Approach To Chest PainApproach To Chest Pain

Chest PainChest Pain TABLE 1-2 DIFFERENTIAL DIAGNOSIS OF EPISODIC CHEST PAIN RESEMBLING ANGINA PECTORIS DURATION QUALITY

PROVOCATIONRELIEF LOCATION COMMENT

Effort angina 5-15 minutes Visceral (pres- During effort or Rest, nitroglyc- Substernal, radi- First episode sure) emotion erin ates vivid

Rest angina 5-15 minutes Visceral (pres- Spontaneous (? Nitroglycerin Substernal, radi- Often nocturnal sure) with exercise) ates Mitral prolapse Minutes to Superficial Spontaneous (no Time Left anterior No pattern, vari- hours (rarely visceral) pattern able character Esophageal re- 10 minutes to 1 Visceral Recumbency, Food, antacid Substernal, epi- Rarely radiates flux hour lack of food gastricEsophageal 5-60 minutes Visceral Spontaneous, Nitroglycerin Substernal, Mimics anginaspasm cold liquids, ex- radiates ercisePeptic ulcer Hours Visceral, burning Lack of food, Foods, antacids Epigastric, substernal

‘‘acid’’ foods Biliary disease Hours Visceral (waxes Spontaneous, Time, analgesia Epigastric, ? Colic and wanes) food radiatesCervical disc Variable (gradu- Superficial Head and neck Time, analgesia Arm, neck Not relieved by ally subsides movement, pal- rest pationHyperventilation 2-3 minutes Visceral Emotion, tachy- Stimulus removal Substernal Facial paresthe- pnea siaMusculoskeletal Variable Superficial Movement, Time, analgesia Multiple Tenderness palpationPulmonary 30 minutes + Visceral (pres- Often spontane- Rest, time, bron- SubsternalDyspneic sure) ous chodilator Reproduced with permission from Christie, L.G., Jr., and Conti, C.R.: Systematic approach to the evaluation of angina-like chest pain. Am. Heart J. 1027, 1981.

Chest PainChest Pain TABLE 1-3 SOME FEATURES DIFFERENTIATING CARDIAC FROM NONCARDIAC CHEST PAIN

FAVORING ISCHEMIC ORIGIN AGAINST ISCHEMIC ORIGIN

Character of Pain

Constricting

Squeezing ‘‘Knife-like,’’ sharp, stabbing

Burning ‘‘Jabs’’ aggravated by respiration

‘‘Heaviness,’’ ‘‘heavy feeling’’

Location of Pain

Substernal In the left submammary area

Across mid-thorax, anteriorly In the left hemithorax

In both arms, shoulders

In the neck, cheeks, teeth

In the forearms, fingers

In the interscapular region

Factors Provoking Pain

Exercise Pain after completion of exercise

Excitement Provoked by a specific body motion

Other forms of stress

Cold weather

After meals

From Selzer, A.: Principles and Practice of Clinical Cardiology. 2nd ed. Philadelphia, W.B. Saunders

Company, 1983, p. 17.

Patterns of PainPatterns of Pain

Differential Dx by LocationDifferential Dx by Location

Chest PainChest PainPhysical ExamPhysical Exam

Vital Signs– Febrile- Endocarditis, Dressler’s, Demand

Ischemia– BP- Hypertensive, Ischemia, Aortic Dissection,

CHF (diastolic dysfxn)– Hypotensive, Cardiogenic Shock, CHF

(systolic dysfxn, AS) – HR- arrhythmia, afib, v-tach, heart block– RR/SaO2- CHF, PE

Chest PainChest PainPhysical ExamPhysical Exam

Mental Status- alertness (shock), anxiety HEENT: Mucous Membranes, Carotid Upstrokes

(AS, AI, Bisferiens, Alternans), Bruits, Thyroid (CHF, Angina), Cx Tenderness, JVP- CHF,valve disease, Cannon a-waves

Lungs: RR, Rales, Wheezing (Bronchoconstriction or CHF), Pleural Effusion

Extrem: Equal BP’s, pulses (dissection, PVD), femoral/abdominal bruits, perfusion (cool, clammy, shock), Edema-CHF

Chest PainChest PainCardiac ExamCardiac Exam

Rate/Rhythm- arrhythmia (Afib, V-Tach, Bradycardia), heart block

PMI- displaced, sustained (CHF), palpable S3, S4 Heart Sounds: S1 Loud (MS), Soft (MR, AVB)

Variable(Afib), OS(MS), Mid Sys Click (MVP) Split S2 (BBB, PE, PA HTN, AS, LV Ischemia, Severe MR)

Murmurs- (Separate topic) AS, AI(esp acute), Ischemic MR

S3- CHF, S4-LV Non compliance (Ischemia, HTN)

ST Elevation Myocardial ST Elevation Myocardial Infarction (STEMI)Infarction (STEMI)

Admit, O2ASASL NTG, +/- IV NTG (SBP>100)MSO4 2-4mg, (MONA)Heparin (UFH or LMW)Beta-blockerCandidate for Thrombolytics

Definite Indications for PTCA/Thrombolytic Therapy

Consistent clinical syndrome– Chest pain, new arrhythmia, unexplained

hypotension, pulmonary edema

Diagnostic EKG– >1mm ST elevation in >2 contiguous leads– New LBBB

Less than 12 hours since onset of pain

Relative Indications for PTCA/Thrombolytic Therapy

Consistent Clinical Syndrome

– Chest pain, new arrhythmia, unexplained hypotension or pulmonary edema

Nondiagnostic ECG

– Left bundle-branch block of unknown duration

Absolute Contraindications for Absolute Contraindications for Thrombolytic TherapyThrombolytic Therapy

History of hemorrhagic stroke Stroke or CVA within 1 year Allergy to the agent Surgery or trauma in past 2 wks Known intracranial neoplasm Suspected aortic dissection Active internal bleeding

(except menstruation)

Relative Contraindications for Relative Contraindications for Thrombolytic TherapyThrombolytic Therapy

Severe uncontrolled hypertension (>180/110 mm Hg)

History of chronic severe hypertensionCVA or intracerebral pathology > 1 yr agoCurrent anticoagulant useRecent trauma (within 2-4 weeks)Allergy or prior exposure to streptokinase

Relative Contraindications for Thrombolytic Therapy

Relative Contraindications for Thrombolytic Therapy

Active peptic ulcer disease Significant hepatic dysfunction Recent (2-4 weeks) internal bleeding Bleeding diathesis Noncompressible arterial or central

venous puncture Pregnancy

PTCA vs. ThrombolysisPTCA vs. Thrombolysis

PAMI Trial Demonstrated Superiority of PTCA over Thrombolysis– Hospital Mortality 6.5% with Thrombolysis vs

2.6% with PTCA– ICH 2% with Thrombolysis vs 0.2% with

PTCA– 90 min Door to Balloon Time– Experienced Operators

Non-ST Elevation MI Non-ST Elevation MI (NSTEMI)(NSTEMI)

NSTEMI, Early Invasive NSTEMI, Early Invasive StrategyStrategy

No. Pts

1o Endpoint

Death/MI

Death

MI

Rehosp ACS

P value

1114

7.4

4.7

2.2

3.1

3.4

INV (%)

1106

10.5

7.0

1.6

5.8

5.5

CONS (%)

Cardiac Events at 30 DaysCardiac Events at 30 Days

0.67

0.65

1.40

0.51

0.61

OR

0.009

0.02

0. 29

0.002

0.018

No. Pts

1o Endpoint

Death/MI

Death

MI

Rehosp ACS

P value

1114

7.4

4.7

2.2

3.1

3.4

INV (%)

1106

10.5

7.0

1.6

5.8

5.5

CONS (%)

Cardiac Events at 30 DaysCardiac Events at 30 Days

0.67

0.65

1.40

0.51

0.61

OR

0.009

0.02

0. 29

0.002

0.018

No. Pts

1o Endpoint

Death/MI

Death

MI

Rehosp ACS

1114

15.9

7.3

3.3

4.8

11.0

1106

19.4

9.5

3.5

6.9

13.7

P valueINV (%)CONS (%)

Cardiac Events at 6 MonthsCardiac Events at 6 Months

0.78

0.74

0.93

0.67

0.78

OR

0.025

<0.05

0.74

0.029

0.054

No. Pts

1o Endpoint

Death/MI

Death

MI

Rehosp ACS

1114

15.9

7.3

3.3

4.8

11.0

1106

19.4

9.5

3.5

6.9

13.7

P valueINV (%)CONS (%)

Cardiac Events at 6 MonthsCardiac Events at 6 Months

0.78

0.74

0.93

0.67

0.78

OR

0.025

<0.05

0.74

0.029

0.054

CONS CONS INVINV(%)(%) (%)(%)19.419.4 15.315.319.619.6 17.017.0

17.817.8 14.914.921.721.7 17.117.1

27.727.7 20.120.116.416.4 14.214.2

26.326.3 16.416.415.315.3 15.615.6

19.419.4 15.915.9

11OO EndpointEndpoint %Pts%Pts

MenMen (66%)(66%)WomenWomen (34%)(34%)

Age < 65 yrsAge < 65 yrs (57%)(57%)Age Age >> 65 yrs65 yrs (43%)(43%)

DiabetesDiabetes (28%)(28%)No diabetesNo diabetes (72%)(72%)

ST ST ** (38%)(38%)No ST No ST (62%)(62%)

Total PopulationTotal Population

Death, MI, Rehosp ACS at 6 MonthsDeath, MI, Rehosp ACS at 6 Months

*Interaction P=0.006*Interaction P=0.006others P=NSothers P=NS

Subgroups: Primary Endpoint Subgroups: Primary Endpoint

INV Better CONS Better00 0.50.5 11 1.51.5

CONS CONS INVINV(%)(%) (%)(%)19.419.4 15.315.319.619.6 17.017.0

17.817.8 14.914.921.721.7 17.117.1

27.727.7 20.120.116.416.4 14.214.2

26.326.3 16.416.415.315.3 15.615.6

19.419.4 15.915.9

11OO EndpointEndpoint %Pts%Pts

MenMen (66%)(66%)WomenWomen (34%)(34%)

Age < 65 yrsAge < 65 yrs (57%)(57%)Age Age >> 65 yrs65 yrs (43%)(43%)

DiabetesDiabetes (28%)(28%)No diabetesNo diabetes (72%)(72%)

ST ST ** (38%)(38%)No ST No ST (62%)(62%)

Total PopulationTotal Population

Death, MI, Rehosp ACS at 6 MonthsDeath, MI, Rehosp ACS at 6 Months

*Interaction P=0.006*Interaction P=0.006others P=NSothers P=NS

Subgroups: Primary Endpoint Subgroups: Primary Endpoint

INV Better CONS Better00 0.50.5 11 1.51.5

1 4.5

24 .2

1 6.914 .3

0

5

1 0

1 5

2 0

2 5

3 0

T nT - T nT +

(%)

C O N S IN V

T ro p o n in T : 1 oE P a t 6 m o n th s

T n T cu t p o in t = 0 .01 n g /m l (54% o f P ts T n T + )

D e ath , M I, R eh o sp A C S a t 6 M o n th sD e ath , M I, R eh o sp A C S a t 6 M o n th s

O R = 0 .52O R = 0 .52*p < 0 .00 1*p < 0 .00 1

In terac tio nIn terac tio nP < 0 .0 01P < 0 .0 01

p = N Sp = N S

**

N = 414N = 414 N = 396N = 396 N = 463N = 463 N = 495N = 495

1 4.5

24 .2

1 6.914 .3

0

5

1 0

1 5

2 0

2 5

3 0

T nT - T nT +

(%)

C O N S IN V

T ro p o n in T : 1 oE P a t 6 m o n th s

T n T cu t p o in t = 0 .01 n g /m l (54% o f P ts T n T + )

D e ath , M I, R eh o sp A C S a t 6 M o n th sD e ath , M I, R eh o sp A C S a t 6 M o n th s

O R = 0 .52O R = 0 .52*p < 0 .00 1*p < 0 .00 1

In terac tio nIn terac tio nP < 0 .0 01P < 0 .0 01

p = N Sp = N S

**

N = 414N = 414 N = 396N = 396 N = 463N = 463 N = 495N = 495

Chest Pain Uncertain EtiologyChest Pain Uncertain Etiology

EKG with Symptoms– 4% of MI’s normal EKG

Non Invasive Imaging :Resting Nuclear Imaging/Echo/Contrast During Symptoms, CT Angio, EBCT, MRI Hyperenhancement

Cardiac EnzymesStress TestingCardiac Catheterization

Bayes TheroemBayes Theroem

Predictive ValuePredictive Value

Predictive Value ETTPredictive Value ETT

ETT in WomenETT in Women

Cardiac Stress TestingCardiac Stress TestingNuclearNuclear

TABLE 9-4 SENSITIVITY AND SPECIFICITY FOR DETECTION OF CORONARY ARTERY

DISEASE BY 201Tl SINGLE-PHOTON EMISSION COMPUTERIZED TOMOGRAPHY

NUMBER OF

AUTHOR PATIENTS SENSITIVITY (%) SPECIFICITY

Tamaki et al. 104 91 92 De Pasquale et al. 210 95 71

Borges-Neto et al. 100 92 69

Maddahi et al. 110 96 56

Fintel et al. 112 91 90 Iskandrian et al. 164 88 62

Go et al. 202 76 80 Mahmarian et al. 360 93 87

van Train et al. 242 95 56

Total 1901 91 73

Stress EchoStress Echo

Contraindications to ETT Contraindications to ETT

ETT High Risk FeaturesETT High Risk Features

TABLE 5-4 EXERCISE PARAMETERS ASSOCIATED WITH

AN ADVERSE PROGNOSIS AND MULTIVESSEL CORONARY ARTERY DISEASE Duration of symptom-limiting exercise (< 6 METs) Failure to increase systolic blood pressure ³120 mm Hg, or a sustained decrease ³10 mm Hg, or below rest levels, during progressive exercise ST segment depression ³2 mm, downsloping ST segment, starting at < 6 METs, involving ³5 leads, persisting ³5 min- utes into recovery Exercise-induced ST segment elevation (a Vr excluded) Angina pectoris during exercise Reproducible sustained (> 30 sec) or symptomatic ventricular tachycardia

EBCTEBCT

Multislice CTMultislice CTSensitivity Specificity

Segment <50% >50% >75%

Mid/Prox 80 75 88 97

Distal 76 67 60 97

All 79 73 80 97

Leber et al., JACC July 2005

Diagnostic Accuracy CTADiagnostic Accuracy CTA

Leshka et.al. Eur Heart Journal 2005

CTA ExclusionsCTA Exclusions

BMI>30 Afib Coronary Calcium Previous Stent HR>75 Hemodynamic Instability, inability to take beta-

blockers Renal Insufficiency, Contrast allergy Coronary Size <3mm

Coronary AngiographyCoronary Angiography

Cardiac CatheterizationCardiac Catheterization

Remains the “Gold Standard”High risk patientsNon diagnostic non-invasive testsHemodynamic, Anatomical, Physiological

Assessment– FFR, IVUS

Immediate Intervention if Needed