Post on 04-Aug-2020
Many Faces of Chest PainIan McLeod, MS, MEd, PA-C, ATC
Northern Arizona University
ASAPA Spring Conference 2019
Disclosures
• I have no financial disclosures to report
Objectives
• Following the presentation attendees will be able to:• Develop a concise differential diagnosis for patients with chest pain including
cardiac and non-cardiac causes.
• Describe key clinical characteristics and management of the following chest pain etiologies: angina, embolism, gastroesophageal reflux, costochondritis, costochondral dysfunction, anxiety and pneumonia.
• Discuss appropriate use of diagnostic studies utilized in the evaluation of patients presenting with chest pain.
Chest Pain – Primary Care Setting
• ~1.5% of all visits are for chest pain
• Musculoskeletal 35-50%
• Gastrointestinal 10-20%
• Cardiac 10-15%
• Pulmonary 5-10%
• Psychogenic 1-2%
Chest Pain Differentials
• Cardiac• Stable angina• Acute coronary syndrome• Pericarditis• Aortic dissection
• MSK• Costochondritis• Tietze syndrome• Costovertebral joint dysfunction
• GI• Gastroesophageal reflux disease
(GERD)• Medication induced esophagitis
• Pulmonary• Pneumonia• Pulmonary embolism• Spontaneous pneumothorax
• Psych• Panic disorder
Setting the stage
• Non-traumatic
• Acute chest pain
• Primary care setting• H&P
• ECG
• CXR
Myocardial Ischemia Risk Factors
• Increasing age
• Male sex
• Chronic renal insufficiency
• Diabetes Mellitus
• Known atherosclerotic disease → coronary or peripheral
• Early family history of coronary artery disease• 1st degree male relative < 55 y/o
• 1st degree female relative < 65 y/o
• ASCVD risk calculator
Myocardial Ischemia – Pain Characteristics• Pain descriptors
• Deep (retrosternal)
• Poorly localized → center or left sided
• Oppressive
• Pressure
• Heaviness
• Tightness
• Constriction
• Radiation• Neck
• Jaw
• Shoulder
• Arms
• Uncharacteristic / unlikely• Sharp, knife-like, stabbing
• Change with respiration or body position
• Provoked / worsened with chest wall palpation
Myocardial Ischemia – Pain Characteristics
• Stable angina• Gradual onset and offset
• Precipitated by exertion and relieved by rest
• Emotional stress
• Cold
• Sublingual nitroglycerin
• Acute coronary syndrome → unstable angina or AMI• Angina at rest
• New-onset angina
• ↑ angina severity or ↑ duration
Myocardial Ischemia – Associated Symptoms
• Dyspnea
• Nausea and vomiting
• Diaphoresis
• Presyncope
• Palpitations
• Atypical presentations→ females, dementia, older patients• Absence of chest pain
• Epigastric discomfort
• Dyspnea
• Indigestion
• Nausea and vomiting
• Weakness
• Pleuritic chest pain
Barstow C, et al. 2017
Myocardial Ischemia – Diagnostic Testing
• Electrocardiogram• ST Elevation MI (STEMI)
• ST segment elevation at the J-point in 2 contiguous leads with the cut-points:
• ≥1 mm in all leads other than leads V2-V3
• Leads V2-V3:
• ≥2 mm in men ≥40 years
• ≥2.5 mm in men <40 years
• ≥1.5 mm in women regardless of age
• Non-ST Elevation MI (NSTEMI)• Horizontal or downsloping ST-depression ≥0.5 mm in two contiguous leads
and/or
• T inversion >1 mm in two contiguous leads with prominent R wave
Limb and Chest Lead “Views” of the Heart
Myocardial Injury – ST Segment Elevation
• Zone of injury does not repolarize completely so it remains more positive than surrounding tissue leading to ST segment elevation
Myocardial Ischemia – ST Segment Depression
• ST segment depression
• Area of ischemia is more negative than surrounding tissue
Myocardial Ischemia – T Wave Inversion
• T wave inversion because ischemic tissue does not repolarize normally
• ST-segment elevation myocardial infarction (STEMI)• ST elevations across the precordium (V1-V5) with reciprocal ST depressions
inferiorly (II, III, aVF) • Concerning for proximal left anterior descending (LAD) lesion causing
ischemia
• Episode of chest pain at rest in a patient with unstable angina• ST-segment depression above 1 mm is present in leads V4 to V6• Chest pain and ST-segment depression disappeared promptly after the
administration of sublingual nitroglycerin
Acute Pericarditis
• M>F
• 20 to 50 y/o MC
• Causes• Idiopathic (presumed viral)• Infectious
• Viral / Bacterial / Fungal / TB / HIV
• Non-infectious• Connective tissue disease / autoimmune disorders• Malignancy• Cardiac disorder• Renal failure (uremia)• Radiation• Medication adverse reaction• Trauma
Acute Pericarditis – History
• Sudden onset of retrosternal chest pain (>95%)• Sharp and pleuritic
• ↑ coughing, inspiration and / or swallowing
• ↑ lying supine
• ↓ sitting and leaning forward
• +/- radiating pain → similar to MI
• Prolonged duration
• +/- Preceding viral syndrome (URI or GI)
• +/- Fever
• +/- Dyspnea
Pericarditis – Physical Exam
• Pericardial friction rub• Scratching or grating sound
• Highly specific
• Loudest left sternal border
• Increases with leaning forward
• +/- Fever (>100.4°F)
• +/- Tachypnea
• +/- Tachycardia
Yelland, MJ. Outpatient evaluation of the adult with chest pain. In: UpToDate, Aronson, MD (Ed), UpToDate, Waltham, MA, 2018.
Acute Pericarditis – Diagnostic Studies
• ECG• Diffuse concave ST elevation
• PR depression
• Blood work• CBC → leukocytosis if infectious
• ESR / CRP → elevated
• Cardiac troponin → elevation indicates myopericarditis
• Additional bloodwork based upon suspected causes
• CXR → typically normal
Acute Pericarditis – Electrocardiogram
Imazio, M. Acute pericarditis: Clinical presentation and diagnostic evaluation. In: UpToDate, LeWinter, M (Ed), UpToDate, Waltham, MA, 2017.
Acute Pericarditis – Treatment
• High-risk features that necessitate hospital admission• Fever > 100.4°F
• Subacute course
• Hemodynamic compromise (cardiac tamponade)
• Large pericardial effusion
• Immunocompromised
• Current anticoagulant therapy
• Elevated cardiac biomarkers
• Failure to clinically improve with 7 days of appropriate NSAID therapy
Acute Pericarditis – Treatment
• Idiopathic (presumed viral)• Ibuprofen 600 to 800 mg TID or• Aspirin 650 to 1000 mg TID or• Indomethacin 25 to 50 mg TID• Plus colchicine 0.5 mg QD if < 70 kg or BID if >70 kg x 3 months
• Bacterial• Vancomysin 30 mg/kg/day and• Ceftriaxone 3 mg/kg/day• Pericardiocentesis
• Restrict from exertional activities until symptoms resolve and labs normalize
Taper when symptom free & CRP normalizes
Aortic Dissection
• Acute severe / sharp chest and back pain• +/- ripping or tearing quality• UE peripheral pulses and blood pressures may be diminished or unequal• Surgical emergency
Costochondritis
• MC cause of MSK anterior chest pain
• F=M
• > 40 y/o
• Idiopathic – hx of preceding illness with coughing or recent strenuous exercise is common
• Inflammation of costochondral or chondrosternal junction• Unilateral
• 90% > 1 level
• 2nd – 5th ribs most common Mayo Clinic
Costochondritis – History & Physical Exam
• Sharp, aching or pressure like pain• Anterior
• May radiate laterally
• ↑ deep breathing, coughing, sneezing and laughing
• ↑ upper body movements
• Reproduction of pain with palpation
• No overlying discoloration or swelling
• ROM restriction uncommon
Mayo Clinic
Tietze Syndrome
• Rare
• F=M
• < 40 y/o
• Idiopathic – hx of preceding illness with coughing
• Inflammation of costochondral or costosternal junction• Unilateral
• 70% 1 level only
• 2nd – 3rd ribs most common
Tietze Syndrome – History & Physical Exam
• Sharp, aching or pressure like pain• Anterior
• May radiate laterally
• ↑ deep breathing, coughing, sneezing and laughing
• ↑ upper body movements
• Reproduction of pain with palpation
• Swelling overlying the involved joints
• ROM restriction uncommon
Costochondritis & Tietze Syndrome – Treatment
• Analgesics• NSAIDs
• APAP
• Activity modification
• Variable course• Weeks to months
• Rare to exceed a year
• Chest wall tenderness has a tendency to linger
• Refractory cases → lidocaine/corticosteroid injection
Costovertebral Dysfunction
• F>M
• Recent history of restricted chest posture
• Rib hypomobility / “subluxation”• Functional disruption of the
costovertebral and costosternal articulations
• Alteration of rib mechanics with inspiration and expiration
Costovertebral Dysfunction – History
• Sharp stabbing pain• Present upon waking
• Unilateral
• Anterior and posterior → “feels like a knife is being stabbed through my chest”
• May radiate laterally along dermatomal distribution
• ↑ deep breathing → subconscious alteration of inspiratory effort
• ↑ coughing, sneezing and laughing
• ↑ trunk movements
Costovertebral Dysfunction – Physical Exam
• Reproduction of pain with palpation
• PA mobilization of adjacent vertebra• ↑ pain
• Hypomobility
• Protective muscle spasm
• Restricted trunk range of motion• Extension, ipsilateral rotation and ipsilateral flexion
→ limited by pain
• Opposite movements → limited by tightness
• Sudden reduction in pain with physical exam → rib relocation
Costovertebral Dysfunction – Management
• Pharmacologic• Analgesics
• NSAIDs or
• APAP
• Muscle relaxants
• Manual therapy• Physical therapy
• Chiropractic therapy
• Massage therapy
GERD
• Reflux esophagitis• Abnormal LES function
• Reflux of stomach contents into esophagus
• Prolonged exposure to gastric acid
• Contributing factors• Hiatal hernia
• Obesity
• Pregnancy (30 to 50%) and exogenous estrogen
• Diet and medications
Mayo Clinic
GERD – History & Physical Exam
• Heartburn• Retrosternal burning or squeezing• ↑ lying down, bending over• MC postprandial• +/- nocturnal pain• +/- exacerbation due to emotional
stress• Pain may last minutes to hours• Some relief with antacids
• Regurgitation• Dysphagia• Chest pain → may mimic angina• Nausea / vomiting (rare)• Nonspecific physical exam findings
• Alarm symptoms• Anemia
• Loss of weight
• Anorexia
• Recent onset of progressive symptoms
• Melena or hematemesis
• Swallowing difficulties (dysphagia or odynophagia)
GERD – Treatment
• No alarm symptoms• Lifestyle and dietary modifications combined with 4-8 week trial of PPIs
• Alarm symptoms• GI consult (urgent or emergent)
Medication Induced Esophagitis• F>M
• Mean age 41.5 y/o
• Indirect mechanism• Adverse reactions → weakening LES
• Disrupting protective barrier → NSAIDs
• Medication induced infection → Antibiotics
• Direct mechanism• Medication lodged at area of esophageal narrowing → aortic
arch
• Local caustic injury to adjacent mucosa
• Antibiotics: tetracycline, doxycycline and clindamycin
• Bisphosphonates
• Potassium chloride, quinidine preparations, iron compounds
Medication Induced Esophagitis – History & Physical Exam• Sharp retrosternal pain or heartburn
• Odynophagia
• Dysphagia
• Infrequent but alarming symptoms• Inability to swallow saliva
• Hematemesis
• Abdominal pain
• Weight loss
• Nonspecific physical exam findings
Medication Induced Esophagitis – Treatment
• Discontinue medication or switch to liquid form
• +/- acid suppression agents
• Endoscopy indications:• Alarm symptoms
• Severe pain
• Persistent symptoms >1 week after discontinuing medication
Pneumonia
• Infection of the lung parenchyma• Bacterial
• S. Pneumoniae ~60% of all CAP• Viral• Fungal
• Risk factors• Immunocompromised• <2 y/o or > 65 y/o• Alcohol abuse• Tobacco use• Asthma• Lung disease• Heart disease• Institutionalization
Pneumonia
• Alveolar inflammation
• Accumulation of WBCs, fluid and proteins in the alveolar space
• Impairment of gas exchange
Ramirez, JA. Overview of community-acquired pneumonia in adults. In: UpToDate, File, TM (Ed), UpToDate, Waltham, MA, 2018.
Pneumonia – History
• Specific (more common)• Cough
• +/- sputum
• +/- hemoptysis
• Pleuritic pain
• Dyspnea
• Non-specific• Sweats, chills, rigors
• Fatigue, myalgias
• Headache
• Chest discomfort
• Abdominal pain
• N/V
• Anorexia
• Mental status changes
Pneumonia – Physical Exam
• Asymmetric breath sounds
• Rales
• Egophony
• ↑ tactile fremitus
• Local dullness to percussion
• Fever > 100.4° F
• Tachypnea
• Tachycardia
• ↓ O2 saturation
Pneumonia – Diagnostic Studies
Radiology Masterclass
Pneumonia – Treatment (CURB-65)
• CRB-65 (remove BUN)• 0 → outpatient• 1-2 → consider hospitalization• 3-4 → urgent hospitalization
Pneumonia – Treatment
• CAP outpatient empiric treatment• Healthy with no antibiotic use in past 3 months
• Macrolide or doxycycline
• Potential for macrolide resistance or antibiotic use in past 3 months• Respiratory fluoroquinolone or high dose amoxicillin* (or Augmentin*) + macrolide
* Ceftin (cefuroxime) alternative option
Pulmonary Embolism
Pulmonary Embolism
Pulmonary Embolism – History & Physical ExamSymptoms• Dyspnea 73%
• Rapid onset within seconds or minutes
• Pleuritic chest pain 66%
• Cough 37%
• Orthopnea 28%
• Calf or thigh pain and/or swelling 44%
• Wheezing 21%
• Hemoptysis 13%
• Pre(syncope) <10%
Signs• Tachypnea 54%
• LE signs of DVT 47%
• Tachycardia 24%
• Rales 18%
• Decreased breath sounds 17%
• Fever, mimicking pneumonia 3%
• ↓ O2 saturation
Pulmonary Embolism – Wells Criteria
• Scoring< 2 low probability (3.4%)
2-6 moderate probability (27.8%)
> 6 high probability (78.4%)
Pulmonary Embolism – Diagnostic Studies
• Electrocardiogram → common but non-specific abnormalities• Sinus tachycardia and non-specific T wave changes → 70%
• Classic S1Q3T3 pattern <10%• S wave in lead I, Q wave in lead III and inverted T wave in lead III
• CXR• 50% are normal / non-diagnostic → useful in ruling out other conditions
• PE specific abnormalities• Hampton's hump (pulmonary infarction) → wedge shaped consolidation in the periphery
w/ base against pleural surface
• Westermark’s sign (vasculature collapse) → sharp cut-off of pulmonary vessels with distal hypoperfusion (oligemia)
Thompson, BT, et al. Acute pericarditis: Clinical presentation, evaluation, and diagnosis of the nonpregnantadult with suspected acute pulmonary embolism. In: UpToDate, Mandel, J (Ed), UpToDate, Waltham, MA, 2018.
Thompson, BT, et al. Acute pericarditis: Clinical presentation, evaluation, and diagnosis of the nonpregnantadult with suspected acute pulmonary embolism. In: UpToDate, Mandel, J (Ed), UpToDate, Waltham, MA, 2018.
Spontaneous Pneumothorax
• Primary• M:F 6:1• Tall, thin young men (20-40 y/o)• Rupture of small blebs, usually
located near the apex of the upper lobes
• Secondary• Most common: COPD• Other: pneumonia, bronchogenic
carcinoma, mesothelioma, sarcoidosis, tuberculosis, cystic fibrosis, iatrogenic
Spontaneous Pneumothorax – History
• Pleuritic chest pain (90%)• Sudden onset of sharp pain → progresses to becoming dull after a few hours
• Unilateral
• Dyspnea (80%)
• Cough (10%)
• Symptom severity is related to the size of the pneumothorax
Spontaneous Pneumothorax – Physical Exam
• Tachycardia
• Tachypnea
• ↓ O2 saturation
• Diminished breath sounds
• Hyperresonance to percussion
• Decreased tactile fremitus
• Subcutaneous emphysema
Spontaneous Pneumothorax – Diagnostic Studies
Radiology Masterclass
Spontaneous Pneumothorax – Diagnostic Studies
Radiology Masterclass
Spontaneous Pneumothorax – Diagnostic Studies
Radiology Masterclass
Panic Disorder
• F>M
• Median age 24 y/o
• Risk factors• Neuroticism→ proneness to experiencing negative emotions• Anxiety sensitivity → disposition to believe that anxiety symptoms are
harmful• Childhood sexual and physical abuse• Smoking• Life stress
• Anticipate catastrophic outcome from a mild physical symptom• Chest pain → heart attack
Panic Disorder – DSM V Criteria
• Recurrent unexpected panic attacks
• Abrupt surge of intense fear or discomfort → peaks within several minutes
• 4 or more associated symptoms
• Inquire about previous workup
• Palpitations, pounding heart, or accelerated heart rate
• Sweating
• Trembling or shaking
• Sensations of shortness of breath or smothering
• Feelings of choking
• Chest pain or discomfort
• Nausea or abdominal distress
• Feeling dizzy, unsteady, light-headed, or faint
• Chills or heat sensations
• Paresthesias (numbness or tingling sensations)
• Derealization (feelings of unreality) or depersonalization (being detached from oneself)
• Fear of losing control or “going crazy”
• Fear of dying
Panic Disorder – Treatment
• Cognitive behavioral therapy (CBT)
• SSRI or SNRI → considering tapering after ~1 year• Sertraline (Zoloft) – 50mg/day – increase dosage after 6 weeks
• Venlafaxine (Effexor) – 37.5 mg/day – increase dosage after 6 weeks
• Partial response after 8 – 12 week trial consider adding clonazepam (Klonopin)
References
• UpToDate
• Radiology Masterclass (https://www.radiologymasterclass.co.uk/)
• Barstow, C, et al. Acute Coronary Syndrome: Diagnostic Evaluation. Am Fam Physician. 2017; 95(3): 170-177.
• McConaghty, JR and Oza, RS. Outpatient Diagnosis of Acute Chest Pain in Adults. Am Fam Physician. 2013; 87(3): 177-182.
• Proulx, AM and Zryd, TW. Costochondritis: Diagnosis and Treatment. Am Fam Physician. 2009; 80(6): 617-620.
• Jameson J, et al. Harrison's Principles of Internal Medicine: Chest Discomfort, 20e; 2018. https://accessmedicine.mhmedical.com/ViewLarge.aspx?figid=192010949