dull ache CP

1. Approach to Chest Pain
2020
Dull ache
Ihab suliman
MBBS ECFMG MRCP(UK) MRCP
specialty(Endocrinology &DM) ABcv FESC CBNC
0505244473
4475
Ihab.suliman@gmail.com

2. Differential
 Cardiac
 MI
 Pericarditis
 Myocarditis
 Aortic Stenosis
 Pulmonary
 PE
 PNA
 Asthma/COPD
 Acute Chest Syndrome
 Pleura
 Pleuritis
 Pneumothorax
 Aorta
 Dissection
 Perforated ulcer
 Chest wall
 Costocondiritis/musculoskeletal
 Esophagus
 Esophageal Spasm
 Eosinophilic Esophagitis
 Esophageal
Rupture/Perforation
 GERD
 Mediastinitis
 RUQ pathology
 Panic attack

4. Lethal Causes of Chest Pain
1- Acute Coronary Syndrome
2- Acute Aortic dissection Type A.
3-Massive Pulmonary Embolism
4-Pericardial Tamponade
5-Esophageal Rupture
6-Tension Pneumothorax

5. Pearl: ALWAYS have
the patient point to
the pain!

6. Typical vs. Atypical Chest Pain
Typical
 Characterized as
discomfort/pressure rather than
pain
 Time duration >2 mins
 Provoked by activity/exercise
 Radiation (i.e. arms, jaw)
 Does not change with
respiration/position
 Associated with
diaphoresis/nausea
 Relieved by rest/nitroglycerin
 Post Coital
Atypical
 Pain that can be localized with
one finger
 Constant pain lasting for days
 Fleeting pains lasting for a few
seconds
 Pain reproduced by
movement/palpation

7. Typical vs. Atypical Chest Pain
UpToDate 2012

8. Evaluation of Chest Pain
Case 1:
 Ask nurse for most current set of vital signs
 Ask nurse to get an EKG
 See the patient!

9. Evaluation of Chest Pain
 Once at bedside, determine if patient is stable or unstable
 Perform focused history and physical exam
 Read and interpret the EKG. Compare EKG to old EKG if
available
 If patient looks unstable or has concerning EKG findings, call
ER/Cardio On call for help
 Write a clinical event note!

10. Evaluation of Chest Pain
focused physical exam for chest pain
 Vital Signs: tachycardia, hypertension/hypotension or hypoxia
 General: Sick appearing, actively having chest pain
 HEENT: JVD, carotid bruits
 Chest: Rales, wheezes or decreased breath sounds
 CVS: New murmurs, reproducible chest pain, s3 gallop
 Abd: Abdominal tenderness, pulsatile mass
 Ext: Edema, peripheral pulses
 Skin: Rash on chest wall

11. Case 1
 25 years old lady suddenly developed chest pain that is L-sided,
8/10 and worse with breathing. Vital signs: Afebrile, HR 120, BP
110/70, RR 28, O2 sat 89% on 2L (was 95% on RA this morning)
 Physical exam
 Gen – in distress, using accessory muscles of respiration
 Lungs – CTAB, no rales/wheezes
 Heart – tachycardic, nl s1, loud s2, no mumurs
 Abd – soft, NT/ND, active BS
 Ext – b/l LEs warm and well perfused
 Labs:
 CBC wnl, RFP wnl, BNP = 520, D-dimer = positive, Troponin = 0.12

12. Case 1

13. Case 1

14. Differential
 Cardiac
 MI
 Pericarditis
 Myocarditis
 Pulmonary
 PE
 PNA
 Asthma/COPD
 Acute Chest Syndrome
 Pleura
 Pleuritis
 Pneumothorax
 Aorta
 Dissection
 Perforated ulcer
 Chest wall
 Costocondiritis/musculoskeletal
 Esophagus
 Esophageal Spasm
 Eosinophilic Esophagitis
 Esophageal
Rupture/Perforation
 GERD
 Mediastinitis
 RUQ pathology
 Panic attack

15. Modified Wells Criteria
 Clinical symptoms of DVT (3 points)
 Other diagnoses less likely than PE (1 point)
 Heart Rate >100 (1.5 points)
 Immobilization >/= 3 days or surgery within 4 weeks (1.5 points)
 Previous DVT/PE (1.5 points)
 Hemoptysis (1 point)
 Malignancy (1 point)
 Interpretation:
 >6: high
 2-6: moderate
 <2: low

16. Next moves
 DDIMER: 95% sensitive, VERY nonspecific
 ABG – Elevated A-a gradient fairly sensitive, highly
nonspecific
 EKG – most commonly nonspecific changes (ST/T wave
changes, etc)
 V/Q scan – helpful in patients with HIGH or LOW pretest
probabilities in whom a CTPE cannot be obtained (eg CKD)
 LE Ultrasound: not sensitive
 CTPE
 Sensitivity 83%
 Specificity 96%
 Moderate - high clinical probability and positive CTPE: 92-96%
chance of PE

17. Pearl
A CT angiogram (important for evaluating for Pulmonary
Embolism or Aortic Dissection) requires EITHER:
1) At least a 20G peripheral IV
OR
2) A Power injectable central line

18. Case 1

19. Diagnostic approach is simple if you
suspect PE…
 Probability low: obtain D-DIMER
 If positive: obtain CTPE
 If negative: PE excluded
 Probability moderate or high: obtain CTPE
 If positive: treat
 If negative: PE excluded

20. Acute Pulmonary Embolism
 Stabliize patient
 oxygen
 Fluids if hypotensive!
 Fibrinolytic Therapy if SBP less 90 mmHg
 Anticoagulants
 Preferred: LMWH or Fondaparinux
 Enoxaparin 1.5mg/kg daily or 1mg/kg BID
 Fondaparinux subcutaneous once daily (weight based)
 Alternative: UFH (IV or SC) – select high intensity protocol
 Hemodynamically unstable patients
 High risk of bleeding (reversible)
 GFR < 30
 Can initiate warfarin on same day
 IVC filter an alternative in patients with mod-high bleeding
risk
Management

21. Pearl: If you have a moderate
or high suspicion of PE, you
can start anticoagulation while
awaiting full diagnostic workup

22. PE with hypotension
 Thrombolysis
 Administer over short infusion time
 Catheter based thrombectomy
 For failure of thrombolysis or likelihood of shock/death before
thrombolysis can take effect (hours)
 Surgical thrombectomy
 Failure of above therapies

23. Case 2
Mr. M is a 67 yo man with PMHx of HTN, DLD,
DMT2 and CAD s/p PCI in 2017. He presents
with new onset chest pain x 2 hours that is
retrosternal, 7/10, associated with nausea and
diaphoresis.

24. Case 2
VS: T 37 HR 108 BP 105/60 RR 20 O2 sat 93%
on RA
Physical exam:
Gen – actively having chest pain, diaphoretic
Lungs – crackles at bilateral bases
Heart – tachycardic, nl s1/s2, no mumurs or rub
Rest of the exam benign
Labs: CBC wnl, RFP wnl, Troponin = 0.05

25. Next Steps
 Review EKG
 Review CXR
 Troponin
 SL Nitroglycerin
 ASA Soluble or Chewable

26. Case 2

27. Case 2 Diagnosis:
UA/NSTEMI
 EKG changes in Acute Coronary Syndromes:
 ST elevations
 ST depressions
 T wave inversions
 “pseudonormalization” – inversion of previously inverted T waves when
compared with old EKG
 New conduction block
 Q waves
 Importance of serial EKG monitoring: sensitivity of single
EKG is only 50% sensitive for acute MI

29. Next steps
 Vitals
 Repeat EKG
 Repeat SL nitro
 Assess patient in person
 Call ER/Cardio On call/Cath Lab Consultant

30. Trivia

35. Criteria for type 1 MI
 Detection of a rise and/or fall of cTn values with at least one
value above the 99th percentile URL and with at least one of
the following:
 Symptoms of acute myocardial ischaemia;
 New ischaemic ECG changes;
 Development of pathological Q waves;
 Imaging evidence of new loss of viable myocardium or new
regional wall motion abnormality in a pattern consistent with
an ischaemic aetiology;
 Identification of a coronary thrombus by angiography
including intracoronary imaging or by autopsy.a

37. What typical ACS med should you
NOT give this patient?

38. Nitroglycerin contraindicated in
inferior MI with RV infarction
 Other contraindications to NG:
 Preload dependent states
 Inferior MI
 Aortic outflow obstruction (HOCM, severe AS)
 Likelihood of hemodynamic instability
 HR <50 or >100
 SBP<90mmHg or more than 30mmHg below baseline
 Use of PGE inhibitors, NO TELLING

39. Case 3
 You are called on to admit a 65 yo man for ACS rule out.
 Mr Q is a gentleman with a history of DMT2, NASH, remote
NSTEMI, and HTN presenting with severe retrosternal chest
pain. Pain is different than prior MI but is very severe.
Radiates to neck. Began 3 hours ago; has subsided slightly
but is still 8/10 in severity.

40. You take report, quickly review
chart, and go to assess the patient
in the ER.
 VS: T37.1, HR110, BP145/80 in R arm, RR16, Pox 98%RA
 Focused Exam:
 GEN: in discomfort but mentating well
 HEENT mmm, JVP at clavicle
 CV normal s1/s2, no murmurs
 PULM ctab, no w/c/r
 EXTR: cool
 Bilateral BP: 145/80R, 110/60L
 EKG identical to previous EKG which you printed from portal

43. Thoracic aortic dissection
 CT angiography – first line
 83-100% sensitive, specificity 87-100%
 TEE – second line; good for proximal, cannot visualize
descending aorta well
 MRI – useful for surveillance
Diagnosis
Images:
reference.medscape.com
rwjms1.umdnj.eduen.wikipedia.org
en.wikipedia.org

44. Thoracic aortic dissection
 Hypertension
 Atherosclerosis
 Preexisting aneurysm (known history in 13% of patients)
 Inflammatory conditions affecting aorta (Takayasu, Giant Cell
Arteritis, RA, syphilis)
 Collagen disorders (Marfan, Ehlers-Danlos)
 Bicuspid aortic valve
 Aortic coarctation
 Turner syndrome
 History of CABG, AVR, Cardiac Cath
 High intensity weight lifting
 Cocaine use
 Trauma
Risk Factors

46. Type A Type B
Thoracic aortic dissection
 Surgery!
 Do not delay surgery, even
for LHC
 Beta blockers, titrate to HR
50-60 (labetalol, esmolol)
 BP control (nitroprusside)
 Beta blockers, titrate to HR
50-60 (labetalol, esmolol)
 BP control – add
nitroprusside or similar agent
to SBP goal 100-120mmHg
 Surgery for those with end
organ damage or those who
do not respond to medical
therapy
 Watch for hypotension – give
fluids if needed, consider
tamponade, MI, or rupture as
complications if hypotensive
Management

48. Case 4
53 yo M with chest pain and EKG abnormalities
PMHx:
 HTN
 Dyslipidemia
You go see the patient and he tells you that
he has had this chest pain for ~2 days, but
it has progressively gotten worse. His
chest pain is worse with breathing. He
notes a recent viral URI.

49. Case 4
 VS: T 37.9 HR 104 BP 140/76 RR 20 O2 sat 95% on RA
 Physical exam:
 Gen – in mild distress due to chest pain, leaning forward while in
bed
 Lungs – CTAB
 Chest wall – no visible rash, chest wall NT to palpation
 Heart – tachycardic, nl s1/s2, no rub
 Rest of physical exam benign
 Labs:
 WBC = 14, RFP wnl, AMI panel x 1 = negative
 CXR = negative

50. Case 4
 EKG on admission:

51. Case 4 - Pericarditis
Refers to inflammation of pericardial sac
Idiopathic pericarditis typically preceded by
viral prodrome, i.e. flu-like symptoms
Typically, patients have sharp, pleuritic
chest pain relieved by sitting up or leaning
forward

52. Goyle 2002

53. Case 4 - Pericarditis
Goyle 2002

54. Case 4 - Pericarditis
 Diagnostic criteria
UpToDate 2012

55. Case 4 – Pericarditis
 High risk features:
 Fever (>38ºC [100.4ºF]) and leukocytosis
 Evidence suggesting cardiac tamponade
 A large pericardial effusion (ie, an echo-free space of more than
20 mm)
 Immunosuppressed state
 A history of therapy with vitamin K antagonists (eg warfarin)
 Acute trauma
 Failure to respond within seven days to NSAID therapy
 Elevated cardiac troponin, which suggests myopericarditis

56. Case 4 - Pericarditis
 Treatment
UpToDate 2012

57. Case 5
 This is a 45 yro M with PMHx of rheumatoid arthritis who
presented with progressive sob. He was found to have a R-
sided pleural effusion and underwent an US guided
thoracentesis with removal of 1.5 liters of pleural fluid. Two
hours after his procedure, he develops new onset R-sided
chest pain

58. Case 5

59. Case 5 - Pneumothorax
 Management of Pneumothorax
 100% O2 and observation in stable patients for PTX < 3 cm in
size
 Needle aspiration in stable patients for PTX >3 cm
 Chest tube placement if PTX >3 cm and if needle aspiration fails
 Chest tube placement in unstable patients

60. Thank You very much