ABCDs of Chest Pain

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

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  • ABCDs of Chest Pain

    1. 1. ABCD’s of Chest Pain Michael Aref, MD, PhD Hospitalist, Carle Physician GroupAdjunct Assistant Professor, Department of Nuclear, Plasma, and Radiological Engineering, UIUC Clinical Instructor, Department of Medicine, UICOM-UC
    2. 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. 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. 4. Chest Pain
    5. 5. Chest Pain• Use a liberal definition
    6. 6. HistoryAggravating and alleviating factorsSeverityCharacterLocationAssociated symptomsSettingTiming
    7. 7. HistoryAggravating and alleviating factors • Does activity make your symptoms better or worse?SeverityCharacterLocationAssociated symptomsSettingTiming
    8. 8. HistoryAggravating and alleviating factors • Does activity make your symptoms better or worse?Severity • Probably pretty bad, or they wouldn’t be in the hospital.CharacterLocationAssociated symptomsSettingTiming
    9. 9. HistoryAggravating 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, pleuriticLocationAssociated symptomsSettingTiming
    10. 10. HistoryAggravating 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, pleuriticLocation • Where in the “chest” are the symptoms located? Does it radiate anywhere?Associated symptomsSettingTiming
    11. 11. HistoryAggravating 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, pleuriticLocation • Where in the “chest” are the symptoms located? Does it radiate anywhere?Associated symptoms • Diaphoresis, dyspnea, nausea/emesis, fever?SettingTiming
    12. 12. HistoryAggravating 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, pleuriticLocation • 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. 13. HistoryAggravating 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, pleuriticLocation • 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. 14. JAMA 2005;294(20):2623-2629
    15. 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. 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. 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. 18. Framework• Airway• Breathing • Gedanken Ventilation and Perfusion Scan• Circulation • “Home is where the heart is”• Digestive • Gedanken Endoscopic Retrograde Cholangiopancreatography
    19. 19. Airway/Breathing: Ventilation
    20. 20. Constriction Disease Definition Diagnostic Test Severe asthma to Acute or subacute episodes of Peak flowStatus asthmaticus progressively worsening shortness of breath, cough, wheezing, and chest tightness < 40% predicted/bestwww.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 theAcute exacerbation patients 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. 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 infiltratecid.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 ChestSyndrome of Sickle SSD + new infiltrate on CXR + chest pain, cough, wheezing, tachypnea, or fever Chest x-ray Cell Disease
    22. 22. Collapse Disease HxPx Diagnostic Test Severe pleuritic pain, JVD, trachealPneumothorax Chest x-ray deviation, hyperresonance
    23. 23. Airway/Breathing: Perfusion
    24. 24. Disease HxPx Diagnostic Test Revised Geneva Dyspnea (80%), criteria low to pleuritic chest pain intermediatePulmonary 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. 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 5Pain on lower limb deep vein palpation and unilateral edema 4 Annals of Internal Medicine (2006) 144:165–171
    26. 26. Circulation
    27. 27. Walls Disease HxPX Diagnostic Test Precipitating etiology, Improved with Pericarditis TTE leaning forward, Friction rub JVD HypotensionCardiac Tamponade Pulsus paradoxus TTE (inspiratory fall of systolic blood pressure of greater than 10 mm Hg)
    28. 28. Walls Disease HxPX Diagnostic Test Precipitating etiology, Improved with Pericarditis TTE leaning forward, Friction rub JVD HypotensionCardiac Tamponade Pulsus paradoxus TTE (inspiratory fall of systolic blood pressure of greater than 10 mm Hg)
    29. 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. 30. Electrical Disease HxPx Diagnostic Test Irregular pulse,Arrhythmia EKG, K, Mg syncope
    31. 31. Heat (Generator) Disease HxPx Diagnostic Test Acute Orthopnea, HTN, Negative BNP rulesdecompensation of elevated JVP, crackles, out heart failure pedal edema
    32. 32. Digestive
    33. 33. Esophageal Disease HxPx Diagnostic Test Caustic ingestion, Forceful emesis, CXREsophageal Rupture Subcutaneous (pneumomediastinum, pneumothorax, emphysema, pleural effusion) Hamman’s crunch
    34. 34. Esophageal Disease HxPx Diagnostic Test Caustic ingestion, Forceful emesis, CXREsophageal Rupture Subcutaneous (pneumomediastinum, pneumothorax, emphysema, pleural effusion) Hamman’s crunch
    35. 35. Gastrum / Duodenum Disease HxPx Diagnostic Test Cough test Sn CXR (air under thePerforated Ulcer 80-95% for peritonitis diaphragm)
    36. 36. Gall Bladder Disease HxPx Diagnostic Test Leukocytosis Fever Elevated CRPCholecystitis Murphy’s sign Sn 97% US RUQ ACR Rating NPV 93% 9
    37. 37. Pancreas Disease HxPx Diagnostic Test Lipase Epigastric painPancreatitis CT abd/pel ACR radiating to back Rating 6-8
    38. 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. 39. Anginal Pain1. Constricting discomfort in the front of the chest, or in the neck, shoulders, jaw, or arms2. Precipitated by physical exertion3. 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. 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 ofartery disease according to typicality of symptoms, age, sex and risk factorsTable 1 Percentage of people estimated to have coronary artery diseaseaccording to typicality of symptoms, age, sex and risk factors Non-anginal chest Atypical angina Typical angina pain Men Women Men Women Men WomenAge Lo Hi Lo Hi Lo Hi Lo Hi Lo Hi Lo Hi(years) 20 of 39335 3 35 1 19 8 59 2 39 30 88 10 7845 9 47 2 22 21 70 5 43 51 92 20 7955 23 59 4 25 45 79 10 47 80 95 38 8265 49 69 9 29 71 86 20 51 93 97 56 84For 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 ANDwith 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 5disease (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 notbe 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 eachcell of the table.
    41. 41. JAMA 2005;294(20):2623-2629
    42. 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. 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
    44. 44. MONA H BAS Morphine No mortality benefit Oxygen No mortality benefit, if SpO2 > 92% Nitroglycerin No mortality benefit TD = IVAspirin ± clopidogrel Do NOT initiate clopidogrel until discussed with cardiologist CI in active bleedingHeparin / 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
    45. 45. MKSAP Students 4• Cardiovascular Medicine #9• Cardiovascular Medicine #11• Cardiovascular Medicine #15• Cardiovascular Medicine #17• Cardiovascular Medicine #21• Pulmonary Medicine #30• Pulmonary Medicine #31

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