This document provides an overview of chest pain, including the pathophysiology, diagnosis, and treatment of life-threatening causes. It discusses the epidemiology, history, physical exam findings, diagnostic testing and treatment for conditions like acute coronary syndrome, pulmonary embolism, aortic dissection, tension pneumothorax, and esophageal rupture. The differential diagnosis for chest pain is also reviewed, along with algorithms for evaluating and managing common conditions presenting with chest pain like pulmonary embolism and acute coronary syndrome.

1. Chest Pain
LSU Medical Student Clerkship,
New Orleans, LA

2. Chest Pain
Goals
 Review the pathophysiology, diagnosis and
treatment of life threatening causes of chest pain.

3. Chest Pain
Epidemiology
 5% of all ED visits
 Approximately 5 million visits per year

4. Chest Pain
Visceral Pain
 Visceral fibers enter the spinal cord at several levels leading
to poorly localized, poorly characterized pain. (discomfort,
heaviness, dull, aching)
 Heart, blood vessels, esophagus and visceral pleura are
innervated by visceral fibers
 Because of dorsal fibers can overlap three levels above or
below, disease of thoracic origin can produce pain
anywhere from the jaw to the epigastrum

5. Chest Pain
Parietal Pain
 Parietal pain, in contrast to visceral pain, is
described as sharp and can be localized to the
dermatome superficial to the site of the painful
stimulus.
 The dermis and parietal pleura are innervated
by parietal fibers.

6. Chest Pain
Initial Approach
 ABC’s first, always (look for conditions requiring
immediate intervention)
 Aspirin for potential ACS
 EKG
 Cardiac and vital sign monitoring
 Pain relief
 Because of the wide differential, H+P will guide the
diagnostic workup

7. Chest Pain
History
 O- onset
 P-provocation /palliation
 Q- quality/quantity
 R- region/radiation
 S- severity/scale
 T- timing/time of onset

8. Chest Pain
History
 Change in pain pattern
 Associated symptoms: DOE, SOB,
diaphoresis, vomiting, heart burn, food
intolerance
 PHx
 Social history
 FHx

9. Chest Pain
Physical Exam
 General Appearance and Vitals (sick vs not sick)
 Chest exam
-Inspection (scars, heaves, tachypnea, work of
breathing)
-Auscultation (murmurs, rubs, gallops, breath sounds)
-Percussion (dullness)
-Palpation (tenderness, PMI)

10. Chest Pain
Physical Exam
 Neck: JVD, crepitence, bruits
 Abdomen
 Extremities: swelling, pulses, tenderness,
Homan’s

11. Chest Pain
Cardiovascular Acute myocardial infarction, Acute coronary ischemia, Aortic dissection, Cardiac
tamponade, Unstable angina, Coronary spasm, Prinzmetal's angina, Cocaine
induced, Pericarditis, Myocarditis, Valvular heart disease, Aortic stenosis, Mitral
valve prolapse, Hypertrophic cardiomyopathy
Pulmonary Pulmonary embolus, Tension pneumothorax, Pneumothorax, Mediastinitis,
Pneumonia, Pleuritis, Tumor, Pneumomediastinum
Gastrointestinal Esophageal rupture (Boerhaave), Esophageal tear (Mallory-
Weiss), Cholecystitis, Pancreatitis, Esophageal spasm, Esophageal
reflux, Peptic ulcer, Biliary colic
Musculoskeletal Muscle strain, Rib fracture, Arthritis, Tumor, Costochondritis, Nonspecific chest
wall pain
Neurologic Spinal root compression, Thoracic outlet, Herpes zoster, Postherpetic neuralgia
Other Psychologic, Hyperventilation
Differential Diagnoses

12. Chest Pain
Life Threatening Causes of Chest Pain
 Acute Coronary Syndromes
 Pulmonary Embolus
 Tension Pneumothorax
 Aortic Dissection
 Esophageal Rupture
 Pericarditis with Tamponade

13. Chest Pain
Acute Coronary Syndromes - Epidemiology
 In a typical ED population of adults over the age
of 30 presenting with visceral-type chest pain,
about 15 percent will have AMI and 25 to 30
percent will have UA

14. Chest Pain
Acute Coronary Syndromes - History
 “Typical” Chest Pain Story (Pressure-like,
squeezing, crushing pain, worse with exertion,
SOB, diaphoresis, radiates to arm or jaw) The
majority of patients with ACS DO NOT present
with these symptoms!
 Cardiac Risk Factors (Age, DM, HTN, FH,
smoking, hypercholesterolemia, cocaine abuse)

15. Chest Pain
Acute Coronary Syndromes – EKG Findings
 STEMI - ST segment elevation (>1 mm) in
contiguous leads; new LBBB
 T wave inversion or ST segment depression in
contiguous leads suggests subendocardial
ischemia
 5% of patients with AMI have completely normal
EKGs

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Acute Coronary Syndromes – Cardiac Markers
Marker Initial
Rise
Peak Return to
normal
Benefits
Troponin 2-4 hr 10 -24 hr 5 -10 days Sensitive and specific
CK-MB 3-4 hr 10-24 hr 2 – 4 days Unaffected by renal failure
LDH 10 hr 24 -72 hr 14 days
Myoglobin 1-2 hr 4 -8 hr 24 hours Very sensitive, powerful
negative predictive value

19. Chest Pain
Acute Coronary Syndromes – Cardiac Markers

20. Chest Pain
Echocardiogram
 Wall abnormalities occur within minutes
 Will detect abnormalities in 80% of AMI
 Normal resting echo in setting of chest pain
gives low probability
 Early screen for AMI complications:
aneurysms, valve abnormalities, other
structural destruction

21. Chest Pain
Echo

22. Chest Pain
Acute Coronary Syndromes - Treatment
 Aspirin
 Nitroglycerin
 Oxygen
 Analgesia

23. Chest Pain
Treatment
 Beta-Blockers
 Anticoagulation
 Anti-Platelet Agents
 Thrombolysis
 Percutaneous Coronary Interventions
(PCI)

24. Chest Pain
Stress echocardiograms
 Sensitivity 60-90%
 Specificity 75% ?
 Should be employed with moderate to high
risk stratification
 Limitations of reader, image quality, and
previous functional impairment
 Negative test has time limited value

25. Chest Pain
Acute Coronary Syndromes - Treatment
 STEMI (ASA, B-blocker, NTG, anti-platelet,
anticoagulation, thrombolysis, PCI)
 NSTEMI (ASA, B-blocker, NTG, anti-platelet,
anticoagulation, PCI)
 Unstable Angina (ASA, B-blocker, NTG,
anticoagulation, risk stratification)

26. Chest Pain
Acute Coronary Syndromes - Disposition
 Mortality is twice as high for missed MI
 Missed MI is the most successfully litigated
claim against EP's. EP’s miss 3-5% OF AMI,
this accounts for 25% of malpractice costs
against EP’s

27. Chest Pain
Acute Coronary Syndromes - Disposition
 A single set of cardiac enzymes is rarely of use
 Risk Stratification: goal is to predict the
likelihood of an adverse cardiovascular event
 Combination of H+P, EKG, Biomarkers
 No single globally accepted algorithm
 Mathematical models such as TIMI, GRACE,
PURSUIT, and HEART can be helpful but are
no substitute for clinical judgment

28. Chest Pain
Pulmonary Embolism - Pathophysiology
 Thrombosis of a pulmonary artery
 >90% arise from DVT
 Clot from a DVT travels through the venous
system and lodges in the pulmonary vasculature
creating a ventilation/perfusion mismatch

29. Chest Pain
Pulmonary Embolism – History
 Dyspnea is the most common symptom, present
in 90% of patients diagnosed with PE
 Sharp pleuritic chest pain, syncope,
 Prolonged immobilization, neoplasm, known
hypercoagulable disorder

30. Chest Pain
Pulmonary Embolism – Physical Exam
 Tachycardia, tachypnea, diaphoresis,
hypotension, hypoxia, low grade fever, anxiety,
cardiovascular collapse, right ventricular heave

31. Chest Pain
Pulmonary Embolism – Diagnostic Testing
 Sinus Tachycardia is the most frequent EKG
finding
 Classic S1,Q3,T3 finding is seen in less than
20%
 ABG plays no role in ruling out PE
 D-Dimer in a low risk patient can be used to rule
out PE

32. Chest Pain
Pulmonary Embolism – Wells Criteria
 Clinical Signs and Symptoms of DVT? Yes +3
 PE is #1 Diagnosis, or Equally Likely? Yes +3
 Heart Rate > 100? Yes +1.5
 Immobilization at least 3 days, or Surgery in the Previous 4
weeks? Yes +1.5
 Previous, objectively diagnosed PE or DVT? Yes +1.5
 Hemoptysis? Yes +1
 Malignancy w/ Treatment within 6 mo, or palliative? Yes +1
<2 = Low risk, 2.5-6 = moderate risk, >6 = high risk

33. Chest Pain
Pulmonary Embolism – Diagnostic Imaging Algorithm

34. Chest Pain
Pulmonary Embolism – Treatment/Disposition
 Unfractionated heparin vs low molecular weight
heparin (some studies suggest superiority of
LMWH)
 Thrombolysis (for cardiovascular collapse)
 Floor vs ICU

35. Chest Pain
PE CXR

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41. Chest Pain
Aortic Dissection - Pathophysiology
 Intimal tear of the aorta leads to dissection of the
layers of the aorta creating a false lumen

42. Chest Pain
Aortic Dissection - Diagnosis
 Tearing chest pain radiating to the back
 Risk Factors: HTN, connective tissue disease
 Exam: HTN, pulse differentials, neuro deficits
 Radiology: Wide mediastinum on CXR, CT angio
chest, echo

43. Chest Pain

44. Chest Pain
Aortic Dissection - Classification
 De Bakey system: Type I dissection involves both the
ascending and descending thoracic aorta. Type II
dissection is confined to the ascending aorta. Type III
dissection is confined to the descending aorta.
 The Daily system classifies dissections that involve the
ascending aorta as type A, regardless of the site of the
primary intimal tear, and all other dissections as type B.

45. Chest Pain

46. Chest Pain
Aortic Dissection - Treatment
 Patients with uncomplicated aortic dissections confined to the
descending thoracic aorta (Daily type B or De Bakey type III) are
best treated with medical therapy.
 Medical Therapy: Goal to decrease the blood pressure and the
velocity of left ventricular contraction, both of which will decrease
aortic shear stress and minimize the tendency to further dissection.
 Acute ascending aortic dissections (Daily type A or De Bakey type I
or type II) should be treated surgically whenever possible since these
patients are a high risk for a life-threatening complication such as
aortic regurgitation, cardiac tamponade, or myocardial infarction.

47. Chest Pain
Tension Pneumothorax - Pathophysiology
 Collection of air in the pleural space causes
collapse of the ipsilateral lung and then
cardiovascular collapse as intrathoracic
pressures increase.

48. Chest Pain
Tension Pneumothorax - Diagnosis
 Risk factors: COPD; connective tissue disease,
trauma, recent instrumentation, positive
pressure ventilation
 Absent breath sounds unilaterally, hypotension,
distended neck veins, tracheal deviation

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50. Chest Pain
Tension Pneumothorax - Treatment
 Needle decompression
 Tube thoracostomy

51. Chest Pain
Esophageal Rupture - Pathophysiology
 Tear in the esophagus leads to leaking of
gastrointestinal contents into the mediastinum
 Inflammation followed by infection cause rapid
deterioration, sepsis and death

52. Chest Pain
Esophageal Rupture - Diagnosis
 Rare but devastating
 Risk Factors: Iatrogenic, heavy retching,
trauma, foreign bodies, toxic ingestion
 Radiology: Mediastinal air on plain films or CT
scan

53. Chest Pain
Subtle Not so subtle

54. Chest Pain
Imaging

55. Chest Pain
Esophageal Rupture - Treatment
 Antibiotics
 Supportive Care
 Small tears with minimal extraesophageal
involvement can be managed conservatively
 Surgical consult for all regardless of size

56. Chest Pain
Take Home Points
 ABC’s first
 History is key
 Have a low threshold for missed MI