Emergency lectures - Chest pain


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  • Difficult diagnosis to make and CAD affects people in the prime of their life
  • Puts these patients at a higher risk of heart disease
  • Emergency lectures - Chest pain

    1. 1. Hugh Hemsley MDRiverside Regional Medical CenterVirginia, USAFebruary 2011
    2. 2. Chest Pain Cardiovascular disease is the number 1 cause of death in the United States 5.4% of all visits to the ED are for chest pain Etiology can be difficult to diagnose  Includes diseases of the chest and abdomen  Diseases can vary from benign to life-threatening  Different diseases can present with similar signs and symptoms
    3. 3. Evaluation of Chest Pain GOAL-Early detection and safe management of life- threatening diseases Complete history is very important Timely and appropriate testing Do not focus on a benign disease and miss a life- threatening illness
    4. 4. Chest Pain 2.5% of patients with an acute MI are sent home 20% of all ED malpractice claims are for misdiagnosed chest pain complaints.
    5. 5. Chest Pain Why do diseases of different organ systems present with similar symptoms? Visceral versus somatic pain
    6. 6. Visceral Pain Sensory nerves from internal organs enter the spinal cord at multiple levels and thus the pain is difficult to describe and localize  Aching, pressure, heaviness
    7. 7. Somatic Pain Bone, skin, muscle, parietal pleura Sensory nerves from these structures enter the spinal cord at specific levels and the pain is easily described and localized  Sharp, stabbing  Patients will point to an area of well localized pain
    8. 8. Causes of chest pain Cardiovascular  Gastrointestinal  A.C.S.  Esophageal reflux  Pericarditis  Esophageal spasm  Aortic dissection  Esophageal rupture  Aortic stenosis  Peptic ulcer disease  Gallbladder disease Pulmonary  Pancreatitis  Pulmonary embolism  Pleurisy  Chest Wall Pain  Pneumothorax  Herpes Zoster  Pneumonia  Costochondritis  Cervical radiculopathy Pediatrics  Rib fracture  Kawasaki disease  Anxiety  Hypertrophic cardiomyopathy  Congenital heart disease
    9. 9. Evaluation of chest pain Maintain a high index of suspicion for life-threatening illness in all patients complaining of chest pain. Rapid triage of all patients complaining of chest pain Is the patient at risk for serious illness?  Abnormal vitals signs  Patient looks sick, diaphoretic, short of breath, altered level of consciousness.  Risk factors or history of cardiovascular disease  Cardiac monitor, IV, oxygen  EKG within 10 minutes of patient arrival
    10. 10. History Complete history most important Focus on the characteristics of the pain, associated symptoms, risk factors, and history of cardiovascular disease Pain scale 1-10  1-no pain  10-worst possible pain
    11. 11. History Duration of the pain  Pain lasting seconds probably not cardiac  Constant pain for longer than 8-12 hours with negative workup probably not cardiac Intensity of pain  Immediate onset of severe pain think aortic dissection  ACS pain gradually reaches maximum intensity
    12. 12. History Quality of the pain  Burning pain more likely gastrointestinal  Tearing pain typical of aortic dissection  Sharp, stabbing pain usually not ischemic  Up to 20% of patients with an acute MI describe pain as sharp  Pleuritic pain-worse with breathing or coughing  Lung, musculoskeletal, pericardial  Pleuritic chest pain is described in up to 6% of MI patients.
    13. 13. History  Chest wall pain-well localized pain reproduced by movement or palpation of the affected area  ACS-visceral pain radiates to the jaw, arms, and neck  ACS-associated symptoms  Shortness of breath, nausea, diaphoresis, fatigue, vomiting, palpitations
    14. 14. Risk factors Age > 40 Male Post-menopausal female Hypertension Hyperlipidemia Cigarette smoking Diabetes Family history Obesity Drug abuse-cocaine The absence of risk factors does not rule out cardiac disease
    15. 15. Acute Coronary SyndromeACS Unstable Angina  New onset of symptoms  Symptoms that occur at rest  A change in the patient’s usual pattern of angina  No ST elevation, no elevation of cardiac enzymes  EKG will be normal about 50% of patients  Evidence of ischemia-ST depression or T-wave inversion
    16. 16. ACS Acute Myocardial Infarction  STEMI  ST elevation of >1 mm in at least 2 contiguous leads  Elevated cardiac enzymes  Non-STEMI  ST depression and T wave inversion  New left bundle branch block or Q waves  Elevation of cardiac enzymes
    17. 17. STEMI-ST elevation MI
    18. 18. Non-STEMI
    19. 19. ACS Pain starts following exertion, eating, exposure to cold or emotional stress, can occur at rest Pressure, heaviness, tightness, squeezing, “an elephant is sitting on my chest” Pain radiates to the shoulders, arms, or jaw Associated symptoms-diaphoresis, shortness of breath, nausea, vomiting, weakness palpitations
    20. 20. Anginal EquivalentsAtypical Chest Pain Up to 33% of ACS will not have chest pain  Dyspnea with exertion or at rest  Shoulder, arm, or jaw pain only  Nausea  Lightheaded, dizzy, or syncope  Generalized weakness  Diaphoresis  Acute change in mental status  Palpitations  Anginal equilavents are more common in females, diabetics, and the elderly
    21. 21. EKG  The best test to rapidly diagnose an acute MI  Obtain within 10 minutes of patient’s arrival  Up to 50% of initial EKGS will be normal or have non- diagnostic changes  Serial EKGS
    22. 22. Biomarkers Troponin T and I  Preferred marker  Protein located in cardiac muscle  Poor sensitivity first 6 hours after onset of symptoms  Repeat in 8-12 hours after onset of symptoms  Can be elevated with  Pulmonary embolism  Aortic dissection  Renal failure  Sepsis  Cardiac trauma or surgery  CHF
    23. 23. Biomarkers CPK  Located in cardiac and skeletal muscle  CPK/MB is the cardiac isoenzyme  Poor sensitivity first 6 hours after onset of symptoms  Repeat testing in 8-12 hours  Useful in detecting reinfarction Myoglobin  Found in skeletal and cardiac muscle  Good sensitivity early after onset of symptoms but poor specificity
    24. 24. Biomarkers Test Onset Peak Duration CPK/MB 3-12 hours 18-24 hours 36-48 hours Troponin 3-12 hours 18-24 hours Up to 10 days Myoglobin 1-4 hours 6-7 hours 24 hours Repeat in 8-12 hours
    25. 25. Pulmonary Embolism Majority form in the deep veins of the pelvis and lower extremities Size of the clot will determine signs and symptoms  Large clots can cause syncope, abnormal vitals, sudden death
    26. 26. Pulmonary Embolism Risk factors  Previous DVT or PE  Pregnancy  Cancer  Recent surgery  Prolonged bed rest  Age>50  Smoking  Oral contraceptives  Obesity  Inherited blood disorders
    27. 27. Pulmonary Embolism Signs and symptoms  Dyspnea  Pleuritic chest pain  Tachycardia  Cough  Hemoptysis  Cough  Fever rarely >102  Syncope  Evidence of DVT in the extremities
    28. 28. Pulmonary Embolism EKG-obtain to rule out cardiac etiology  Sinus tachycardia  Non-specific ST and T wave changes  Right heart strain pattern RBBB Chest x-ray-obtain to rule out other causes  Usually normal or non-specific changes Arterial blood gas-ABG  Not useful in the diagnosis of a PE  Can have a normal PO2 and A-a gradient with PE
    29. 29. Pulmonary Embolism D-Dimer  Fibrin degradation product  Test sensitivity 95%, specificity low 50%  What can elevate the D-Dimer  Pregnancy  Cancer  Trauma  Recent surgery  Disseminated intravascular coagulation DIC
    30. 30. Pulmonary Embolism Negative D-Dimer and “low risk” no further testing needed Who is “low risk”?  Well’s Criteria  Simplified Geneva Score  PERC score High risk patients-Do not obtain a D-Dimer immediately to go other testing  CT Scan  V/Q Scan  Pulmonary angiogram
    31. 31. Pericarditis Inflammation of the pericardial sac Pain is due to irritation of the parietal pleura Sharp pleuritic substernal pain  Radiates to the back, neck, or shoulder  Worse with cough, inspiration, supine  Improves with leaning forward Pericardial friction rub, tachycardia, dyspnea EKG-diffuse ST elevation Troponin is elevated in up to 22%
    32. 32. Pericarditis EKG
    33. 33. Spontaneous Pneumothorax Sudden rupture of a lung bleb  Tall thin males age 20-40  Underlying lung disease  Smokers Sudden onset of sharp pain, worse with inspiration, and SOB Physical exam-decreased breath sounds on the affected side Tension pneumothorax-Immediate life threat  Decreased venous return to the heart  Severe respiratory distress, tachycardia, hypotension
    34. 34. Pneumothorax
    35. 35. Tension Pneumothorax
    36. 36. Aortic Dissection Starts as a tear in the intima of the aorta that spreads through the medial wall under elevated systolic aortic pressure Mortality untreated  28% in 24 hours  50% in 48 hours  70% in one week Risk factors  Hypertension  Pregnancy  Lupus, syphilis, endocarditis  Marfan’s disease
    37. 37. Aortic DissectionSigns and Symptoms depend on the location of the tear and involvement of the aortic root, coronary ostia, or branches of the aortaHistory Sudden onset of sharp, tearing, maximal pain Pain radiates to the neck or back
    38. 38. Aortic Dissection Physical exam  Majority will be hypertensive  Difference in blood pressure between arms  Murmur of aortic regurgitation  Neurologic deficits  Chest pain with neurologic deficit, THINK DISSECTION EKG-useful to rule in or out MI Chest Xray  Widened mediastinum  Rule out other etioloiges
    39. 39. Aortic Dissection
    40. 40. Gastrointestinal Etiology in up to 40% of chest pain complaints Difficult to discern from ACS Pain described as burning, pressure, or dull Acid Reflux  Substernal, epigastric burning pain  Pain worse with alcohol, caffeine, certain foods  Worse supine and in the morning  Relieved with antacids
    41. 41. Gastrointestinal Esophageal spasm  Often associated with reflux disease  Dull, pressure, substernal pain lasting for hours  Can be relieved with Nitroglycerin  NTG relaxes smooth muscles  Pain relief with NTG NOT diagnostic of ACS Peptic ulcer disease Pancreatitis and gallbladder disease  Include lipase and liver function tests in your workup
    42. 42. Boerhaave’s Syndrome Forceful vomiting after excessive eating and drinking causes esophageal rupture. Mediastinal contamination of stomach contents Sudden onset of severe pain radiating to the back Mortality is 10-50% and directly related to the delay in making the diagnosis and initiating treatment
    43. 43. Boerhaave’s Syndrome
    44. 44. Chest Wall Pain The cause in up to 30% of ED visits Well localized, sharp, positional pain Reproducible by palpating a specific area of the chest wall Costochondritis-pain and tenderness at the costochondral or costosternal joints Treat with rest, heat, NSAID
    45. 45. Mental Illness The cause in up to 10% of ED visits Patients are poor historians with vague symptoms Hyperventilation can cause non-specific ST-T wave changes A diagnosis of exclusion
    46. 46. Chest Pain Cervical disc disease  Nerve root compression causes chest pain Herpes Zoster  Sharp burning pain before the rash  Pain and herpetic rash in a dermatome distribution
    47. 47. Herpes Zoster
    48. 48. Thank you