A M3/4 lecture on the basics of the chest pain work-up

1. ABCD’s of Chest Pain
Michael Aref, MD, PhD
Hospitalist, Carle Physician Group
Adjunct Assistant Professor, Department of Nuclear, Plasma, and Radiological Engineering, UIUC
Clinical Instructor, Department of Medicine, UICOM-UC

2. Goals
• Review the history and physical
examination findings of a chest pain work-
up
• Identify the etiologies of chest pain with
increased mortality
• Understand the history, physical and
diagnostic testing components of cardiac
chest pain

3. Goals
• Review the history and physical
examination findings of a chest pain work-
up
• Identify the etiologies of chest pain with
increased mortality
• Understand the history, physical and
diagnostic testing components of cardiac
chest pain

4. Chest Pain

5. Chest Pain
• Use a liberal definition

6. History
Aggravating and alleviating factors
Severity
Character
Location
Associated symptoms
Setting
Timing

7. History
Aggravating and alleviating factors
• Does activity make your symptoms better or worse?
Severity
Character
Location
Associated symptoms
Setting
Timing

8. History
Aggravating and alleviating factors
• Does activity make your symptoms better or worse?
Severity
• Probably pretty bad, or they wouldn’t be in the hospital.
Character
Location
Associated symptoms
Setting
Timing

9. History
Aggravating and alleviating factors
• Does activity make your symptoms better or worse?
Severity
• Probably pretty bad, or they wouldn’t be in the hospital.
Character
• Pressure, pleuritic
Location
Associated symptoms
Setting
Timing

10. History
Aggravating and alleviating factors
• Does activity make your symptoms better or worse?
Severity
• Probably pretty bad, or they wouldn’t be in the hospital.
Character
• Pressure, pleuritic
Location
• Where in the “chest” are the symptoms located? Does it radiate anywhere?
Associated symptoms
Setting
Timing

11. History
Aggravating and alleviating factors
• Does activity make your symptoms better or worse?
Severity
• Probably pretty bad, or they wouldn’t be in the hospital.
Character
• Pressure, pleuritic
Location
• Where in the “chest” are the symptoms located? Does it radiate anywhere?
Associated symptoms
• Diaphoresis, dyspnea, nausea/emesis, fever?
Setting
Timing

12. History
Aggravating and alleviating factors
• Does activity make your symptoms better or worse?
Severity
• Probably pretty bad, or they wouldn’t be in the hospital.
Character
• Pressure, pleuritic
Location
• Where in the “chest” are the symptoms located? Does it radiate anywhere?
Associated symptoms
• Diaphoresis, dyspnea, nausea/emesis, fever?
Setting
• What were you doing when these symptoms occurred? Any recent surgery or travel?
Timing

13. History
Aggravating and alleviating factors
• Does activity make your symptoms better or worse?
Severity
• Probably pretty bad, or they wouldn’t be in the hospital.
Character
• Pressure, pleuritic
Location
• Where in the “chest” are the symptoms located? Does it radiate anywhere?
Associated symptoms
• Diaphoresis, dyspnea, nausea/emesis, fever?
Setting
• What were you doing when these symptoms occurred? Any recent surgery or travel?
Timing
• How long have you been noticing these symptoms? How long do they last?

14. JAMA 2005;294(20):2623-2629

15. Physical Examination
• VITALS (Verify If They Are Living Still)
• Blood pressure in both arms
• Jugular venous pulses versus distention
• Auscultation (heart and lungs)
• Radial and carotid pulses
• Reproducible chest pain

16. Pulsation versus
Distention
Thus the higher the jugular venous
pulsation the greater the jugular
venous pressure. If the pressure is
too great, jugular venous distention
occurs.
renalfellow.blogspot.com en.wikipedia.org

17. Goals
• Review the history and physical
examination findings of a chest pain work-
up
• Identify the etiologies of chest pain with
increased mortality
• Understand the history, physical and
diagnostic testing components of cardiac
chest pain

18. Framework
• Airway
• Breathing
• Gedanken Ventilation and Perfusion Scan
• Circulation
• “Home is where the heart is”
• Digestive
• Gedanken Endoscopic Retrograde Cholangiopancreatography

19. Airway/Breathing:
Ventilation

20. Constriction
Disease Definition Diagnostic Test
Severe asthma to Acute or subacute episodes of Peak flow
Status asthmaticus progressively worsening shortness of
breath, cough, wheezing, and chest tightness < 40% predicted/best
www.nhlbi.nih.gov/guidelines/asthma/
asthgdln.htm
—or some combination of these symptoms
< 25% predicted/best
An event in the natural course of the
disease characterized by a change in the
Acute exacerbation patient's baseline dyspnea, cough, and/or
of COPD sputum, that is beyond normal day-to-day
variations, is acute in onset and may
Chest x-ray
www.goldcopd.com warrant a change in medication in a patient
with underlying COPD.

21. Consolidation
Disease Definition Diagnostic Test
In addition to a constellation of
suggestive clinical features (cough,
fever, sputum production, and pleuritic
Pneumonia chest pain), a demonstrable infiltrate
cid.oxfordjournals.org/content/44/ by chest radiograph or other imaging Chest x-ray
Supplement_2/S27.full technique, with or without supporting
microbiological data, is required for
the diagnosis of pneumonia.
Acute Chest
Syndrome of Sickle SSD + new infiltrate on CXR + chest pain,
cough, wheezing, tachypnea, or fever Chest x-ray
Cell Disease

22. Collapse
Disease HxPx Diagnostic Test
Severe pleuritic pain,
JVD, tracheal
Pneumothorax Chest x-ray
deviation,
hyperresonance

23. Airway/Breathing:
Perfusion

24. Disease HxPx Diagnostic Test
Revised Geneva
Dyspnea (80%), criteria low to
pleuritic chest pain intermediate
Pulmonary Embolism
(52%), tachypnea probability: D-dimer
(70%) High probability: CT
PE protocol
European Society of Cardiology Guidelines on the Diagnosis and Management of Acute Pulmonary Embolism, European Heart Journal (2008) 29:2276-2315

25. Revised Geneva Score
Age > 65 years old 1
Previous VTE 3
Surgery or fracture within 1 month 2
Active malignancy 2
Unilateral lower limb pain 3
Hemoptysis 2
HR 75-94/min 3
HR ≥ 95/min 5
Pain on lower limb deep vein palpation and unilateral edema 4
Annals of Internal Medicine (2006) 144:165–171

26. Circulation

27. Walls
Disease HxPX Diagnostic Test
Precipitating etiology,
Improved with
Pericarditis TTE
leaning forward,
Friction rub
JVD
Hypotension
Cardiac Tamponade Pulsus paradoxus TTE
(inspiratory fall of systolic blood
pressure of greater than 10 mm
Hg)

28. Walls
Disease HxPX Diagnostic Test
Precipitating etiology,
Improved with
Pericarditis TTE
leaning forward,
Friction rub
JVD
Hypotension
Cardiac Tamponade Pulsus paradoxus TTE
(inspiratory fall of systolic blood
pressure of greater than 10 mm
Hg)

29. Plumbing
Disease HxPX Diagnostic Test
Acute Coronary
Syndrome EKG, CBC, cardiac
More later...
Type 1 “thrombosis” markers
Type 2 “demand”
Radiating to back
Aortic Dissection Syncope / neurological changes
> 20 mmHg differential between arms CTA chest
Absent pulse at carotids or radially

30. Electrical
Disease HxPx Diagnostic Test
Irregular pulse,
Arrhythmia EKG, K, Mg
syncope

31. Heat (Generator)
Disease HxPx Diagnostic Test
Acute Orthopnea, HTN,
Negative BNP rules
decompensation of elevated JVP, crackles,
out
heart failure pedal edema

32. Digestive

33. Esophageal
Disease HxPx Diagnostic Test
Caustic ingestion,
Forceful emesis,
CXR
Esophageal Rupture Subcutaneous (pneumomediastinum, pneumothorax,
emphysema, pleural effusion)
Hamman’s crunch

34. Esophageal
Disease HxPx Diagnostic Test
Caustic ingestion,
Forceful emesis,
CXR
Esophageal Rupture Subcutaneous (pneumomediastinum, pneumothorax,
emphysema, pleural effusion)
Hamman’s crunch

35. Gastrum / Duodenum
Disease HxPx Diagnostic Test
Cough test Sn CXR (air under the
Perforated Ulcer
80-95% for peritonitis diaphragm)

36. Gall Bladder
Disease HxPx Diagnostic Test
Leukocytosis
Fever
Elevated CRP
Cholecystitis Murphy’s sign Sn 97%
US RUQ ACR Rating
NPV 93%
9

37. Pancreas
Disease HxPx Diagnostic Test
Lipase
Epigastric pain
Pancreatitis CT abd/pel ACR
radiating to back
Rating 6-8

38. Goals
• Review the history and physical
examination findings of a chest pain work-
up
• Identify the etiologies of chest pain with
increased mortality
• Understand the history, physical and
diagnostic testing components of cardiac
chest pain

39. Anginal Pain
1. Constricting discomfort in the front of the
chest, or in the neck, shoulders, jaw, or arms
2. Precipitated by physical exertion
3. Relieved by rest or nitroglycerin within
about 5 minutes
• Non-anginal pain: 0-1 of the above
• Atypical anginal pain: 2 of the above
• Typical anginal pain: 3 of the above

40. Two of the three features above are defined as atypical angina.
One or none of the features above are defined as non-anginal
Percentagepain.people estimated to have coronary
chest of
artery disease according to typicality of symptoms, age,
sex and risk factors
Table 1 Percentage of people estimated to have coronary artery disease
according to typicality of symptoms, age, sex and risk factors
Non-anginal chest Atypical angina Typical angina
pain
Men Women Men Women Men Women
Age Lo Hi Lo Hi Lo Hi Lo Hi Lo Hi Lo Hi
(years)
20 of 393
35 3 35 1 19 8 59 2 39 30 88 10 78
45 9 47 2 22 21 70 5 43 51 92 20 79
55 23 59 4 25 45 79 10 47 80 95 38 82
65 49 69 9 29 71 86 20 51 93 97 56 84
For men older than 70 with atypical or typical symptoms, assume an estimate > 90%.
For women older than 70, assume an estimate of 61!90% EXCEPT women at high risk AND
with typical symptoms where a risk of > 90% should be assumed.
Values are per cent of people at each mid-decade age with significant coronary artery
5
disease (CAD) .
Hi = High risk = diabetes, smoking and hyperlipidaemia (total cholesterol > 6.47 mmol/litre).
Lo = Low risk = none of these three.
The shaded area represents people with symptoms of non-anginal chest pain, who would not
be investigated for stable angina routinely.
Note:
These results are likely to overestimate CAD in primary care populations.
If there are resting ECG ST-T changes or Q waves, the likelihood of CAD is higher in each
cell of the table.

41. JAMA 2005;294(20):2623-2629

42. But...
• “Relief of chest pain with nitroglycerin is not a reliable diagnostic test and does not distinguish
between cardiac and non-cardiac chest pain.” (CJEM. 2006 May;8(3):164-9.) and “in a general
population admitted for chest pain, relief of pain after nitroglycerin treatment does not predict active
coronary artery disease and should not be used to guide diagnosis” (Ann Intern Med. 2003 Dec
16;139(12):979-86)
• “Inducible ischemia on stress testing was found in 33 (14%, 95% confidence interval 10% to 19%) of
the 231 patients who had typical anginal pain, 238 (11%, 95% confidence interval 10% to 13%) of the
2,140 patients presenting with atypical/nonanginal chest pain, and 25 (16%, 95% confidence interval
11% to 22%) of the 153 patients who had no complaint of chest pain on presentation. Compared to
patients with atypical or no chest pain, patients with typical chest pain were not significantly more
likely to have inducible ischemia on stress testing (likelihood ratio +1.25, 95% confidence interval 0.89
to 1.78). In conclusion, in our study, the patients who presented with "typical" angina were no more
likely to have inducible myocardial ischemia on stress testing than patients with other presenting
symptoms.” (Am J Cardiol. 2010 Jun 1;105(11):1561-4. Epub 2010 Apr 10.)

43. Stratifying Cardiac
Chest Pain
Non-cardiac /
Unstable Angina Non-ST Elevation MI ST Elevation MI
Stable Angina
History and physical
History and physical supportive Any other reason for positive Well you do need to write and
unsupportive of cardiac
of cardiac etiology cardiac markers? H&P
diagnosis
EKG (+)ve ST elevation
EKG (-)ve EKG equivocal
New LBBB
> 8 hours of pain with negative Don’t wait for cardiac markers
Negative cardiac markers Positive cardiac markers
cardiac markers to turn positive!
MONA H BAS Emergent cardiac
Stress testing
Cardiac catheterization catheterization

45. MONA H BAS
Morphine No mortality benefit
Oxygen No mortality benefit, if SpO2 > 92%
Nitroglycerin No mortality benefit
TD = IV
Aspirin ± clopidogrel Do NOT initiate clopidogrel until discussed with cardiologist
CI in active bleeding
Heparin / Enoxaparin CI in active bleeding
Mortality with heparin > enoxaparin
Beta blockers CI in bradycardia, hypotension
ACE Inhibitor Within 48°, CI in renal failure, hypotension
“Statin” CI in liver failure, disproportionate CK elevation

46. MKSAP Students 4
• Cardiovascular Medicine #9
• Cardiovascular Medicine #11
• Cardiovascular Medicine #15
• Cardiovascular Medicine #17
• Cardiovascular Medicine #21
• Pulmonary Medicine #30
• Pulmonary Medicine #31