Download APPROACH TO CHEST PAIN

APPROACH TO CHEST PAIN
MOHAMMAD GARAKYARAGHI
ASSOCIATE PROFESSOR OF CARDIOLOGY
ISFAHAN UNIVERSITY OF MEDICAL SCIENCES
Chest Pain
Visceral Pain
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Visceral fibers enter the spinal cord at several levels leading
to poorly localized, poorly characterized pain. (discomfort,
heaviness, dull, aching)
Heart, blood vessels, esophagus and visceral pleura are
innervated by visceral fibers
Because of dorsal fibers can overlap three levels above or
below, disease of thoracic origin can produce pain
anywhere from the jaw to the epigastrum
Chest Pain
Parietal Pain
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Parietal pain, in contrast to visceral pain, is
described as sharp and can be localized to the
dermatome superficial to the site of the painful
stimulus.
The dermis and parietal pleura are innervated
by parietal fibers.
As a general rule any chest
pain is ischemic in origin
until proven otherwise!
Chest Pain
Initial Approach
ABC’s first, always look for conditions requiring
immediate intervention
Aspirin for potential ACS
EKG
Cardiac and vital sign monitoring
Pain relief
Because of the wide differential, H+P will guide the
diagnostic workup
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Chest Pain
History
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O- onset
P-provocation /palliation
Q- quality/quantity
R- region/radiation
S- severity/scale
T- timing/time of onset
Chest Pain
History
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Change in pain pattern
Associated symptoms: DOE, SOB, diaphoresis, vomiting,
heart burn, food intolerance
PHx
Social history
FHx
Chest Pain
Physical Exam
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General Appearance and Vitals (sick vs not sick)
Chest exam
-Inspection (scars, heaves, tachypnea, work of
breathing)
-Auscultation (murmurs, rubs, gallops, breath sounds)
-Percussion (dullness)
-Palpation (tenderness, PMI)
Chest Pain
Physical Exam
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Neck: JVD, crepitence, bruits
Abdomen
Extremities: swelling, pulses, tenderness, Homan’s
Differential Diagnoses
Cardiovascular
Acute myocardial infarction, Acute coronary ischemia, Aortic dissection, Cardiac tamponade, Unstable
angina, Coronary spasm, Prinzmetal's angina, Cocaine induced, Pericarditis, Myocarditis, Valvular heart
disease, Aortic stenosis, Mitral valve prolapse, Hypertrophic cardiomyopathy
Pulmonary
Pulmonary embolus, Tension pneumothorax, Pneumothorax, Mediastinitis,
Pneumonia, Pleuritis, Tumor, Pneumomediastinum
Gastrointestinal
Esophageal rupture (Boerhaave), Esophageal tear (Mallory-Weiss), Cholecystitis, Pancreatitis,
Esophageal spasm, Esophageal reflux, Peptic ulcer, Biliary colic
Musculoskeletal
Muscle strain, Rib fracture, Arthritis, Tumor, Costochondritis, Nonspecific chest wall pain
Neurologic
Spinal root compression, Thoracic outlet, Herpes zoster, Postherpetic neuralgia
Other
Psychologic, Hyperventilation
Clinical Classification of Chest Pain
Pretest Likelihood of CAD in Symptomatic Patients
According to Age and Sex* (Combined Diamond/Forrester
and CASS Data)
*Each value represents the percent with significant CAD on
catheterization.
Implementing NICE Guidance
www.nice.org.uk
Life Threatening causes of Chest Pain
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Acute coronary syndrome
Aortic dissection
Pulmonary embolism
Tension pneumothorax
Pericardial tamponade
Mediastinitis (eg, Esophageal rupture)
Ischemic Heart Diseases
• Stable Angina Pectoris
• UA/NSTEMI
• STEMI
Acute Coronary Syndromes (ACS)
• Unstable Angina (UA)
• Non-ST Elevation Myocardial Infarction (Non-STEMI)
• ST Elevation Myocardial Infarction (STEMI)
Evaluation of Chest Pain
• Systematic approach needed!
• Description of chest pain
– Quality of the pain
– Region/location of pain
– Radiation
– Temporal elements
– Provocation
– Palliation
– Severity
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Associated symptoms
Risk factors
Physical examination
Investigations
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ECG
Chest X-ray
Blood work
Other
Cardiac Risk Factors
• Hypertension
– >140/90 or treated
• Diabetes
– More than doubles cardiac risk
• Hyperlipidemia
– LDL > 3.5 mmol/L or treated
• Tobacco use
– current or within 5 yrs, > 40 pack-years ++ significant
• Family History
– 1st degree male or female relative < 60 yrs
Algorithm for diagnosis…
(Adapted from: Diagnostic approach to chest pain in adults. UpToDate Online 19.2)
• Step 1 (Evaluate need for emergent care)
– Consider potentially life-threatening causes of chest pain
– If acute coronary syndrome suspected start emergent care
– If emergent and not ACS, start appropriate emergent care
Emergent Care Initial Steps...
• GET HELP!
• Have staff physician or more senior team member
called/paged
• Don’t forget nurses and RTs
Emergent Care Initial Steps...
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Airway, Breathing, and Circulation assessed
12-lead ECG obtained
Resuscitation equipment brought nearby
Cardiac monitor attached
Oxygen given
IV access and blood work obtained
Aspirin 160 to 325 mg given
Nitrates and morphine given (unless contraindicated)
ACS Emergent Care
• M orphine
– 2 – 4 mg IV q5-15 min
• O xygen
• N itro
– 0.4 mg SL q5min x 3
• A spirin
– 160-325 mg chewed
Algorithm for diagnosis…
(Adapted from: Diagnostic approach to chest pain in adults. UpToDate Online 19.2)
• Step 2 (Emergent care not needed) —
– If cardiac cause likely based on symptoms that are suggestive of angina and/or a history of cardiac risk factors,
proceed to Step 3
– Otherwise, proceed to Step 4
• Step 3 (Symptoms consistent with stable angina) —
– Evaluate the patient for cardiac disease and consider starting outpatient management (aspirin, beta blockers,
nitroglycerin, and education )
– If the results of the evaluation do not demonstrate cardiac disease, proceed to Step 4
• Step 4 (Evaluation for cardiac disease was negative)
– Evaluate the patient for other causes of chest pain
– gastrointestinal disease, respiratory disease, musculoskeletal disease, psychogenic disease
Important points on history…
• Worsening in the frequency, intensity, duration, and timing (eg, nocturnal pain, rest pain) of
prior anginal or anginal equivalent symptoms
• New onset symptoms of shortness of breath, nausea, sweating, extreme fatigue in a patient
with a known history of cardiovascular disease
• Onset of typical anginal symptoms in a patient without a history of cardiovascular disease
• Age greater than 70 years
• Diabetes mellitus
• Women
• Extracardiac vascular disease (PVD, PAD, CVA)
Arguments against cardiac pain…
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Pain less than 30 seconds or lasting weeks
If the pain can be localized with one finger
If the pain is immediately severe with no crescendo pattern
If the pain occurs only at rest
Investigations
• 12 Lead ECG
– Findings depend on
• Duration — hyperacute/acute versus evolving/chronic
• Size — amount of myocardium affected
• Localization
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Lateral = Leads I, AVL, V5, & V6
Inferior = Leads II, III, & AVF
Anterior = Leads V1-4
Posterior = Leads V4R, V8, V9 (need 15 lead ECG)
ECG
• Possible findings in ACS
– ST segment elevation or depression
– Q-waves
– New conduction defect
– T-wave inversion
NORMAL ECG!
T-wave inversion
Inferior myocardial infarction
(Q waves and ST elevations)
Anterior ischemia
(ST depressions in leads V2 and V3)
Points to remember for ECGs
• Initial ECG is often NOT diagnostic in patients with ACS
– In patients who ended up with an MI, initial ECG was
nondiagnostic in 45 percent and normal in 20 percent
• Don’t assume a normal ECG obtained while patient
having chest rules out ACS
Investigations
• Chest x-ray
– Usually non-diagnostic in ACS
– Helps to identify other important conditions
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Congestive heart failure
Pnuemonia
Pnuemothorax
Pleural effusion
Widened mediastinum (aortic dissection)
Normal CXR!
Left lower lobe pneumonia
Investigations
• Blood work
– Standard sets of blood work will be done in ER
– In other locations, you may have to decide
– Troponin-T (@ LHSC) and CK most important for myocardial
infarction
– Other hospitals may use Troponin-I
Cardiac Enzymes
• Cardiac Troponins
– Blood levels rise after 3-6 hours (can be negative at initial assessment!)
– Peak at 12-20 hours
• Creatine Kinase (CK)
– May rise earlier than troponin, but less specific for cardiac muscle
• ALWAYS repeat in 6-8 hours if suspicious for acute cardiac event
(ie, non-STEMI)
Chest Pain
Aortic Dissection - Pathophysiology
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Intimal tear of the aorta leads to dissection of the
layers of the aorta creating a false lumen
Aortic Dissection
• Blood violates aortic intimal
and adventitial layers
• False lumen is created
• Dissection may extend
proximally, distally, or in
both directions
Chest Pain
Aortic Dissection - Diagnosis
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Tearing chest pain radiating to the back
Risk Factors: HTN, connective tissue disease
Exam: HTN, pulse differentials, neuro deficits
Radiology: Wide mediastinum on CXR, CT angio
chest, echo
Chest Pain
Chest Pain
Aortic Dissection - Classification
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De Bakey system: Type I dissection involves both the
ascending and descending thoracic aorta. Type II
dissection is confined to the ascending aorta. Type III
dissection is confined to the descending aorta.
The Daily system classifies dissections that involve the
ascending aorta as type A, regardless of the site of the
primary intimal tear, and all other dissections as type B.
Chest Pain
Aortic Dissection - Treatment
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Patients with uncomplicated aortic dissections confined to the
descending thoracic aorta (Daily type B or De Bakey type III) are
best treated with medical therapy.
Medical Therapy: Goal to decrease the blood pressure and the
velocity of left ventricular contraction, both of which will decrease
aortic shear stress and minimize the tendency to further dissection.
Acute ascending aortic dissections (Daily type A or De Bakey type I
or type II) should be treated surgically whenever possible since these
patients are a high risk for a life-threatening complication such as
aortic regurgitation, cardiac tamponade, or myocardial infarction.
Pericarditis
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Refers to inflammation of pericardial sac
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Preceded by viral prodrome, i.e. flu-like symptoms
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Typically, patients have sharp, pleuritic chest pain relieved by
sitting up or leaning forward
Pericarditis
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Diagnostic criteria
UpToDate 2012
PERICARDITIS
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EKG on admission:
Pericarditis
Goyle 2002
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