This document provides guidance on evaluating and managing chest pain. It lists common cardiac, pulmonary, aortic, chest wall, and esophageal causes of chest pain. It describes typical versus atypical chest pain characteristics and provides the Modified Wells Criteria for evaluating pulmonary embolism risk. Evaluation involves history, physical exam, EKG, and lab tests. The document reviews two case studies of patients presenting with chest pain and outlines diagnostic and treatment approaches.

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