Download Acute Chest Pain “Can I go back to sleep?”

Acute Chest Pain
“Can I go back to sleep?”
Dr. Hussam Al-Faleh
Residents Course
Outline
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Clinical presentations
Causes of chest pain
Clinical aids to diagnose Ischemic CP
summery
It’s so painful I can’t
breath!
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25yr old male with CP for 3 days
Sharp, central, worse with inspiration, and
lying down, better sitting up, No relation to
exertion
H/o URTI 7 days ago
No RF
BP 110/70, HR 100 bpm, triphasic
pericardial rub
Wide spread ST elevation, PR depression
Diagnosis: Pericarditis
The Sky is falling
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40yr old female
CP for 3 months
Can not be described, all over the chest and
both shoulders, radiates to her head,
continuous, not ↑ exertion, but exacerbated
with emotional distress
Divorced and physically abused by daughter
No RF
Normal PE and ECG
Diagnosis: Psychogenic chest pain
Nothing is wrong with me!
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63yr male
CP for last month
Central burning, non radiating
occurring only on exertion , relieved
with rest.
HTN
PE & ECG Normal
Diagnosis: Typical anginal pain
I am like no other!
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45yr male
Upper back pain for 2 weeks
Never occurs at rest or change in posture,
and provoked by effort relived with rest
H/o Premature atherosclerosis
Normal PE & ECG
Diagnosis: very suspicious for ischemic pain
Causes of Chest pains
Panjue et al JAMA 1998;280,14
Goals of CP assessment
1- Need to r/o serious causes of chest pain “
what is the chance that my patient will die
due his underlying condition”
2- Need to refer for further testing i.e EST,
V/Q scan , Angiogram etc..
3- If cause of CP is not serious how can i
help? eg. NSAIDS for MSL CP, PPI trial/GI
consult for Reflux
Risk stratification
1.
2.
3.
High risk AMI, High risk UA Lyse
or cath
NSTEMI, LBBB, High risk UA
Admit to CCU
Low risk UA, Non ischemic pain
admit to ward or see as outpatient
History
Chest Pain description:
Vital signs/ECG
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Location and radiation
Character
Onset and duration
Aggravators and relievers
Severity
Associated symptoms
Panjue et al JAMA 1998;280,14
Panjue et al JAMA 1998;280,14
Typical/Atypical CP
 Typical:
1. Substernal
2. Burning/heavy/squeezing
3. ↑ by exertion ↓ rest or NTG
If clinically angina , classify:
Risk factors
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Age : males ≥45, females ≥55
Gender
DM
Dyslipidemia
HTN
Smoking
Family history of Premature CAD: males ≤55
females ≤65
Metabolic syndrome
Physical exam
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Vitals, Vitals, Vitals
BP (measure both sides)
Pulses paradoxicus
Heart rate (tachy/bradycardia)
Respiratory rate
Fever
O2 Sat
Physical exam
CVS exam:
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JVP
Carotid bruit
Palpation of chest wall (where is the pain?)
Extra Heart sounds (S3 or 4)
Murmurs (eg, early diastolic, )
Pericardial rub
Physical exam
Chest exam:
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Trachea
Breath sounds
Abdomen:
- Tenderness
Investigations
ECG:
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NORMAL ECG DOES NOT ROLE OUT
ISCHEMIA
Serial ECG’s
Always compare to an old ECG
ST ↑ (localized vs. Wide spread)
ST ↓
T wave inversion (location and symmetry)
or peaking
ECG (cont.)
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Q waves (new)
New conduction defects (LBBB/RBBB)
Voltage/electrical
alternans/Tachycardia
PE patterns (Q1 S3 T3), RBBB,
Other investigations (PRN)
Depending on Hx/PE
 CBC
 D-dimers
 ABG’s
 CXR
Troponins I & T
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Most sensitive and specific cardiac
markers
Rise 3-12hr after onset of CP
Peak I (24hr), T (12hr-2 days)
Return to normal 5-14 days
Has both diagnostic and prognostic
values
Sample at baseline and after 6-8hr
Conclusion
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History and physical are corner stones
in diagnosis of Chest pain
Ensure that patient is stable before
taking a detailed history
Serial ECG’s and cardiac enzymes for
selected patients