1. Approach To Chest Pain

2. Chest Pain
TABLE DIFFERENTIAL DIAGNOSIS OF EPISODIC CHEST PAIN RESEMBLING ANGINA PECTORIS DURATION QUALITY PROVOCATION RELIEF LOCATION COMMENT
Effort angina minutes Visceral (pres- During effort or Rest, nitroglyc- Substernal, radi- First episode
sure) emotion erin ates vivid
Rest angina minutes Visceral (pres- Spontaneous (? Nitroglycerin Substernal, radi- Often nocturnal
sure) with exercise) ates
Mitral prolapse Minutes to Superficial Spontaneous (no Time Left anterior No pattern, vari-
hours (rarely visceral) pattern able character
Esophageal re- 10 minutes to 1 Visceral Recumbency, Food, antacid Substernal, epi- Rarely radiates
flux hour lack of food gastric
Esophageal minutes Visceral Spontaneous, Nitroglycerin Substernal, Mimics angina
spasm cold liquids, ex radiates
ercise
Peptic ulcer Hours Visceral, burning Lack of food, Foods, antacids Epigastric, substernal ‘‘acid’’ foods
Biliary disease Hours Visceral (waxes Spontaneous, Time, analgesia Epigastric, ? Colic
and wanes) food radiates
Cervical disc Variable (gradu- Superficial Head and neck Time, analgesia Arm, neck Not relieved by
ally subsides movement, pal rest
pation
Hyperventilation 2-3 minutes Visceral Emotion, tachy- Stimulus removal Substernal Facial paresthe-
pnea sia
Musculoskeletal Variable Superficial Movement, Time, analgesia Multiple Tenderness
palpation
Pulmonary 30 minutes + Visceral (pres- Often spontane- Rest, time, bron- Substernal
Dyspneic sure) ous chodilator
Reproduced with permission from Christie, L.G., Jr., and Conti, C.R.: Systematic approach to the
evaluation of angina-like chest pain. Am. Heart J. 1027, 1981.

3. Chest Pain
TABLE SOME FEATURES DIFFERENTIATING CARDIAC FROM NONCARDIAC CHEST PAIN
FAVORING ISCHEMIC ORIGIN AGAINST ISCHEMIC ORIGIN
Character of Pain
Constricting
Squeezing ‘‘Knife-like,’’ sharp, stabbing
Burning ‘‘Jabs’’ aggravated by respiration
‘‘Heaviness,’’ ‘‘heavy feeling’’
Location of Pain
Substernal In the left submammary area
Across mid-thorax, anteriorly In the left hemithorax
In both arms, shoulders
In the neck, cheeks, teeth
In the forearms, fingers
In the interscapular region
Factors Provoking Pain
Exercise Pain after completion of exercise
Excitement Provoked by a specific body motion
Other forms of stress
Cold weather
After meals
From Selzer, A.: Principles and Practice of Clinical Cardiology. 2nd ed. Philadelphia, W.B. Saunders
Company, 1983, p. 17.

4. Patterns of Pain

5. Differential Dx by Location

6. Chest Pain Physical Exam
Vital Signs
Febrile- Endocarditis, Dressler’s, Demand Ischemia
BP- Hypertensive, Ischemia, Aortic Dissection, CHF (diastolic dysfxn)
Hypotensive, Cardiogenic Shock, CHF (systolic dysfxn, AS)
HR- arrhythmia, afib, v-tach, heart block
RR/SaO2- CHF, PE

7. Chest Pain Physical Exam
Mental Status- alertness (shock), anxiety
HEENT: Mucous Membranes, Carotid Upstrokes (AS, AI, Bisferiens, Alternans), Bruits, Thyroid (CHF, Angina), Cx Tenderness, JVP- CHF,valve disease, Cannon a-waves
Lungs: RR, Rales, Wheezing (Bronchoconstriction or CHF), Pleural Effusion
Extrem: Equal BP’s, pulses (dissection, PVD), femoral/abdominal bruits, perfusion (cool, clammy, shock), Edema-CHF

8. Chest Pain Cardiac Exam
Rate/Rhythm- arrhythmia (Afib, V-Tach, Bradycardia), heart block
PMI- displaced, sustained (CHF), palpable S3, S4
Heart Sounds: S1 Loud (MS), Soft (MR, AVB) Variable(Afib), OS(MS), Mid Sys Click (MVP) Split S2 (BBB, PE, PA HTN, AS, LV Ischemia, Severe MR)
Murmurs- (Separate topic) AS, AI(esp acute), Ischemic MR
S3- CHF, S4-LV Non compliance (Ischemia, HTN)

14. ST Elevation Myocardial Infarction (STEMI)
Admit, O2
ASA
SL NTG, +/- IV NTG (SBP>100)
MSO4 2-4mg, (MONA)
Heparin (UFH or LMW)
Beta-blocker
Candidate for Thrombolytics

15. Definite Indications for PTCA/Thrombolytic Therapy
Consistent clinical syndrome
Chest pain, new arrhythmia, unexplained hypotension, pulmonary edema
Diagnostic EKG
>1mm ST elevation in >2 contiguous leads
New LBBB
Less than 12 hours since onset of pain

16. Relative Indications for PTCA/Thrombolytic Therapy
Consistent Clinical Syndrome
Chest pain, new arrhythmia, unexplained hypotension or pulmonary edema
Nondiagnostic ECG
Left bundle-branch block of unknown duration

17. Absolute Contraindications for Thrombolytic Therapy
History of hemorrhagic stroke
Stroke or CVA within 1 year
Allergy to the agent
Surgery or trauma in past 2 wks
Known intracranial neoplasm
Suspected aortic dissection
Active internal bleeding (except menstruation)

18. Relative Contraindications for Thrombolytic Therapy
Severe uncontrolled hypertension (>180/110 mm Hg)
History of chronic severe hypertension
CVA or intracerebral pathology > 1 yr ago
Current anticoagulant use
Recent trauma (within 2-4 weeks)
Allergy or prior exposure to streptokinase

19. Relative Contraindications for Thrombolytic Therapy
Active peptic ulcer disease
Significant hepatic dysfunction
Recent (2-4 weeks) internal bleeding
Bleeding diathesis
Noncompressible arterial or central venous puncture
Pregnancy

20. PTCA vs. Thrombolysis
PAMI Trial Demonstrated Superiority of PTCA over Thrombolysis
Hospital Mortality 6.5% with Thrombolysis vs 2.6% with PTCA
ICH 2% with Thrombolysis vs 0.2% with PTCA
90 min Door to Balloon Time
Experienced Operators

21. Non-ST Elevation MI (NSTEMI)

22. NSTEMI, Early Invasive Strategy

26. Chest Pain Uncertain Etiology
EKG with Symptoms
4% of MI’s normal EKG
Non Invasive Imaging :Resting Nuclear Imaging/Echo/Contrast During Symptoms, CT Angio, EBCT, MRI Hyperenhancement
Cardiac Enzymes
Stress Testing
Cardiac Catheterization

27. Bayes Theroem

28. Predictive Value

30. Predictive Value ETT

31. ETT in Women

32. Cardiac Stress Testing Nuclear
TABLE SENSITIVITY AND SPECIFICITY FOR DETECTION OF CORONARY ARTERY
DISEASE BY 201Tl SINGLE-PHOTON EMISSION COMPUTERIZED TOMOGRAPHY
NUMBER OF
AUTHOR PATIENTS SENSITIVITY (%) SPECIFICITY
Tamaki et al
De Pasquale et al
Borges-Neto et al
Maddahi et al
Fintel et al
Iskandrian et al
Go et al
Mahmarian et al
van Train et al
Total

33. Stress Echo

34. Contraindications to ETT

35. ETT High Risk Features TABLE 5-4 EXERCISE PARAMETERS ASSOCIATED WITH
AN ADVERSE PROGNOSIS AND MULTIVESSEL CORONARY
ARTERY DISEASE
Duration of symptom-limiting exercise (< 6 METs)
Failure to increase systolic blood pressure ³120 mm Hg, or a
sustained decrease ³10 mm Hg, or below rest levels, during
progressive exercise
ST segment depression ³2 mm, downsloping ST segment,
starting at < 6 METs, involving ³5 leads, persisting ³5 min-
utes into recovery
Exercise-induced ST segment elevation (a Vr excluded)
Angina pectoris during exercise
Reproducible sustained (> 30 sec) or symptomatic ventricular
tachycardia

36. EBCT

37. Multislice CT Leber et al., JACC July 2005 Sensitivity Specificity
Segment
<50%
>50%
>75%
Mid/Prox 80 75 88 97
Distal 76 67 60
All 79 73
Leber et al., JACC July 2005

38. Diagnostic Accuracy CTA
Leshka et.al. Eur Heart Journal 2005

39. CTA Exclusions BMI>30 Afib Coronary Calcium Previous Stent HR>75
Hemodynamic Instability, inability to take beta-blockers
Renal Insufficiency, Contrast allergy
Coronary Size <3mm

40. Coronary Angiography

41. Cardiac Catheterization
Remains the “Gold Standard”
High risk patients
Non diagnostic non-invasive tests
Hemodynamic, Anatomical, Physiological Assessment
FFR, IVUS
Immediate Intervention if Needed