Approach to Chest Pain
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Transcript of Approach to Chest Pain
Approach to Chest PainIntern Bootcamp, 2014Nathan Stehouwer, MDPGY-4, Internal Medicine & Pediatrics
Differential
Pearl: ALWAYS have the patient point to the pain!
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
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
Typical vs. Atypical Chest Pain
UpToDate 2012
Typical vs. Atypical Chest Pain
Cayley 2005
Case 1
You are the orphan intern on Wearn team at 6PM. You are called by the nurse because Ms. Z has developed chest pain. Ms. Z is a 62 yo F with PMHx of CAD s/p remote PCI to the LAD, COPD and right THA 3 weeks ago who was admitted for a COPD exacerbation.
What would you do next?
Evaluation of Chest Pain
Case 1: Ask nurse for most current set of vital signs Ask nurse to get an EKG Obtain the admission EKG from the paper chart Go see the patient!
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 your senior resident for help Write a clinical event note!
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
Case 1
You go see the patient. She had been feeling better after getting duonebs, but suddenly developed chest pain that is L-sided, 8/10 and worse with breathing. This pain is not like her prior MI.
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
Case 1
Case 1
Differential
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
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
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
Case 1
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
Acute Pulmonary Embolism
Stabliize patient oxygen Fluids if hypotensive!
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
Search “heparin infusion orders”
Pearl: If you have a moderate or high suspicion of PE, you can start anticoagulation while awaiting full diagnostic workup
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
Case 2
You are the long call intern on Hellerstein and get a call to 67121 at 6:58PM. You have a new patient in the ER, being admitted for ACS rule out.
What’s your next move?
Evaluation of Chest Pain
Get report from ED physician about the patient Ask ED physician about patient’s initial presentation Ask for most recent set of vital signs Ask about EKG and CXR results Ask what meds have been started in ER and how
patient responded
Evaluation of Chest Pain
Go to UH Portal and print out an old EKG for comparison
Review prior discharge summaries
Quickly review prior cardiac work up –echo, stress tests and cath reports
Go see the patient!
Case 2
Mr. M is a 67 yo man with PMHx of HTN, DLD, DMT2 and CAD s/p PCI in 2007. He presents with new onset chest pain x 2 hours that is retrosternal, 7/10, associated with nausea and diaphoresis.
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 basesHeart – tachycardic, nl s1/s2, no mumurs or rub
Rest of the exam benign Labs: CBC wnl, RFP wnl, Troponin = 0.05
Next Steps
Review EKG Review CXR Troponin SL Nitroglycerin
Case 2
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
Pearl: Positive Troponin does not equal ACS
Risk Stratification
Unstable Angina/NSTEMI: Initial Management
“Stabilize” plaque Dual antiplatelet therapy
Plavix load 600mg followed by daily 75mg ASA 324mg chewable, then 81 daily
Anticoagulant UF Heparin at low intensity protocol
Statin Atorvastatin 80mg
Optimize Myocardial O2 supply/demand Control HR -> Short acting metoprolol, can titrate quickly to HR <60 if
BP allows. Give 5mg IV, can repeat at 5-15min intervals. Be wary of patients with heart failure!
Supplemental O2 if hypoxemic SL nitroglycerin (0.4mg), repeat every 4-5 minutes Morphine if still having active chest pain
Case 2 continued
You are now the nightfloat intern, and the patient is signed out to you at 10PM. At midnight, you are called for continued chest pain. Improved from admission but still 5/10 severity.
Next steps
Vitals Repeat EKG Repeat SL nitro Assess patient in person Call your senior!
Dose additional morphine start IV nitroglycerin after 3-4 doses of SL nitroglycerin
Start 5 mcg/min Increase by 5mcg/min every 20 minutes Floor maximum: 30mcg/min
Pearl
Inability to ELIMINATE chest pain in a patient with ACS using maximal medical therapy
=Urgent call to cardiology for consideration of
immediate catheterization
Trivia
What typical ACS med should you NOT give this patient?
Pearl: Nitroglycerin contraindicated in inferior MI
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
Case 3
You are called on Hellerstein 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.
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
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.comrwjms1.umdnj.eduen.wikipedia.orgen.wikipedia.org
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
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
Case 4
You are on long call on VA Blue. You are called to admit a 53 yo M from the ED for 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.
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
Case 4
EKG on admission:
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
Goyle 2002
Case 4 - Pericarditis
Goyle 2002
Case 4 - Pericarditis
Diagnostic criteria
UpToDate 2012
Case 4 – Pericarditis
Per 2003 ACC guidelines, all patients diagnosed with pericarditis should receive echocardiogram
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
Case 4 - Pericarditis Treatment
UpToDate 2012
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
Case 5
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
Pearl
Great EKG Practice Site:http://ecg.bidmc.harvard.edu/maven/mavenmain.asp
References
Kearon C, Akl EA, Comerota AJ, Prandoni P, Bounameaux H, Goldhaber SZ, Nelson ME, Wells PS, Gould MK, Dentali F, Crowther M, Kahn SR. Antithrombotic therapy for VTE disease: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2012 Feb;141(2 Suppl):e419S-94S.Cayley, W.E. Diagnosing the cause of chest pain. (2005). American Family Physician, Vol 72 (10), 2012-21.
Anderson JL et al. 2012 ACCF/AHA Focuse Update of the Guideline for Management of Patients with Unstable Angina/NSTEMI. JACC 60 (7) 2012.
Thrumurthy SG et al. The diagnosis and management of aortic dissection. BMJ 344, 2012. Imazio M, Demichelis B, Parrini I, Giuggia M, Cecchi E, Gaschino G, Demarie D, Ghisio A, Trinchero R. Day-hospital treatment of
acute pericarditis: a management program for outpatient therapy. J Am Coll Cardiol. 2004;43(6):1042. Goyle, K.K. and Walling, A.D. Diagnosing pericarditis. (2002). American Family Physician, Vol 66 (9), 1695-1702. Diagnostic approach to chest pain in adults. (2014). UpToDate. http://www.uptodate.com/contents/diagnostic-
approach-to-chest-pain-in-adults?source=search_result&search=chest+pain&selectedTitle=1%7E150 Differential diagnosis of chest pain in adults. (2014). UpToDate. http://www.uptodate.com/contents/differential-
diagnosis-of-chest-pain-in-adults?source=search_result&search=chest+pain&selectedTitle=3%7E150 Evaluation of chest pain in the emergency department. (2014). UpToDate.
http://www.uptodate.com/contents/evaluation-of-chest-pain-in-the-emergency-department?source=search_result&search=chest+pain&selectedTitle=5%7E150
Clinical presentation and diagnostic evaluation of acute pericarditis. (2014). UpToDate. http://www.uptodate.com/contents/clinical-presentation-and-diagnostic-evaluation-of-acute-pericarditis?source=search_result&search=pericarditis&selectedTitle=1%7E150
Treatment of acute pericarditis. (2014). UpToDate. http://www.uptodate.com/contents/treatment-of-acute-pericarditis?source=search_result&search=pericarditis&selectedTitle=2%7E150
Thanks to Sumit Bose for use of a number of his excellent slides!