General approach and a take on using Clinical prediction tools

1. Chest Pain in the Emergency
Department
Firas Ashour

2. Overview
Acute chest pain is one of the most frequent reasons to attend the ED, accounting for
approximately 10% of non- injury related visits
Patients present with a spectrum of signs and symptoms reflecting the many potential etiologies
of chest pain. Diseases of the heart, aorta, lungs, esophagus, stomach, mediastinum, pleura, and
abdominal viscera may all cause chest discomfort.
Clinicians in the ED focus on the immediate recognition and exclusion of life-threatening causes
of chest pain. Patients with life-threatening etiologies for chest pain may appear deceptively well,
manifesting neither vital sign nor physical examination abnormalities.

3. Epidemiology
Half of the patients presenting with chest pain can be discharged from the ED without further hospitalization .
Of the patients admitted to the hospital, only about 25% have a final diagnosis of an ACS
. Another 25% of the patients will be discharged with a diagnosis of angina pectoris or with other non- ischaemic cardiac
problems
. In the remaining half of the admitted patients, the final diagnosis will be unspecified chest pain (26%) or a non- cardiac
cause (27%) .
Acute vascular emergencies and PE constitute only a tiny minority (2– 3%) of the patients
Approximately 2% of chest pain patients with an ACS are mistakenly discharged from the ED
Of patients presenting to the ED without diagnosis- specific symptoms, AMI was the final diagnosis in 1.6%

4. Pathophysiology
The cardiovascular system, respiratory system, part of the gastrointestinal system, and the great vessels
give off afferent visceral input via common thoracic autonomic ganglia. Painful stimuli in any of the
aforementioned systems are usually sensed as originating from the chest. However, due to the fact that
afferent nerve fibers overlap in the dorsal ganglia, pain in the thorax may be experienced at any point
between the umbilicus and the ear, as well as in the upper limbs.

5. What Is The Cause Of This Patient
Chest pain?

6. Life-threatening conditions
— Causes of chest pain that pose an immediate threat to life include
●Acute coronary syndrome
●Aortic dissection
●Pulmonary embolism
●Tension pneumothorax
●Pericardial tamponade
●Mediastinitis (eg, esophageal rupture)

7. Common conditions
Cardiac Casues Stable Angina AHF VHD Inflammatory Pericarditis Myocarditis Endocarditis
Pulmonary/pleural causes – Respiratory infections, pneumonia, tracheitis, bronchitis,asthma .right
sided heart dysfunction (cor pulmonale). Pulmonary malignancy pleural effusions
Gastrointestinal causes – Gastroesophageal reflux and esophageal spasm, rupture (Boerhaave's
syndrome), or inflammation . sliding hiatal hernia. Pancreatitis
Musculoskeletal causes – rib contusions and fractures, intercostal muscle strains, and costochondritis.
Psychiatric causes – panic attack"
Other conditions less common: herpes zoster, referred pain, and pain associated with various
inflammatory conditions and collagen vascular diseases.

8. Let's take few cases

9. Case 1
A 42-year-old, previously healthy woman presents to the emergency
department with 45 minutes of crushing substernal chest pain. On arrival to
the emergency department, the pain is completely relieved by nitroglycerin,
the electrocardiogram (ECG) is unremarkable, and initial troponin level is
0.01 ng/mL (reference range, 0.00-0.08 ng/mL).

10. Case 2
A 74-year-old man with a myocardial infarction 3 years prior presents to
the emergency department with several days of intermittent burning
retrosternal chest pain. The ECG shows Q waves in leads II, III, and aVF that
were present on his last ECG 3 months prior;there are no new ischemic
changes.His initial troponin level is 0.14 ng/mL (reference range, 0.00-0.08
ng/mL).

11. Are these patients having acute
coronary syndrome (ACS)?

12. History
General approach — Obtain a detailed history of the patient's chest pain, including:
●Onset of pain (eg, abrupt or gradual)
●Provocation/Palliation (which activities provoke pain; which alleviate pain)
●Quality of pain (eg, sharp, squeezing, pleuritic)
●Radiation (eg, shoulder, jaw, back)
●Site of pain (eg, substernal, chest wall, diffuse, localized)
●Timing (eg, constant or episodic, duration of episodes, when pain began)

13. Ask about prior diagnostic studies (eg, stress test or coronary CT angiography)
similar symptoms or prior procedures (eg, cardiac catheterization)
. Ask whether the discomfort is similar to prior illness.
Associated symptoms, such as nausea, vomiting, diaphoresis, dyspnea, syncope, and palpitations,
. Ask about risk factors for life-threatening illness, especially acute coronary syndrome, aortic dissection, and
pulmonary embolus,
●Comorbidities: hypertension, diabetes mellitus, peripheral vascular disease, malignancy
●Recent events: trauma, major surgery or medical procedures (eg, endoscopy), periods of immobilization (eg, long
plane ride)
●Other factors: cocaine use, cigarette use, family history

14. Physical Examination
Focuses on vital signs
Most often unremarkable in ACS
May point to other diagnosis or reveal complications of AMI

15. ECG
Should be obtained and interpreted within 10 minutes of patient presentation
Finding of ST segment elevation or equivalents should trigger rapid response (catheterization lab activation, or
fibrinolytic therapy) beware of causes other than STEMI
single ECG performed during the patient's initial presentation detects fewer than 50 percent of AMIs.
It's important to repeat the ECG as early as 10 minutes especially in case of ongoing chest pain
ECG can be normal or shows non ischemic findings in patients with evidence of AMI
Although ischemic changes on initial ECG was associated with poorer diagnosis

19. CXR
A chest radiograph (CXR) is obtained in all chest pain patients with hemodynamic instability or a
potentially life-threatening diagnosis. A nondiagnostic CXR is typical in patients with ACS.
Approximately 90 percent of patients with aortic dissection will have some CXR abnormality
Can diagnose Pneumonia PTX
May show Cardiomegaly and pulmonary congestion
Pneumomediastinum left sided pneumo/hydrothorax suggests esophageal rupture

20. Lab Investigations
Troponin
CKmB
D-Dimer
CBC
BNP
ABG

21. Echocardiograpgy and Other POCUS
An echocardiogram can also help in defining the extent of an infarction and in assessing overall function
of the left and right ventricles. In addition, an echocardiogram can help to identify complications, such as
acute mitral regurgitation, LV rupture, and pericardial effusion.
Absence of segmental wall-motion abnormality on echocardiography during active chest discomfort is a
highly reliable indicator of a nonischemic origin of symptoms, although echocardiography is of limited
value in patients whose symptoms have resolved or who have pre-existing wall-motion abnormalities.
Differential diagnosis with POCUS

22. Can we distinguish between cases of
ACS and non cardiac chest pain with
History Examination and ECG?

23. STEMI can be excluded by ECG and occurs in less than 25% of patients presenting with
symptoms concerning for ischemia.
The key distinction in the majority of patients is between NSTE-ACS and noncardiac chest pain.
Studies found that the accuracy of risk factors and symptoms for diagnosing ACS was generally
poor,some are specific more than sensitive.
Overall clinical impression,incorporating history and physical examination performed better,
but the best diagnostic tests were clinical prediction tools( eg,TIMI score, HEART score) that
incorporated historical elements along with the initial ECG and cardiac troponin results.

27. What can we use?

28. clinical prediction tools
Using 1 of the available clinical prediction tools at the initial evaluation gives the highest likelihood of
correctly identifying or excluding ACS. Physicians should use the results of the prediction tools when
deciding whether or not to forgo serial evaluation and testing.

31. Case 1
A 42-year-old, previously healthy woman
presents to the emergency department with
45 minutes of crushing substernal chest pain.
On arrival to the emergency department, the
pain is completely relieved by nitroglycerin,
the electrocardiogram (ECG) is unremarkable,
and initial troponin level is 0.01 ng/mL
(reference range, 0.00-0.08 ng/mL).
The patient, despite a story consistent with
typical angina, has a HEART risk score of 2. A
HEART risk score of 2 has an LR for the diagnosis
of ACS of 0.2, and the posttest probability is 3%.
Relief of her pain with nitroglycerin is unhelpful
for diagnosing or ruling out ACS. She could be
considered for anaccelerated diagnostic protocol
with early discharge if a second cardiac troponin
is negative

32. Case 2
A 74-year-old man with a myocardial
infarction 3 years prior presents to the
emergency department with several days of
intermittent burning retrosternal chest pain.
The ECG shows Q waves in leads II, III, and
aVF that were present on his last ECG 3
months prior;there are no new ischemic
changes.His initial troponin level is 0.14 ng/mL
(reference range, 0.00-0.08 ng/mL).
The patient has known CAD and is elderly. His
ECG does not show dynamic changes,and
troponin elevationnis mild.With a HEART
score of 6,he is at intermediate
risk(LR,2.4),yielding a post test probability of
26%.He should be admitted and treated for
ACS.