Download Case rounds: chest pain

Case Rounds
Laura Miles
Teams Case Rounds
February 10 2012
Case 1
Objectives

Develop a differential diagnosis for chest pain

Review the common causes of chest pain in children
and adolescents

Recognize ‘red flags’ needing further investigation

Go through cardiac causes of chest pain

16 yo old male

Admitted to emerg with crushing chest pain
History

Several months of intermittent CP

CP occurs for 5-10 minutes at a time

No relieving factors

No obvious aggravating factors

Occasionally feels lightheaded with chest pain

Several ?syncopal episodes
More History

Chest pain is worse in left anterior chest but does
radiate across both sides

Usually 8-10/10 pain

No respiratory symptoms

No association with eating

No history of trauma
Past Medical History

No major medical illnesses

Immunizations probably up to date (he thinks)

No known allergies

No regular medications
Social Hx

Smoker – ½ ppd

Hx of drug use – cocaine, ecstasy, marijuana etc.
Denies recent use

Currently living with Aunt – mom unable to care for
him
Ddx?

MSK

Respiratory

GI

Cardiac
Red Flags

Syncope

Family Hx


Need to ask specifically about sudden deaths

Include unexplained drownings, single vehicle collisions
Exercise induced
MSK

Chest wall pain accounts for over 30% of pediatric
chest pain

Can be muscular, bony or involving connective tissue

Can be traumatic or atraumatic

Costochondritis – usually related to traumatic strain

Precordial catch – short duration, unclear etiology
Respiratory

Significant proportion of children/adolescents
presenting with chest pain actually have uncontrolled
asthma

Dyspnea

Cough

Pneumothorax

Pneumonia

PE
GI

Hx of chest pain worsening after meals can be very
suspicious for reflux

Peptic ulcer disease
Psychogenic

History can be key
Cardiac

Arrhythmias



Coronary Arteries



SVT
VT
Kawasaki disease
Anomalous origin of coronary artery  compression
between aortic and pulmonary roots
Myocardial


Myocarditis
Cardiomyopathy
Cardiac continued

Aortic


Pericardial


Dissection associated with connective tissue disease
Acute pericarditis
Valvular


Severe aortic or subaortic obstruction
 Limited cardiac output during exercise
Severe mitral regurgitation
 Volume overload of the left ventricle and increased
myocardial work
Back to our patient…

Any further history you want?
Physical Exam
Ix?

Normal CBC and extended electrolytes

Troponins normal x 3

Urine tox screen positive only for cannabis
ECG

Ok, so for those of you who know the case, that
wasn’t his actual ECG…
The conclusions…

Despite some abnormal findings on his actual ECG
his chest pain was thought to be psychosomatic

Chest pain in retrospect could be brought on by stress

Chest pain would improve as he was able to calm
himself down
Case 2
Objectives

To recognize some of the more common arrhythmias
and their ECG pattern and symptoms

To develop an approach and differential diagnosis to
an uncommon arrhythmogenic presentation

16 year old male

Seen in peripheral hospital for palpitations, chest
pain and feeling generally unwell

You are called by the emerg doc at the peripheral site
who is looking for advice
What do you want to
know?
Had been playing hockey
Initially felt unwell and had to leave the ice and sit
down
Developed chest pain, some shortness of breath and
noticed his heart was ‘beating funny’
Chest pain was predominantly on the left side
Stabbing pain 8/10
Hx continued

Feeling lightheaded, worse with standing

HR 200

RR 30

BP 85/40

O2 sats 95% on room air

Looks very pale and overall unwell

Well hydrated

Pulses slightly weak

CRT 3-4 seconds peripherally

Cardiac exam: normal S1,split S2 no murmur

Quiet precordium

Respiratory exam clear

Normal abdominal exam
What should I do??

IV access and started fluid bolus

ECG – ‘looks like SVT’

Drawing up medication – but chest pain and
increased HR spontaneously stop
What’s going on?
SVT

Paroxysmal supraventricular tachycardia

Narrow complex tachycardia originating above the
ventricular tissue

Accessory pathway

Sudden onset and usually sudden cessation
Diagnosing SVT

ECG during event

Palpitation diary – teach parents or patient how to
count a HR and record HR during events

Event Recorder
SVT ECG
SVT Management

Initially – vagal maneuvers

Beta blockers

Ablation
SVT in infants…

Need to be especially careful in this population

Because infants can’t tell you about a racing heart,
they can go into heart failure if not discovered early

Teach parents how to count HR
Repeat ECG
Wolff Parkinson White

‘Preexcitation’  a portion of the ventricle is being
activated ahead of schedule

Can present with AV Reentry tachycardia

At risk for antegrade conduction

Can consider ablation in certain cases
Your patient finally
arrives…

HR 100

RR 20

BP 100/60

Sats 100 % on room air

CRT improved – 2 seconds peripherally

Looks much better than previously advertised
ECG
Ventricular Tachycardia

Incidence of ventricular ectopy  0.5% in infants up
to 18-50% in adolescents

Differential diagnosis includes SVT with aberrancy,
antidromic reciprocating tachycardia (AV reentry
with atrial to ventricular conduction)

Classified as VT once you have at least 3 ventricular
ectopic beats in a row
Ventricular Tachycardia

Most commonly seen after repair or palliation of
congenital cardiac lesions

Cardiomyopathy

Channelopathies


Long QT

Brugada syndrome
Abnormal coronary artery placement
Ventricular Tachycardia

Idiopathic – often has absent symptoms

Arrhythmogenic right ventricular dysplasia


RV dilatation

Myocardial thinning

Fatty replacement of the myocardium

Familial inheritance

Increased risk of sudden death
Cardiac tumours
Ventricular Tachycardia

Catecholamine related polymorphic VT

Occurs with emotion or stress

Often results in syncope

Can degenerate into V fib

Tx with beta blockers to prevent recurrent episodes

ICD in refractory cases
Management of VT

Unstable: synchronised cardioversion

Antiarrhythmic medication for asymptomatic/stable
patients

Amiodarone

Torsade de pointes – magnesium

Cardiology referral

Further testing – echo, MRI, stress testing
Thanks!
Any
questions?