CHEST PAIN: HOW TO EVALUATE?

Dr Syed RazaMD, MRCP(UK), Dip Card(UK), CCT(UK)

MESC, FCCP

OBJECTIVES

– Provide an approach to the evaluation of patients with chest pain

– Review and briefly discuss life-threatening and common causes of chest pain

Case 1

62 M , smokerLeft sided chest pain Serial ECGs , cardiac enzymes and Trop. NormalLow risk for ACSStress ECG – Normal Discharged

Case 2

• 32 f• Returned from holiday in US• Sharp chest pain. Seen by ER physician• D-dimer - N• Diagnosis – MS pain and discharged on

analgesic• Returned to ER • ? Pericardial rub – admitted. NSAIDS Referred to Cardio. Not rub but ED murmur

Wide Mediastinum

Aortic dissection

Case 3

• 38 yrs old male football player• Chest pain after working out in Gym• No risk factors • Very anxious• Chest wall tenderness present • Initial Cardiac work up normal• Discharged : MS pain with anxiety overlay

Acute Infero-lateral wall STEMI

• Chest pain accounts for approximately six million annual visits to the emergency departments (ED) in the United States (US)

• Chest pain is the second most common complaint a patient visits ER for

• Patients present with a spectrum of signs and symptoms reflecting various potential aetiologies of chest pain.

• May range from benign to catastrophic conditions

• Clinicians should focus on the immediate recognition and exclusion of life-threatening causes of chest pain.

• Patients with life threatening etiologies for chest pain may appear deceptively well, manifesting neither vital sign nor physical examination abnormalities.

Chest Pain : Classification

CARDIAC Ischemic: Coronary artery disease Non Ischemic: Aortic dissection, Pericarditis, AS, HOCM, MVP NON CARDIAC PE, Pleurisy,Pneumothorax Oesophagitis Costo-condritis , Myositis Neuralgia : Herpes Zoster

© Continuing Medical Implementation …...bridging the care

gap

Classification of Chest Pain

Typical angina1. Retrosternal – radiation to left arm/jaw2. Provoked by exertion or stress 3. Relieved by rest or NTG

Atypical – Fulfill only some criteria

Non-anginal chest pain– Do not fulfill any of the above criteria

HISTORY IS THE KEY TO THE DIAGNOSIS OF ETIOLOGY OF CHEST PAIN

FOCUSSED HISTORYOPQRST

• Onset and Duration• Provocative/Palliative • Quality• Radiation• Severity

PAIN ASSESSMENT SCALES

• Visual Analog Scales (VAS) > Numeric Pain Intensity Scale > Simple Descriptive Pain Intensity Scale > Graphic Rating Scale > Verbal Rating Scale > Pain Faces Scale > Numeric Pain Intensity & Pain Distress Scales

• > Memorial Pain Assessment Card

Accompanied Symptoms

• Shortness of breath• Diaphoresis• Excessive anxiety• Sense of doom • Nausea, light headedness, dizziness• Neurological symptom/s

FOCUSSED PHYSICAL EXAMINATION

• VITAL SIGNS• BP in both arms• Pericardial rub• Murmur• Pleural rub• Chest wall tenderness• Epigastric tenderness• Rash

From Hurst

Differential diagnosis:

ANGINA PECTORIS

• Typical distribution• Exertional • May occur at rest• May be precipitated by meals and cold

weather• Accompanied symptoms• Relieved by rest and GTN

LEVINE SIGN

POINTING SIGN

Pericarditis

– Chest pain – Pericardial rub– ECG changes (wide spread ST elevation with PR

depression)

Pericarditis: ECG:

PE: Diagnosis

Pneumothorax: Diagnosis

• Sharp chest pain• CXR: Look for

pleural line• Can be difficult in

patients with COPD

Esophageal rupture: Boerhaave syndrome

• CXR: early shows mediastinal or free peritoneal air–Hours to days

later: widening of mediastinum, pleural effusion

MUSCULO-SKELETAL PAIN

• Diagnosis of exclusion• Consider in young low risk group• Usually a triggering factor• Tenderness on chest wall palpation• Pain should be re-producible• Analgesics relieve pain

IS IT ‘HEART BURN’ OR MY HEART DOCTOR ??

ANGINA vs DYSPEPSIA

• Sometimes difficult to differentiate• Both cause central chest pain with similar

accompanied symptoms• Nitrate will relieve both pain• Ground rule : Exclude angina first

ANGINA• Dull• On exertion• Gets better with rest• Radiation to arm and jaw• SOB

DYSPEPSIA• Burning• Worst with meals• Gets better with antacids/

burping• Radiation to back Epigastric involvement No SOB

MALPRACTICE CLAIMS

All patients of chest should be considered high risk unless proven otherwise.

Improper evaluation and inadequate

management of such cases are frequent sources of malpractice claims

TO DISCHARGE OR NOT TO DISCHARGE ? THATS THE QUESTION

• The decision to discharge a patient who presents with chest pain as the primary complaint should be made only after careful consideration of potential consequences.

• Evaluation and decision (with reasoning) must be well documented.

Cost Analysis

• Legal costs due to malpractice claims when patient is discharged mistakenly can be immense. In addition this leads to psychological stress to treating physician as well as patient /relatives

• On the other hand unnecessary admissions and tests are a heavy burden to available resources and should be avoided.

• Patients’ subjective complaints can distort the history and obscure the actual diagnosis.

• The risk of error in emergency departments is increased by the constraints of time, limited resources, and difficulty obtaining timely consultation and referral.

Missed MIs• 8-10% MIs mistakenly discharged from ER

• Published studies of post mortem evaluation and routine annual EKG show a high rate of missed MIs—more than 25 percent and as high as 40 percent.

• Short term mortality due to MI 12% when admitted 25% when not admitted

But it is not MI. Why should I admit the patient?

• If it is not MI, remember that there are other reasons to consider admitting patients who have chest pain.

• One must have a clear cut alternative diagnosis which is of benign nature, before considering discharging the patient.

• Remember that diabetics and elderly patients are prone to silent ischemia with minimal symptoms. May not complain of chest pain.

• However, changes in clinical condition—including dizziness, confusion, pulmonary edema do provide some clue.

• Patients with Chest Pain Are at Risk—Use Both Liberal Consultation and Liberal Admission Policies

• It is better to sound foolish than be unsafe

Are you a safe physician? Review of your medical record should

demonstrate that• high-risk conditions were considered and

effectively ruled out, • that you made an orderly, intelligent

evaluation of the patient, • and that the appropriate treatment and

disposition were accomplished, given the risks.

Practical application:

When called by nursing to evaluate patient with chest pain

• Ask for vitals over phone, stability of the patient and brief details

• ECG• Go to see the patient• Make a diagnosis with open mind and lateral

thinking

Practical application

• ECG: compare to old, repeat frequently• Other imaging studies as indicated by

presentation: CXR, stat TTE etc.• Biomarkers • KEY: Commit to a diagnosis. At the back of

your mind think of alternative • Begin initial therapy• Call for help at any point you are not

comfortable

How safety can be improved?

• Proper triage of patients with chest pain• Chest pain units and clinics• Good history taking skills• Protocols and Algorithms• Use of sensitive biomarkers

Conclusions:

• Chest pain is one of the most frequently encountered complaints in both the inpatient and outpatient settings and is a significant financial burden on our health care system

• Clinicians must be able to rapidly and accurately assess a patient with chest pain to maximize patient outcomes and minimize unnecessary workup

• The evaluation of chest pain requires good history and physical exam skills, ECG, CXR and few other diagnostic tests