3 TIPS TO HELP YOU MASTER THE EVALUATION OF CHEST PAIN

Natalie R. Nyren, PA-CUniversity Hospital System, UMA Cardiology Clinic November 2, 2019

DISCLOSURES

◉ None

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OBJECTIVES

o Background o Initial Evaluationo Risk assessment o Causes of Chest Pain o Cases

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610,000People die from heart disease every year (1 in 4 deaths)

8,000,000Office visits with the chief compliant of chest pain per year

735,000People have a heart attack each year

4 https://www.cdc.gov/heartdisease/facts.htm

What about San Antonio…

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Heart disease in San Antonio

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Life Expectancy in San Antonio

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Heart Disease in the United States

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Tip # 1Does the patient need to go to the ED??

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Initial Evaluation

The initial evaluation is key

◉ Ischemic versus non- ischemic pain??◉ History & physical alone are not enough◉ Individual risk factors are not enough

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Big picture◉ A combination of

characteristics can provide more accuracy in your diagnosis of ACS

Initial Evaluation

Helpful hints…◉ Quality of chest pain◉ Male sex◉ Age, older than 60 years

old◉ History of angina or MI◉ PE findings (3rd heart

sound), diaphoresis◉ Hypotension, unstable

vitals11

Women, elderly and diabetic patients then to have more atypical symptoms, such as nausea, fatigue, and GERD- like symptoms

PEARL

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Initial Evaluation

Angina◉ Deep, poorly localized

chest or arm discomfort (pain or pressure)

◉ Reproducible with physical exertion or emotional stress

◉ Relieved promptly with rest or nitroglycerine

Unstable Angina◉ Angina at rest◉ Angina that has

become more severe or longer in duration

◉ Negative troponin

Acute MI◉ STEMI/NSTEMI◉ +/- ST segment

changes (elevations/depressions)

◉ Positive troponin

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Initial Evaluation

◉ Exertional angina occurs when plaque burden is greater than 70% of the lumen of the coronary artery

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Initial Evaluation

◉ 12 Lead ECG is the test of choice for the initial evaluation of acute chest pain

Signs of ACS include…o ST segment changes (elevation or depressions)o New- onset left bundle branch block o Presence of Q waveso New onset T wave inversion

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Relief of symptoms with Nitroglycerine alone is not predictive of ACS

PEARL

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Tip # 2Use Validated Tools to help with Risk Assessment

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RISK ASSESSMENT

◉ Tool to help predict if CP is caused by CAD

Positive likelihood ratio0- 1 = 1.092- 3 = 1.83 4- 5 = 4.52

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Component Point

Age/SexMen >55 years oldWomen > 65 years old

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Known vascular disease (CAD, PVD, cerebrovascular disease)

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Pain worse with exercise 1

Pain not elicited with palpation 1

Patient assumes pain is of cardiac origin

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RISK ASSESSMENT

◉ HEART Score◉ Risk of major adverse

cardiac event (MACE) over next 6 weeks

◉ 0- 3 = 2.5%◉ 4- 6 = 20% ◉ 7- 10 = 72.7

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RISK ASSESSMENT

◉ HEART Score + Serial Troponins = Heart Pathway○ Low risk heart score + negative troponins = Early Discharge○ High risk heart score + negative troponins = Observation +/- more

testing○ High risk heart score + positive troponins = Admission/Intervention

○ High negative predictive value (99%) for MACE in 6 weeks

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RISK ASSESSMENT

◉ Low Risk patients○ Consider other cause of

CP○ Medical management○ Therapeutic lifestyle

modifications

◉ High Risk patients ○ Send to ED○ Admission

○ Further work up warranted

○ Refer to Cardiology

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Tip # 3Don’t ignore it!

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The American Heart Association Recommends

Door-to-balloon time< 90 minutes

Time is of the essence!

NSTEMI vs STEMI

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Cardiac Testing

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Cardiac Testing

◉ Anatomic and functional testing

◉ Helpful in risk assessment○ Guide management○ Pre- op assessment

Options ○ Cardiac catherization○ CT heart angiogram○ Exercise stress test○ Nuclear stress test○ Stress echocardiography

○ Echocardiogram*

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Cardiac catherization is the gold standard for diagnosing coronary artery disease

PEARL

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Cardiac Testing/ Stress Testing

◉ Clinical Indications ○ Symptomatic patients○ Heart failure○ Cardiomyopathy ○ Valvular heart disease○ Planned non- cardiac

surgery

◉ Considerations○ Ability to perform

exercise○ Resting ECG○ Body habitus ○ History of prior coronary

revascularization

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Cardiac Testing/ Stress Testing

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Test Exercise Pharmacologic (Medication)

Time Radiation Sensitivity/ Specificity/ NPV

Contraindications/ AVOID

Exercise stress test (treadmill)

Y * Quick N 67-68% / 72-77% /28-94%

Unable to exercise, Abnormal ECG (LBBB), h/o CABG, PCI

Nuclear stress test

Y Lexiscan Long Y 85-90%80-90%98-99%

Avoid in bronchospastic airway disease, Seizure history

Stress Echo

Y Dobutamine Quick N 85-88%80-83%96-97%

Abnormal ECG (LBBB)

Absolute CI - h/o allergy to these medications, active chest pain, uncontrolled blood pressure (>180/100/ or <90 systolic), pregnancy breast feeding

Cardiac Testing

◉ CT Heart Angiogram ○ Comparable to nuclear stress testing for

intermediate- risk patients○ Images are at rest○ Less radiation exposure ○ Gives coronary calcium score○ Helpful in risk stratification

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Cardiac Testing

◉ CT Heart Angiogram ○ Heart rate must be slow○ BMI <40 ○ Caution in renal disease (contrast)

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Other Causes of CP

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Causes of Chest Pain

◉ Ischemia ◉ Infection/Inflammation◉ Vasospasm◉ Neuropathic ◉ Mass effect/constriction◉ Rupture

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Causes of Chest Pain

◉ Ischemia ◉ Infection/Inflammation◉ Vasospasm◉ Neuropathic ◉ Mass effect/constriction◉ Rupture

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MSK, 50%

GI, 20%

Stable Angina, 10%

Respiratory, 5%Unstable

Angina/MI, 4%

Other, 11%

0%

10%

20%

30%

40%

50%

60%

MSK GI Stable Angina Respiratory UnstableAngina/MI

Other

CAUSE OF CHEST PAIN IN OUTPATIENT SETTING

Common Causes of Chest Pain

Chest Wall Pain• Localized pain• Stinging pain• Pain reproducible• No cough

GERD• Burning retrosternal

pain• Acid reflux/sour taste in

mouth• Relief with antacids

PsychHistory of anxiety attacks, suddenly feeling fear or panic in last 4 weeks

Pericarditis• Pleuritic chest pain• Pericardial friction rub• EKG changes with

diffuse ST- segment elevation

Pulmonary Embolism• High pretest probability

based on Wells criteria • Tachycardia • Dyspnea

Pneumonia• Fever• Clinical

impression/Cough• Egophony• Dullness to percussion

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Causes of Chest Pain

◉ Cardiac○ Angina pectoris

(stable angina)○ Pericarditis○ Cardiomyopathy○ Acute coronary

syndrome○ Aortic dissection○ Cardiac tamponade

◉ Pulmonary○ Pneumothorax○ Pneumonia ○ Malignancy○ Pleuritis○ Asthma/COPD○ Sarcoidosis○ Pulmonary

embolism

◉ GI○ GERD○ Peptic ulcer disease○ Esophageal pain○ Esophagitis○ Esophageal rupture

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Cases

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Case 1

◉ V.L. is a 64 year old female who presents with chest discomfort, described as chest pressure, associated with exertion such as walking up a flight of stairs. Resolves with rest. She first noticed her symptoms several years ago, but now they seem more frequent and she finds herself very fatigued doing her regular daily housework activities.

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Case 1

◉ PMH: HTN, DM2, HLD, Tobacco dependence (20 pack- year hx), +family Hx heart disease

◉ Meds: ○ Enalapril 10mg once daily ○ Atorvastatin 20mg qhs○ Metformin 1000mg bid

◉ Vitals: ○ 135/68 mmHg, HR 80 bpm

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Case 1

◉ Does this patient have ischemic heart disease?◉ What is the next step in the management of

this patient?

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Case 1

◉ Nuclear stress test – Positive◉ Echocardiogram – mild concentric LVH, Estimated

LVEF 50- 55%

◉ Referred to cath lab, started on ASA, Nitroglycerin prn

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Case 2

◉ O.A. is a 23- year- old college student with no significant PMH who presents to the clinic for evaluation of chest pain x 4 years.

◉ He describes the pain as pressure like sensation to his left chest, occurring several times a day and lasting for 5- 10 minutes. Worse with eating greasy foods and walking to class, better with rest.

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Case 2

◉ Social Hx: negative for TED, he exercises 4- 5 x week and plays competitive sports

◉ Family Hx: negative for heart disease, he is one of 8 siblings

◉ Meds: None ◉ Vitals: BP 115/70 mmHg, HR 75

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Case 2

◉ What is the best next step in the work- up of this patient?

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Case 2

◉ What is the next step in the management of this patient?

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◉ Echocardiogram, Heart MRI○ Diagnosed with Hypertrophic Cardiomyopathy○ Referred to EP for ICD

Case 3

◉ K.N. is a 47- year- old female presents to the clinic for evaluation of palpitations and chest pain x 4 months. Palpitations occur intermittently during the day, no known alleviating or aggravating factors. Chest pain occurs less frequently, central, sharp pain, lasting for up to 10 minutes, no known aggravating or alleviating factors.

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Case 3

◉ PMH: Hyperlipidemia◉ Social Hx: Nurse, works night shift, exercises

regularly and eats fairly healthy diet◉ Family Hx: Mother with CAD, Sister with heart

arrhythmia ◉ Current Meds: Aspirin 81mg daily◉ Physical Exam: unremarkable, chest pain not

reproducible on exam 50

Case 3

◉ What is the best next step in the work- up of this patient?

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Case 3

◉ Exercise stress test – negative◉ Echocardiogram – no structural abnormalities,

normal ejection fraction◉ Labs: TC 358, LDL 181, HDL 55 ◉ Treatment: Aggressive TLC, started on

Diltiazem 120mg qd, Atorvastatin 20mg, trial of Protonix qd for GERD – palpitations improved, chest pain less frequent

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Summary

◉ Its difficult to differentiate between non-ischemic and ischemic chest pain

◉ Heart disease is the number one cause of death in the US for both men and women

◉ Use tools available to help evaluate risk ◉ Listen to your patient for clues to the cause of

their pain54

Remember the 3 Tips

ED? Yes or No

Don’t Ignore it!

Use your tools

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“

“I don’t understand why asking people to eat a well- balanced vegetarian diet is

considered drastic, while it is medically conservative to cut people open and put

them on cholesterol lowering drugs for the rest of their lives.” – Dean Ornish , MD

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Any questions ?You can find me at◉ Natalie.Nyren@gmail.com◉ Natalie.Nyren@uhs- sa.com

Thanks!

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References

◉ Askew, J, Chareonthaitawee, P, Arruda- Olson, A., Selecting the optimal cardiac stress test. Uptodate.com. 4/26/2019. Retrieved 9/1/2019

◉ Barstow, C, Rice, M. McDivitt , J. Acute Coronary Syndrome: Diagnostic Evaluation. American Academy of Family Physicians. 2017;95(3):170-177

◉ FihnSD, GardinJM, Abrams J, et al. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons.J Am Coll Cardiol 20 12;60 :e44- e164.

◉ Mahler, S., Riley, R., Hiestand, B., Russel, G., et al. The HEART Pathway Randomized Trial IdentifiyingEmergency Department Patients with Acute Chest Pain for Early Discharge

◉ McConaghy, J, Oza, R.s. Outpatient Diagnosis of Acute Chest Pain in Adults. American Family Physician. 20 13;87(3):177- 182.

◉ 20 17 Morbidity and Mortality Report, San Antonio, Metro Health

◉ https:/ / www.cdc.gov/ heartdisease/ facts.htm 58