1. Acute Chest Pain “Can I go back to sleep?” Dr. Hussam Al-Faleh Residents Course

2. Outline Clinical presentations Clinical presentations Causes of chest pain Causes of chest pain Clinical aids to diagnose Ischemic CP Clinical aids to diagnose Ischemic CP summery summery

3. It’s so painful I can’t breath!

4. 25yr old male with CP for 3 days 25yr old male with CP for 3 days Sharp, central, worse with inspiration, and lying down, better sitting up, No relation to exertion Sharp, central, worse with inspiration, and lying down, better sitting up, No relation to exertion H/o URTI 7 days ago H/o URTI 7 days ago No RF No RF BP 110/70, HR 100 bpm, triphasic pericardial rub BP 110/70, HR 100 bpm, triphasic pericardial rub Wide spread ST elevation, PR depression Wide spread ST elevation, PR depression Diagnosis: Pericarditis Diagnosis: Pericarditis

5. The Sky is falling

6. 40yr old female 40yr old female CP for 3 months CP for 3 months Can not be described, all over the chest and both shoulders, radiates to her head, continuous, not ↑ exertion, but exacerbated with emotional distress Can not be described, all over the chest and both shoulders, radiates to her head, continuous, not ↑ exertion, but exacerbated with emotional distress Divorced and physically abused by daughter Divorced and physically abused by daughter No RF No RF Normal PE and ECG Normal PE and ECG Diagnosis: Psychogenic chest pain Diagnosis: Psychogenic chest pain

7. Nothing is wrong with me!

8. 63yr male 63yr male CP for last month CP for last month Central burning, non radiating occurring only on exertion, relieved with rest. Central burning, non radiating occurring only on exertion, relieved with rest. HTN HTN PE & ECG Normal PE & ECG Normal Diagnosis: Typical anginal pain Diagnosis: Typical anginal pain

9. I am like no other!

10. 45yr male 45yr male Upper back pain for 2 weeks Upper back pain for 2 weeks Never occurs at rest or change in posture, and provoked by effort relived with rest Never occurs at rest or change in posture, and provoked by effort relived with rest H/o Premature atherosclerosis H/o Premature atherosclerosis Normal PE & ECG Normal PE & ECG Diagnosis: very suspicious for ischemic pain Diagnosis: very suspicious for ischemic pain

11. Causes of Chest pains

13. Panjue et al JAMA 1998;280,14

14. Goals of CP assessment 1- Need to r/o serious causes of chest pain “ what is the chance that my patient will die due his underlying condition” 2- Need to refer for further testing i.e EST, V/Q scan, Angiogram etc.. 3- If cause of CP is not serious how can i help? eg. NSAIDS for MSL CP, PPI trial/GI consult for Reflux

15. Risk stratification 1. High risk AMI, High risk UA  Lyse or cath 2. NSTEMI, LBBB, High risk UA  Admit to CCU 3. Low risk UA, Non ischemic pain  admit to ward or see as outpatient

16. History

17. Chest Pain description: Location and radiation Location and radiation Character Character Onset and duration Onset and duration Aggravators and relievers Aggravators and relievers Severity Severity Associated symptoms Associated symptoms Vital signs/ECG

18. Panjue et al JAMA 1998;280,14

21. Typical/Atypical CP Typical: Typical: 1. Substernal 1. Substernal 2. Burning/heavy/squeezing 2. Burning/heavy/squeezing 3. ↑ by exertion ↓ rest or NTG 3. ↑ by exertion ↓ rest or NTG

23. If clinically angina, classify:

24. Risk factors Age : males ≥45, females ≥55 Age : males ≥45, females ≥55 Gender Gender DM DM Dyslipidemia Dyslipidemia HTN HTN Smoking Smoking Family history of Premature CAD: males ≤55 females ≤65 Family history of Premature CAD: males ≤55 females ≤65 Metabolic syndrome Metabolic syndrome

25. Physical exam Vitals, Vitals, Vitals Vitals, Vitals, Vitals BP (measure both sides) BP (measure both sides) Pulses paradoxicus Pulses paradoxicus Heart rate (tachy/bradycardia) Heart rate (tachy/bradycardia) Respiratory rate Respiratory rate Fever Fever O2 Sat O2 Sat

26. Physical exam CVS exam: - JVP - Carotid bruit - Palpation of chest wall (where is the pain?) - Extra Heart sounds (S3 or 4) - Murmurs (eg, early diastolic, ) - Pericardial rub

27. Physical exam Chest exam: - Trachea - Breath sounds Abdomen: - Tenderness

28. InvestigationsECG: - NORMAL ECG DOES NOT ROLE OUT ISCHEMIA - Serial ECG’s - Always compare to an old ECG - ST ↑ (localized vs. Wide spread) - ST ↓ - T wave inversion (location and symmetry) or peaking

29. ECG (cont.) - Q waves (new) - New conduction defects (LBBB/RBBB) - Voltage/electrical alternans/Tachycardia - PE patterns (Q1 S3 T3), RBBB,

30. Other investigations (PRN) Depending on Hx/PE CBC CBC D-dimers D-dimers ABG’s ABG’s CXR CXR

31. Troponins I & T Most sensitive and specific cardiac markers Most sensitive and specific cardiac markers Rise 3-12hr after onset of CP Rise 3-12hr after onset of CP Peak I (24hr), T (12hr-2 days) Peak I (24hr), T (12hr-2 days) Return to normal 5-14 days Return to normal 5-14 days Has both diagnostic and prognostic values Has both diagnostic and prognostic values Sample at baseline and after 6-8hr Sample at baseline and after 6-8hr

32. Conclusion History and physical are corner stones in diagnosis of Chest pain History and physical are corner stones in diagnosis of Chest pain Ensure that patient is stable before taking a detailed history Ensure that patient is stable before taking a detailed history Serial ECG’s and cardiac enzymes for selected patients Serial ECG’s and cardiac enzymes for selected patients