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3. Kim A. Eagle, M.D. University of Michigan Health System Kim A. Eagle, M.D. University of Michigan Health System The Evaluation of Chest Pain C ARDIOVASCULAR S EQUENCE Fall 2012

4. Kim A. Eagle, MD Director University of Michigan Cardiovascular Center Grants: NIH, Hewlett Foundation, Mardigian Foundation, Varbedian Fund, GORE Consultant: NIH NHLBI

5. THE EVALUATION OF CHEST PAIN Key Words: Angina pectoris, pericarditis, aortic dissection, differential diagnosis Objectives: 1.To learn the differential diagnosis of chest pain. 2.To learn the key life threatening causes of chest pain. 3.To diagnose aortic dissection. 4.To become familiar with Bayes Theorem. Key Words: Angina pectoris, pericarditis, aortic dissection, differential diagnosis Objectives: 1.To learn the differential diagnosis of chest pain. 2.To learn the key life threatening causes of chest pain. 3.To diagnose aortic dissection. 4.To become familiar with Bayes Theorem.

6. C AUSES O F R ECURRENT C HEST P AIN CardiacCardiac GastrointestinalGastrointestinal MusculoskeletalMusculoskeletal AorticAortic PulmonaryPulmonary PsychologicPsychologic CardiacCardiac GastrointestinalGastrointestinal MusculoskeletalMusculoskeletal AorticAortic PulmonaryPulmonary PsychologicPsychologic

7. C ARDIAC C HEST P AIN Angina PectorisAngina Pectoris Retrosternal tightnessRetrosternal tightness Radiates to neck, jaw, shoulder or arms (L > R)Radiates to neck, jaw, shoulder or arms (L > R) Brought on by:Brought on by: – Exertion – Emotion Angina PectorisAngina Pectoris Retrosternal tightnessRetrosternal tightness Radiates to neck, jaw, shoulder or arms (L > R)Radiates to neck, jaw, shoulder or arms (L > R) Brought on by:Brought on by: – Exertion – Emotion Lasts minutes (1 - 10 min)Lasts minutes (1 - 10 min) Relieved by NTG or restRelieved by NTG or rest EKG: Transient STE or ST depressionEKG: Transient STE or ST depression Lasts minutes (1 - 10 min)Lasts minutes (1 - 10 min) Relieved by NTG or restRelieved by NTG or rest EKG: Transient STE or ST depressionEKG: Transient STE or ST depression

8. C ARDIAC C HEST P AIN PericarditisPericarditis Sharp pleuritic chest painSharp pleuritic chest pain Worse lying; better sittingWorse lying; better sitting Friction rub heard on auscultationFriction rub heard on auscultation Lasts hours to daysLasts hours to days EKG: Typically PR depression and ST elevationEKG: Typically PR depression and ST elevation PericarditisPericarditis Sharp pleuritic chest painSharp pleuritic chest pain Worse lying; better sittingWorse lying; better sitting Friction rub heard on auscultationFriction rub heard on auscultation Lasts hours to daysLasts hours to days EKG: Typically PR depression and ST elevationEKG: Typically PR depression and ST elevation

9. G ASTROINTESTINAL C HEST P AIN Retrosternal burningRetrosternal burning Precipitated by foods or supine position (night-time)Precipitated by foods or supine position (night-time) Relieved by antacids, not NTGRelieved by antacids, not NTG Retrosternal burningRetrosternal burning Precipitated by foods or supine position (night-time)Precipitated by foods or supine position (night-time) Relieved by antacids, not NTGRelieved by antacids, not NTG Gastroesophageal Reflux: (GERD)

10. G ASTROINTESTINAL C HEST P AIN Epigastric ache or burningEpigastric ache or burning After meals, not exertionalAfter meals, not exertional Gnawing pain at nightGnawing pain at night Relieved by antacids, not NTGRelieved by antacids, not NTG Epigastric ache or burningEpigastric ache or burning After meals, not exertionalAfter meals, not exertional Gnawing pain at nightGnawing pain at night Relieved by antacids, not NTGRelieved by antacids, not NTG Peptic Ulcer Disease:

11. G ASTROINTESTINAL C HEST P AIN Retrosternal pain and dysphagiaRetrosternal pain and dysphagia Precipitated by mealsPrecipitated by meals Not exertionalNot exertional May be relieved by NTGMay be relieved by NTG Retrosternal pain and dysphagiaRetrosternal pain and dysphagia Precipitated by mealsPrecipitated by meals Not exertionalNot exertional May be relieved by NTGMay be relieved by NTG Esophageal Spasm:

12. G ASTROINTESTINAL C HEST P AIN Constant deep RUQ painConstant deep RUQ pain Brought on by fatty foods, not exertionBrought on by fatty foods, not exertion Not relieved by antacids or NTGNot relieved by antacids or NTG Constant deep RUQ painConstant deep RUQ pain Brought on by fatty foods, not exertionBrought on by fatty foods, not exertion Not relieved by antacids or NTGNot relieved by antacids or NTG Biliary Colic:

13. M USCULOSKELETAL C HEST P AIN Sternal pain worsened by chest movementSternal pain worsened by chest movement Costrochondral junctions sensitive to palpitationCostrochondral junctions sensitive to palpitation Worse on left sideWorse on left side Relieved by antiinflammatory agent or steroid injectionRelieved by antiinflammatory agent or steroid injection Sternal pain worsened by chest movementSternal pain worsened by chest movement Costrochondral junctions sensitive to palpitationCostrochondral junctions sensitive to palpitation Worse on left sideWorse on left side Relieved by antiinflammatory agent or steroid injectionRelieved by antiinflammatory agent or steroid injection Costrochondritis:Costrochondritis:

14. M USCULOSKELETAL C HEST P AIN Constant pain or shooting painsConstant pain or shooting pains May be in dermatomal distributionMay be in dermatomal distribution Worsened by neck motionWorsened by neck motion Constant pain or shooting painsConstant pain or shooting pains May be in dermatomal distributionMay be in dermatomal distribution Worsened by neck motionWorsened by neck motion Cervical Radiculitis:

15. A ORTIC C HEST P AIN Sudden and severe at inceptionSudden and severe at inception May be chest and/or back painMay be chest and/or back pain Pulse deficits or aortic valve insufficiencyPulse deficits or aortic valve insufficiency Sudden and severe at inceptionSudden and severe at inception May be chest and/or back painMay be chest and/or back pain Pulse deficits or aortic valve insufficiencyPulse deficits or aortic valve insufficiency Aortic Dissection:

16. A ORTIC C HEST P AIN Deep steady pain located at site of pressure on musculoskeletal systemDeep steady pain located at site of pressure on musculoskeletal system May have cough, dysphagia, or other sx from local compressionMay have cough, dysphagia, or other sx from local compression Deep steady pain located at site of pressure on musculoskeletal systemDeep steady pain located at site of pressure on musculoskeletal system May have cough, dysphagia, or other sx from local compressionMay have cough, dysphagia, or other sx from local compression Aortic Aneurysm:

17. P ULMONARY C HEST P AIN Sharp pleuritic chest painSharp pleuritic chest pain Worse lying; better sittingWorse lying; better sitting Pleural rub on examPleural rub on exam Lasts hours or daysLasts hours or days Often with cough, respiratory infectionOften with cough, respiratory infection Sharp pleuritic chest painSharp pleuritic chest pain Worse lying; better sittingWorse lying; better sitting Pleural rub on examPleural rub on exam Lasts hours or daysLasts hours or days Often with cough, respiratory infectionOften with cough, respiratory infection Pleurisy:Pleurisy:

18. P ULMONARY C HEST P AIN Sudden severe pain with SOBSudden severe pain with SOB Pleuritic in naturePleuritic in nature Predisposition to venous clottingPredisposition to venous clotting Hypoxia and tachycardiaHypoxia and tachycardia Sudden severe pain with SOBSudden severe pain with SOB Pleuritic in naturePleuritic in nature Predisposition to venous clottingPredisposition to venous clotting Hypoxia and tachycardiaHypoxia and tachycardia Pulmonary Embolus:

19. P SYCHOLOGIC C HEST P AIN Dull constricting ache with SOBDull constricting ache with SOB Circumoral numbness or lightheadednessCircumoral numbness or lightheadedness Recent unusual stressRecent unusual stress Recurrent episodes in healthy peopleRecurrent episodes in healthy people Dull constricting ache with SOBDull constricting ache with SOB Circumoral numbness or lightheadednessCircumoral numbness or lightheadedness Recent unusual stressRecent unusual stress Recurrent episodes in healthy peopleRecurrent episodes in healthy people Panic Disorder:

20. D IAGNOSTIC T ESTS I N P ATIENTS W ITH C HEST P AIN EKGCXR Upper GI series or endoscopy EKGCXR Upper GI series or endoscopy T EST T ARGET D IAGNOSIS Myocardial ischemiaMyocardial ischemia PericarditisPericarditis Aortic dissection orAortic dissection oraneurysm GERDGERD UlcerUlcer Myocardial ischemiaMyocardial ischemia PericarditisPericarditis Aortic dissection orAortic dissection oraneurysm GERDGERD UlcerUlcer

21. D IAGNOSTIC T ESTS I N P ATIENTS W ITH C HEST P AIN Abdomen ultra sound Chest CT or MRI Esophageal motility VQ scan/CT Angio Stress test/CT Angio Abdomen ultra sound Chest CT or MRI Esophageal motility VQ scan/CT Angio Stress test/CT Angio T EST T ARGET D IAGNOSIS Gall stonesGall stones Aortic diseaseAortic disease Pulmonary embolusPulmonary embolus Esophageal spasmEsophageal spasm Pulmonary embolusPulmonary embolus AnginaAngina Gall stonesGall stones Aortic diseaseAortic disease Pulmonary embolusPulmonary embolus Esophageal spasmEsophageal spasm Pulmonary embolusPulmonary embolus AnginaAngina

22. D IAGNOSTIC T ESTS I N P ATIENTS W ITH C HEST P AIN 2 - D Echo Transesophageal echo 2 - D Echo Transesophageal echo Pericardial fluidPericardial fluid Aortic dissectionAortic dissection Pericardial fluidPericardial fluid Aortic dissectionAortic dissection

23. A PPLICATION O F D IAGNOSTIC T ESTS Pre test Probability Probability TestTest Post test Probability Probability B AYE’S T HEOREM

24. P ROBABILITY O F M AJOR CAD I N P ATIENTS W ITH C HEST PAIN AgeAge MMFFMMFF MM FF No Sx Atypical Angina Typical Angina 35 - 44 1.91.90.30.321.821.84.24.269.769.725.825.8 45 - 54 5.55.51.01.046.146.113.313.387.387.355.255.2 55 - 64 9.79.73.23.258.958.932.432.492.092.079.479.4 > 65 12.312.37.57.567.167.154.454.494.394.390.690.6 All numbers reflect percentagesAll numbers reflect percentages NEJM 1979; 300; 1350-1358NEJM 1979; 300; 1350-1358 All numbers reflect percentagesAll numbers reflect percentages NEJM 1979; 300; 1350-1358NEJM 1979; 300; 1350-1358