings, call your senior resident for help
Write a clinical event note!

11. Evaluation of Chest Pain
focused physical exam for chest pain
Vital Signs: tachycardia, hypertension/hypotension or hypoxia
General: Sick appearing, actively having chest pain
HEENT: JVD, carotid bruits
Chest: Rales, wheezes or decreased breath sounds
CVS: New murmurs, reproducible chest pain, s3 gallop
Abd: Abdominal tenderness, pulsatile mass
Ext: Edema, peripheral pulses
Skin: Rash on chest wall
Question: would would rash on chest wall indicate?

12. Case 1
You go see the patient. She had been feeling better after getting duonebs, but suddenly developed chest pain that is L-sided, 8/10 and worse with breathing. This pain is not like her prior MI.
Vital signs: Afebrile, HR 120, BP 110/70, RR 28, O2 sat 89% on 2L (was 95% on RA this morning)
Physical exam
Gen – in distress, using accessory muscles of respiration
Lungs – CTAB, no rales/wheezes
Heart – tachycardic, nl s1, loud s2, no mumurs
Abd – soft, NT/ND, active BS
Ext – b/l LEs warm and well perfused
Labs:
CBC wnl, RFP wnl, BNP = 520, D-dimer = positive, Troponin = 0.12

13. Case 1

14. Case 1

15. Differential Cardiac Chest wall Pulmonary Esophagus Pleura
Dissection MI
Perforated ulcer
Pericarditis
Chest wall
Myocarditis
Costocondiritis/musculoskeletal
Pulmonary
Esophagus PE
Esophageal Spasm
PNA
Eosinophilic Esophagitis
Asthma/COPD
Esophageal Rupture/Perforation
Acute Chest Syndrome
Pleura
GERD
Mediastinitis
Pleuritis
Pneumothorax
RUQ pathology
Aorta
Panic attack

16. Modified Wells Criteria
Clinical symptoms of DVT (3 points)
Other diagnoses less likely than PE (1 point)
Heart Rate >100 (1.5 points)
Immobilization >/= 3 days or surgery within 4 weeks (1.5 points)
Previous DVT/PE (1.5 points)
Hemoptysis (1 point)
Malignancy (1 point)
Interpretation:
>6: high
2-6: moderate
<2: low

17. Next moves DDIMER: 95% sensitive, VERY nonspecific
ABG – Elevated A-a gradient fairly sensitive, highly nonspecific
EKG – most commonly nonspecific changes (ST/T wave changes, etc)
V/Q scan – helpful in patients with HIGH or LOW pretest probabilities in whom a CTPE cannot be obtained (eg CKD)
LE Ultrasound: not sensitive
CTPE
Sensitivity 83%
Specificity 96%
Moderate - high clinical probability and positive CTPE: 92-96% chance of PE
ABG – A-a gradient can be normal in ~6% of patients with PE,
EKG – 70% had changes, in one study
LE ultrasound: only 29% of patients with known PE had + u/s in one study. False positive ~3%.
Can help to define clot burden in cases of known PE
Echo: only 30-40% sensitive
Echocardiolography – useful for suspected massive/submassive PE where use of thrombolytics is in question.
V/Q Scan:
Useful in the following scenarios:
Renal insufficiency
Contrast allergy
Morbid obesity
Inconclusive CTPE
- Helpful scenarios:
High clinical probability with high likelihood V/Q: 95% chance of PE
Low clinical probability with low probability V/Q: 4% chance of PE
Normal V/Q essentially excludes PE
Other situations, V/Q scan is insufficient to diagnose or exclude PE

18. Pearl
A CT angiogram (important for evaluating for Pulmonary Embolism or Aortic Dissection) requires EITHER:
1) At least a 20G peripheral IV OR
2) A Power injectable central line

19. Case 1

20. Diagnostic approach is simple if you suspect PE…
Probability low: obtain D-DIMER
If positive: obtain CTPE
If negative: PE excluded
Probability moderate or high: obtain CTPE
If positive: treat

21. Acute Pulmonary Embolism
Management
Stabliize patient
oxygen
Fluids if hypotensive!
Anticoagulants
Preferred: LMWH or Fondaparinux
Enoxaparin 1.5mg/kg daily or 1mg/kg BID
Fondaparinux subcutaneous once daily (weight based)
Alternative: UFH (IV or SC) – select high intensity protocol
Hemodynamically unstable patients
High risk of bleeding (reversible)
GFR < 30
Can initiate warfarin on same day
IVC filter an alternative in patients with mod-high bleeding risk
Fluids important particularly with submassive/massive PE causing RH failure – patients are preload dependent
Choice of anticoagulant: ACCP recommends LMWH or Fonda over UFH, evidence level 2B for LMWH, 2C for fonda
Once daily dosing for LMWH typically OK – use BID for patients with cancer, extensive clot burden, or higher BMI (>30)
Fondaparinux dosing– 5mg for patients <50kg, 7.5mg for patients between kg, and 10mg daily for patients >100mg
IV heparin protocol is useful for:
Hemodynamically unstable patients (excluded from trials of LMWH)
High risk of bleeding, because IV heparin can be shut off, and reversed with protamine sulfate
GFR < 30 -> UFH can be more easily monitored and adjusted
Patients in whom thrombolytics are being considered – can shut off IV heparin while thrombolytics being infused, to avoid simultaneous administration of thrombolytics and anticoagulants
Morbidly obese patients – subcu absorption of LMWH and Fonda may be affected
Bleeding risk
-one risk factor: 3.2% in first 3 months, 1.6 per year thereafter
-Two or more risk factors: 12.8% in first 3 months, 6.5 per year thereafter
-contrast with risk of recurrent PE 25% in those who fail to achieve ther
Bleeding risk factors:
Age >65
Thrombocytopenia
Recent surgery
Poor med adherence DM
Previous stroke
Anemia
Cancer
Renal failure
Liver failure
Alcohol abuse

22. Search “heparin infusion orders”

23. Pearl: If you have a moderate or high suspicion of PE, you can start anticoagulation while awaiting full diagnostic workup
Per ACCP algorithm:
High clinical suspicion of PE: start anticoagulation, then proceed to diagnostic evaluation
Moderate clinical suspicion of PE: start anticoagulation if diagnostic eval anticipated to take more than 4 hours
Low clinical suspicion of PE: start anticoagulation if diagnostic eval anticipated to take more than 24 hours

24. PE with hypotension Thrombolysis Catheter based thrombectomy
Administer over short infusion time
Catheter based thrombectomy
For failure of thrombolysis or likelihood of shock/death before thrombolysis can take effect (hours)
Surgical thrombectomy
Failure of above therapies

25. Case 2
You are the long call intern on Hellerstein and get a call to at 6:58PM. You have a new patient in the ER, being admitted for ACS rule out.
What’s your next move?

26. Evaluation of Chest Pain
Get report from ED physician about the patient
Ask ED physician about patient’s initial presentation
Ask for most recent set of vital signs
Ask about EKG and CXR results
Ask what meds have been started in ER and how patient responded

27. Evaluation of Chest Pain
Go to UH Portal and print out an old EKG for comparison
Review prior discharge summaries
Quickly review prior cardiac work up –echo, stress tests and cath reports
Go see the patient!

28. Case 2
Mr. M is a 67 yo man with PMHx of HTN, DLD, DMT2 and CAD s/p PCI in He presents with new onset chest pain x 2 hours that is retrosternal, 7/10, associated with nausea and diaphoresis.

29. Case 2 VS: T 37 HR 108 BP 105/60 RR 20 O2 sat 93% on RA Physical exam:
Gen – actively having chest pain, diaphoretic
Lungs – crackles at bilateral bases
Heart – tachycardic, nl s1/s2, no mumurs or rub
Rest of the exam benign
Labs: CBC wnl, RFP wnl, Troponin = 0.05

30. Next Steps
Review EKG
Review CXR
Troponin
SL Nitroglycerin

31. Case 2
Can you make a diagnosis at this point?
What is your diagnosis?

32. Case 2 Diagnosis: UA/NSTEMI
EKG changes in Acute Coronary Syndromes:
ST elevations
ST depressions
T wave inversions
“pseudonormalization” – inversion of previously inverted T waves when compared with old EKG
New conduction block
Q waves
Importance of serial EKG monitoring: sensitivity of single EKG is only 50% sensitive for acute MI

34. Pearl: Positive Troponin does not equal ACS
Can be indicative of many causes of myocardial strain or damage, including “type II” MI (caused by systemic mismatch of myocardial O2 supply/demand rather than any focal coronary lesion.)

35. Risk Stratification
Low risk 0-2
Intermediate Risk 3-4
High Risk 5-7

36. Unstable Angina/NSTEMI: Initial Management
“Stabilize” plaque
Dual antiplatelet therapy
Plavix load 600mg followed by daily 75mg
ASA 324mg chewable, then 81 daily
Anticoagulant
UF Heparin at low intensity protocol
Statin
Atorvastatin 80mg
Optimize Myocardial O2 supply/demand
Control HR -> Short acting metoprolol, can titrate quickly to HR <60 if BP allows. Give 5mg IV, can repeat at 5-15min intervals. Be wary of patients with heart failure!
Supplemental O2 if hypoxemic
SL nitroglycerin (0.4mg), repeat every 4-5 minutes
Morphine if still having active chest pain

39. Case 2 continued
You are now the nightfloat intern, and the patient is signed out to you at 10PM. At midnight, you are called for continued chest pain. Improved from admission but still 5/10 severity.

40. Next steps Vitals Repeat EKG Repeat SL nitro Assess patient in person
Call your senior!
Dose additional morphine
start IV nitroglycerin after 3-4 doses of SL nitroglycerin
Start 5 mcg/min
Increase by 5mcg/min every 20 minutes
Floor maximum: 30mcg/min

41. Pearl
Inability to ELIMINATE chest pain in a patient with ACS using maximal medical therapy =
Urgent call to cardiology for consideration of immediate catheterization
Why? Only 80% of patients with a completely occluded coronary have ST elevations. The other 20% are identified by NSTEMI which CANNOT BE MEDICALLY CONTROLLED.

42. Trivia
Wellen’s sign – Deep TWI in V4-V5 = tight proximal LAD

43. What typical ACS med should you NOT give this patient?
Nitroglycerin!
Inferior MI = RV infarct -> RV failure -> preload dependence

44. Pearl: Nitroglycerin contraindicated in inferior MI
Other contraindications to NG:
Preload dependent states
Inferior MI
Aortic outflow obstruction (HOCM, severe AS)
Likelihood of hemodynamic instability
HR <50 or >100
SBP<90mmHg or more than 30mmHg below baseline
Use of PGE inhibitors

45. Case 3
You are called on Hellerstein to admit a 65 yo man for ACS rule out.
Mr Q is a gentleman with a history of DMT2, NASH, remote NSTEMI, and HTN presenting with severe retrosternal chest pain. Pain is different than prior MI but is very severe. Radiates to neck. Began 3 hours ago; has subsided slightly but is still 8/10 in severity.

46. You take report, quickly review chart, and go to assess the patient in the ER.
VS: T37.1, HR110, BP145/80 in R arm, RR16, Pox 98%RA
Focused Exam:
GEN: in discomfort but mentating well
HEENT mmm, JVP at clavicle
CV normal s1/s2, no murmurs
PULM ctab, no w/c/r
EXTR: cool
Bilateral BP: 145/80R, 110/60L
EKG identical to previous EKG which you printed from portal
Symptoms: decrased perfusion based on extent of dissection
Carotids: neuro sx with decreased consciousness, stroke, paraplegia
LE ischemia
Exam
BP: both arms (sens/spec?)
Cool extremities
Pain to back
CXR: wide mediastinum

47. Widened aortic knob
CXR findings:
-mediastinal widening in 56% (type B) and 63% (type A);
-pleural effusion in 19%
-normal in 11% (type A) and 16% (type B)

48. Thoracic aortic dissection
Diagnosis
CT angiography – first line
83-100% sensitive, specificity %
TEE – second line; good for proximal, cannot visualize descending aorta well
MRI – useful for surveillance
TEE: advantage, can diagnose aortic incompetence
Disadvantage; cannot visualize descending aorta
78% sensitive, specificity 83% for Type A dissections in one prospective cohort trial
Another meta-analysis found
->Relate anecdote about patient in ER
Images:
reference.medscape.com
rwjms1.umdnj.eduen.wikipedia.org
en.wikipedia.org

49. Thoracic aortic dissection
Risk Factors
Hypertension
Atherosclerosis
Preexisting aneurysm (known history in 13% of patients)
Inflammatory conditions affecting aorta (Takayasu, Giant Cell Arteritis, RA, syphilis)
Collagen disorders (Marfan, Ehlers-Danlos)
Bicuspid aortic valve
Aortic coarctation
Turner syndrome
History of CABG, AVR, Cardiac Cath
High intensity weight lifting
Cocaine use
Trauma

51. Thoracic aortic dissection
Management
Type A
Type B
Surgery!
Do not delay surgery, even for LHC
Beta blockers, titrate to HR (labetalol, esmolol)
BP control (nitroprusside)
Beta blockers, titrate to HR (labetalol, esmolol)
BP control – add nitroprusside or similar agent to SBP goal mmHg
Surgery for those with end organ damage or those who do not respond to medical therapy
Watch for hypotension – give fluids if needed, consider tamponade, MI, or rupture as complications if hypotensive
Medical Management:
-Begin with IV beta-blockade to goal HR 50-60
-If SBP fails to reach mmHg with beta blockade alone, and patient not showing signs of hypoperfusion (particularly altered mental status) then add nitroprusside to reach SBP goal

53. Case 4
You are on long call on VA Blue. You are called to admit a 53 yo M from the ED for chest pain and EKG abnormalities
PMHx:
HTN
Dyslipidemia
You go see the patient and he tells you that he has had this chest pain for ~2 days, but it has progressively gotten worse. His chest pain is worse with breathing. He notes a recent viral URI.

54. Case 4 VS: T 37.9 HR 104 BP 140/76 RR 20 O2 sat 95% on RA
Physical exam:
Gen – in mild distress due to chest pain, leaning forward while in bed
Lungs – CTAB
Chest wall – no visible rash, chest wall NT to palpation
Heart – tachycardic, nl s1/s2, no rub
Rest of physical exam benign
Labs:
WBC = 14, RFP wnl, AMI panel x 1 = negative
CXR = negative

55. Case 4
EKG on admission:

56. Case 4 - Pericarditis Refers to inflammation of pericardial sac
Idiopathic pericarditis typically preceded by viral prodrome, i.e. flu-like symptoms
Typically, patients have sharp, pleuritic chest pain relieved by sitting up or leaning forward

57. Goyle 2002

58. Case 4 - Pericarditis Goyle 2002
Early Repol: J point elevated, ST segment otherwise normal
Goyle 2002

59. Case 4 - Pericarditis Diagnostic criteria UpToDate 2012
Effusion: present in 180/300 in one series (60%); of those, 79% small and 10% moderate. Tamponade in only 5%.
UpToDate 2012

60. Case 4 – Pericarditis
Per 2003 ACC guidelines, all patients diagnosed with pericarditis should receive echocardiogram
High risk features:
Fever (>38ºC [100.4ºF]) and leukocytosis
Evidence suggesting cardiac tamponade
A large pericardial effusion (ie, an echo-free space of more than 20 mm)
Immunosuppressed state
A history of therapy with vitamin K antagonists (eg warfarin)
Acute trauma
Failure to respond within seven days to NSAID therapy
Elevated cardiac troponin, which suggests myopericarditis
In a series of 300 patients, 85% low risk and none had serious complications

61. Case 4 - Pericarditis
Treatment
UpToDate 2012

62. Case 5
This is a 45 yro M with PMHx of rheumatoid arthritis who presented with progressive sob. He was found to have a R-sided pleural effusion and underwent an US guided thoracentesis with removal of 1.5 liters of pleural fluid. Two hours after his procedure, he develops new onset R-sided chest pain

63. Case 5

64. Case 5 - Pneumothorax Management of Pneumothorax
100% O2 and observation in stable patients for PTX < 3 cm in size
Needle aspiration in stable patients for PTX >3 cm
Chest tube placement if PTX >3 cm and if needle aspiration fails
Chest tube placement in unstable patients
Nitrogen washout: In animal models, administration of 100% FiO2 increased reabsorption of PTX 6-fold. The reason this works is likely due to the altered gradient in pressure of dissolved gas in the distal capillary bed. A patient on room air might have a partial pressure of nitrogen of ~570mmHg which is present in both arterial and post-capillary samples. A patient on 100%FiO2 has a partial pressure of nitrogen of zero, since nitrogen has been replaced by oxygen. The arterial PO2 might be ~650mmHg in such a patient, but because of the efficient uptake of dissolved O2 by body tissue, the distal capillary PO2 might only be a small amount higher than in a patient on room air (55mmHg vs 40mmHg.) This provides a substantial pressure gradient for reabsorption of the air in the pneumothorax.

65. Pearl
Great EKG Practice Site:

66. References
Kearon C, Akl EA, Comerota AJ, Prandoni P, Bounameaux H, Goldhaber SZ, Nelson ME, Wells PS, Gould MK, Dentali F, Crowther M, Kahn SR. Antithrombotic therapy for VTE disease: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest Feb;141(2 Suppl):e419S-94S.Cayley, W.E. Diagnosing the cause of chest pain. (2005). American Family Physician, Vol 72 (10),
Anderson JL et al ACCF/AHA Focuse Update of the Guideline for Management of Patients with Unstable Angina/NSTEMI. JACC 60 (7) 2012.
Thrumurthy SG et al. The diagnosis and management of aortic dissection. BMJ 344, 2012.
Imazio M, Demichelis B, Parrini I, Giuggia M, Cecchi E, Gaschino G, Demarie D, Ghisio A, Trinchero R. Day-hospital treatment of acute pericarditis: a management program for outpatient therapy. J Am Coll Cardiol. 2004;43(6):1042.
Goyle, K.K. and Walling, A.D. Diagnosing pericarditis. (2002). American Family Physician, Vol 66 (9),
Diagnostic approach to chest pain in adults. (2014). UpToDate.
Differential diagnosis of chest pain in adults. (2014). UpToDate.
Evaluation of chest pain in the emergency department. (2014). UpToDate.
Clinical presentation and diagnostic evaluation of acute pericarditis. (2014). UpToDate.
Treatment of acute pericarditis. (2014). UpToDate.
Thanks to Sumit Bose for use of a number of his excellent slides!