Download Cutting Edge Care for Patients with Acute Coronary Syndromes

Chest Pain and Shortness of Breath:
Pattern Recognition and Treatment of
Potential Emergencies
James Hoekstra, MD, FACEP
Wake Forest University
Atraumatic Chest Pain: Differential Dx
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Acute Coronary Syndrome (STEMI, UA, NSTEMI)
Pulmonary Embolus
Thoracic Aortic Dissection
Borehaave’s Syndrome
Pneumothorax
Pneumonia/Bronchitis
Musculoskeletal CP/Costochondritis
Pleurisy
GERD
Cancer
Classic History and Physical Patterns
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Quality of Pain
Location
Radiation
Duration/Chronology
Exacerbating/Alleviating Factors
Associated Symptoms
Risk Factors
Case #1
• 56 yo male presents with midline chest tightness for one
hour, constant.
• Radiates to jaw, left arm
• SOB, diaphoresis, nausea
• Intermittent, exertional in past
• Hx of HTN, Cholesterol, FH AMI
• BP 150/90, P 100, exam normal, nontender
• ECG with NSST changes
Acute Coronary Syndromes
STEMI
UA/NonSTEMI
Presumed ACS
Initial Risk Stratification Scheme
Chest Pain
History, Physical
EKG
STEMI
UA/NSTEMI/
High Risk
Mod Risk
Low Risk
Definite
Non-Cardiac
ED Risk Stratification Tools
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Clinical History
Initial ECG
Continuous or Serial ECG
Serum Markers of AMI
Provocative Testing/Imaging
Serum Markers
• Myoglobin: Early peak in serum after MI, nonspecific,
good negative predictive value for MI.
• CKMB: Gold standard for many years. False elevation
in muscle damage, renal failure. Must take relative index
into account. Good risk stratifier
• TnI, TnT: Peaks at same time as CKMB, prolonged
elevation in serum after MI, more sensitive and specific
for MI than CKMB, but low levels (<1.0) can still be
false positives. Best predictor of increased risk for bad
outcomes
TIMI Risk Score For ACS
TIMI > 4 is high risk
Antman et al JAMA 2000;284: 835
Download  www.timi.org
Non STE ACS Features
 High Risk Features
 Accelerated pattern of angina
 Ongoing rest pain > 20 min
 Signs of CHF
 Hemodynamic instability
 Arrhythmias - Atrial or ventricular
 Advanced age (> 75 years)
 Ischemic ECG changes
 Elevated cardiac markers
ACS Risk Stratification Levels
• Level 1: STEMI: ST segment elevation MI
• Level 2: NSTE ACS: ST depression, positive
markers (objective findings)
• Level 3: Moderate Risk: No ECG or marker
changes but high risk of UA by history, risk
factors, known CAD, high TIMI risk
• Level 4: Low: No ECG or marker changes and
possibility of UA (atypical story, low TIMI risk)
• Level 5: Noncardiac Pain
Class I ED Treatment of STEMI
(ST Elevation, BBB, Pain<12 Hours)
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Targeted ED Protocol, Door to Needle <30 minutes
O2, IV, monitor
ASA immediately
Nitrates, beta blockers
Heparin weight based dosing (max 4000/1000)
Clopidogrel 300 mg
Thrombolytics in less than 30 minutes or PCI less than
90 minutes
• PCI should be utilized with IIb/IIIa therapy
• Treatment of Complications
Thrombolytic Therapy Inclusions
• Symptoms >30 minutes<12 hours
• ECG ST elevation >2mm in 2 contiguous
precordial leads or >1mm in 2 contiguous limb
leads, or ST depression >2mm in precordial leads
with reciprocal ST elevation in II, AVF, V6
• New BBB
• Patient Consent
Thrombolytic Therapy Exclusions
• Active Bleeding
• Altered Mental Status
• Major CNS Surgery <6
weeks PTA
• CVA <2 yrs PTA
• Bleeding Diathesis
• SBP >180, DBP >110
• CNS AVM, Aneurysm,
Tumor
• AAA
• Hemorrhagic Pancreatitis
Thrombolytic Therapy Relative
Contraindications
• Recent Surgery or Trauma
<2 wks
• Pericarditis
• Coumadin Use
• Liver Disease
• Presumed SBE
• Diabetic Retinopathy
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Cardiogenic Shock
Peptic Ulcer Disease
Recent GI/GU bleed
Pregnancy
Thrombophlebitis
Facilitated PCI
• Primary angioplasty or stent placement is the gold
standard treatment of STEMI in cath lab centers.
• ASA, NTG, Heparin weight based dosing
• Abciximab either prior to or at the same time as
PCI decreases reocclusion and has some
fibrinolytic effects equal to streptokinase.
• Benefits of cath over thrombolytics lost if time
from door to cath lab greater than 90 minutes.
WFU Treatment of STEMI
(ST Elevation, BBB, Pain<12 Hours)
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IV, O2, Monitor
ASA 325 mg po
Nitrates, beta blockers, MS as indicated
Clopidogrel 600 mg po
Heparin 40 U/kg IVP (max 4000), 7 U/kg/hr infusion
Abciximab 0.25 mg IVP, 0.125 mcg/kg/min (max 10
mcg/min) infusion prior to PCI started in the ED
• Call Cardiology for PCI FAST
ED Treatment of NSTE ACS
(ST Depression, Transient ST elevation, or +Markers)
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O2, IV, monitor
ASA immediately
Nitrates/BB/Pain relief
Clopidogrel 600 mg po
LMWH (better than heparin)
PCI in high risk, continued symptoms
IIb/IIIa therapy, initiated in the ED
Dosing
• ASA 325 mg PO on arrival
• Clopidogrel 300 mg po
and
• Enoxaparin 1mg/kg Subq q 12 hr
or Heparin 60 U/kg IVP, 12 U/kg/hr infusion
and
• Eptifibatide 180 mcg/kg IVP, 2 mcg/kg/min infusion
(preferred) or
Tirofiban 0.4mcg/kg/min for 30 min, then 0.1mcg/kg/min
infusion or
Abciximab 0.25 mg/kg IVP, 10mcg/min infusion (only if
going to cath immediately, heparin reduced to 7
U/kg/hour)
ED Treatment of Moderate Risk CP
(High or Moderate Risk UA, Nonspecific ECG and -Markers)
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O2, IV, monitor
ASA immediately
Nitrates/BB/Pain relief
Enoxaparin Subq
Clopidogrel 300 mg
Admit to Telemetry Bed
Serial enzymes
Protocol driven care
Angiogram versus provocative testing prior to discharge
Any positive enzymes or ECG leads to Level 2 Treatment
ED Treatment of Low Risk CP: Day
Hospital Chest Pain Evaluation
Intermediate Risk Chest Pain Resolved, Neg ECG, Neg Enzymes
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ECG, CK, CKMB, TnI on arrival
Day Hospital Admission
Serial ECGs as indicated
CK, CKMB, TnI at 0,4, and 8 hours
Stress Thallium or Dobutamine Echo
Admit if positive stress, enzymes, or ECG changes
D/C if negative
CPC Flow Summary
Non ST-elevation patients suspicious for ACS
Risk Stratification
Negative (Low/Moderate Risk)
• History and age
• ECG/ECG criteria
• Serum markers
Chest Pain Center
Positive
(High Risk)
• Serial markers
• Serial ECGs
• ST-trend monitoring
Negative
• GXT
• Radionuclide
• Stress Echo
Positive
Admit
Positive
Treat
Accordingly
Negative
Discharge
Case #2
• 44 year old female presents with sharp, left sided chest
pain, no radiation
• Acute onset
• Pleuritic
• Short of breath, apprehensive, cough, no sputum
• Recent surgery on left knee
• Family history of DVT
• BP 110/60, P 115, Pulse Ox 98%
• Normal exam, not reproduceable
Pulmonary Embolism:
DVT and PE
VTE/PE Risk Stratification:
Patient Factors: Clinical
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Previous VTE
Malignancy
Age > 70
Obesity
Prolonged bed rest
Severe medical illness
Pregnancy / postpartum
*“Economy class syndrome”
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Stroke
Myocardial infarction
Varicose veins
Oral contraceptives
Antipsychotic drugs?
Travel*
VTE/PE Risk Stratification:
Patient Factors: Molecular
Inherited
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Antithrombin III deficiency
Protein C deficiency
Protein S deficiency
Heparin cofactor 2 deficiency
Activated protein C resistance
Prothrombin G20210A mutation
Hyperhomocysteinemia
Elevated factor XI levels
Elevated Factor VIII levels
Acquired
• Myeloproliferative disease
• Hyperhomocysteinemia
• Antiphospholipid antibodies
– lupus anticoagulant
– Anticardiolipin Abs
Pulmonary Embolism:
*†
Patient History
• Dyspnea
73%
• Palpitations
• Pleuritic CP 66%
• Syncope
• Cough
37%
• Wheezing
• Leg swelling 28%
• “Anginal” CP
• Leg pain
26%
• Sudden death
• Hemoptysis 13%
*PIOPED (JAMA 1990;263:2753-9)
10%
<10%
9%
4%
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†No previous cardiopulmonary disease
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Pulmonary Embolism:
Physical Examination*†
• Fever
Tachycardia
70%
• Wheezing
Tachypnea
30%
• RV lift
Crackles
51%
• Homans’
Loud P2
23%
• Pleural rub
Diaphoresis
11%
• Cyanosis
Hypotension
8%
* From PIOPED (JAMA 1990;263:2753-9)
7%
5%
4%
4%
3%
1%
†No previous cardiopulmonary disease
Suspected PE: A Simple Clinical Model and Ddimer to Assess Pretest Probability
(n=946 patients)
Specific Factors
Points
Clinical DVT (objective swelling, tenderness)
3.0
Heart rate > 100 beats/ min
1.5
Immobilization > 3 days or surgery in previous 4 wks
1.5
Previous DVT/PE
1.5
Hemoptysis
1.0
Malignancy
1.0
PE as likely, or more likely than alternative dx
3.0
Pretest probability of PE:
Low:
<2.0
Moderate: between 2.0 and 6.0
High:
>6.0
Wells PS et al. Ann Intern Med 2001;135:98-107.
D-dimer
Pulmonary Embolism:
Laboratory Tests
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ELISA D-dimer very sensitive for DVT/ PE
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ELISA most sensitive (latex agglutination not sensitive)
Very nonspecific! (Commonly positive in other
settings!)
Newer D-dimer tests are more rapid bedside assays
Most useful if negative and pretest probability is low
Ahearn GS, Bounameaux H. Sem Respir Crit Care Med 2000;21:521-36.
Tapson VF et al. Am J Respir Crit Care Med 1999;160:1043-66.
Pulmonary Embolism:
Laboratory Tests
Arterial blood gas
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pO2 usually abnormal (low)
pCO2 usually abnormal (low)
Alveolar-arterial oxygen difference nearly
always abnormal*
*May be normal, particularly in young patients
150-1.25(pCO2)-pO2=A-a gradient on room air
Pulmonary Embolus Workup
Low Risk
Intermediate Risk
D Dimer
D/C
High Risk
Helical CT
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Dopplers
D/C
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Admit
Helical CT
Admit
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for
Admit
Angio
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Admit
Pulmonary Embolus Rx
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IV, O2, Monitor
Ventilatory and Oxygenation Support
IV Fluids
Heparin or Enoxaparin
Thrombolytics if low BP, Poor Oxygenation
Case #3
• 75 year old female presents with SOB of two days
duration
• Tightness, DOE, Orthopnea, PND, leg swelling
• Hx of HTN, MI, CAD
• BP 210/110, P 60, R 24
• Rales in bases, JVD, ankle edema
Heart Failure Pathophysiology
Myocardial injury
Fall in LV performance
Activation of RAAS, ET,
and others
ANP
BNP
Peripheral vasoconstriction
Hemodynamic alterations
Myocardial toxicity
Morbidity and mortality
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Remodeling and
progressive
worsening of
LV function
Heart failure symptoms
Causes of CHF
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CAD
HTN
Valvular Disease (aortic and mitral)
Cardiomyopathy (Etoh, amyloid, idiopathic, etc)
High Output:
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Thyrotoxicosis
Anemia
AV Fistula
Beri Beri, Pagets
Causes of Acute CHF Exacerbation
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AMI/Ischemia
Arrhythmias (afib)
Accelerated HTN
Acute Valve Decompensation
Big PE (right sided failure, shock)
Heart Failure Signs and Symptoms
Symptoms Include:
 Dyspnea
Shortness of breath
 Fatigue
Feeling of tiredness
 Peripheral Edema
Swelling of legs and ankles
 Orthopnea
Pulmonary congestion
 Weight gain
Due to fluid retention
 Rales
Abnormal lung sounds
Right versus Left Heart Failure
• Left Heart Failure
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SOB
DOE
Orthopnea
Rales
S3
Wheezes
Tachycardia
Fatigue
• Right Heart Failure
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Peripheral Edema
Abdominal Swelling
JVD
Liver Enz Elevation
HJR
– Most common cause is left heart
failure, but COPD is common as
well
CHF Lab and Xray Findings
• CXR: Vascular congestion, cardiomegaly, butterfly
infiltrates, Kirley B lines, effusion
• ABG or Pulse Ox: Hypoxia
• ECG: LVH and strain patterns, nonspecific
• Enzymes: Rule out AMI as a cause
• Cardiac Output: Swan CO or CI, bioimpedance, etc. not
practical in the ED.
• BNP Levels: Elevated with atrial wall stretch >100
• Echocardiogram: Low EF, Valves
Therapy of CHF in the ED
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Airway Control
IV, O2, Monitor
Sitting Posture
Oxygenation Adjuncts: BiPAP, CPAP
Nitrates and Afterload Reducers
Diuretics
Continuous Monitoring of Urine Output, Hemodynamics
It’s Not That Simple
Current Treatment of Acute Heart Failure
Diuretics
Vasodilators
Reduce
fluid
volume
Decrease
Preload
And
Afterload
Inotropes
Augment
Contractility
Case #4
• 76 yo male presents with acute, severe chest pain
of 15 minutes duration
• Midsternal, radiates to back, pleuritic
• Sweaty, vomiting, writhing, SOB
• Hx HTN, PVOD
• BP 220/140, P 110, R 24
• Normal Exam
Thoracic Aortic Dissection
Aortic Dissection: Clinical History
• Risk Factors: HTN, collagen synthesis defects,
pregnancy, aortic stenosis, advanced age
• History: Severe, intermittent chest pain, tearing
in nature, radiation to back, migratory
• May be signs of peripheral embolus, inequality of
pulses, stroke signs, or pulses lost
• Usually hypertensive, but my be hypotensive if
volume loss in chest or mediastinum
Aortic Dissection: Lab and Xray
• Chest Xray: Nonspecific. May have tortuous
aorta, medistinal widening, pleural effusion,
dilated aorta, separation of calcifcations from wall
• ECG: nonspecific
• Chest CT: Best screening test, unlikely if
negative
• Aortography or TEE: More specific, but less
readily avalable
Aortic Dissection: Treatment
• ABC, IV (X2) O2, Monitor
• Blood Pressure Control:
– Nipride
– Beta Blockers
• Consulation with CT Surgery
• Surgery if Proximal, Medical if Distal
Case #4
• 44 yo alcoholic presents with acute onset of
midsternal CP post vomiting
• Pleuritic, diaphorsis, SOB, radiates to neck, back
• Sweats and chills, no cough or sputum
• BP 90/60, P 130, T 101
• No pain with palpation, clear lungs
• Palpable sub q crepitance in left neck
Esophageal Perforation
• Acute onset pleuritic CP post vomiting
• Fever, SOB, hemodynamic instability, sub q or
mediastinal gas
• EtOH, forced vomiting, instrumentation
• Dx CXR, CT Chest,gGastrografin swallow, EGD
• Rx: Abx, fluids, prepare for surgery
Case #5
• 32 year old male with acute onset left sided CP,
SOB
• Four hours duration nonrelenting
• Pleuritic, nonradiating, left sided
• Hx HIV, AIDS
• BP 110/60, P 110, R 28
• No breath sounds on left
Spontaneous Pneumothorax
• Acute, one sided pleuritic CP
• Decreased BS, hypoxia, SOB
• Watch for tension pneumo, but rare in
spontaneous
• Repeat offenders, COPD, asthma, HIV, IVDA,
instrumented
• Dx CXR
• Rx Observation, aspiration, chest tube, surgery
Case #6
• 24 year old female presents with burning, central
chest pain of three days duration
• Worse with cough, deep breath
• Cough, fever, sputum, URI sx
• BP 110/60, P 130, R 24, T 101
• Rales and wheezed on chest exam
Pneumonia/Bronchitis
• Cough, Fever, Sputum, and chest pain with cough
• Pathogens vary with age, comorbidities, and
season
• Dx: Clinical, CXR
• Rx: Antibiotics if pneumonia, NSAIDS, cough
suppressants, albuterol
Case #7
• 30 year old male with chest pain for one week
duration.
• Anterior, left parasternal, sharp, worse with
movement, deep breath
• No SOB, no associated Sx
• History of recent URI, resolved
• Exam normal, but chest wall tender
Musculoskeletal Chest
Pain/Costochondritis
• Gradual onset, localized, worse with movement,
deep breath, palpation
• No SOB, no lung sx, no assoc sx
• Tender to exam
• Hx of trauma, stress or strain
• Workup: CXR and ECG unless young
• Rx NSAIDs, pain meds
Case #8
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44 year old male with burning substernal CP
Present for weeks
Exacerbated by foods, hot drinks, lying flat
Worse in AM
Hx of smoking, EtOH
Exam normal, but some epigastric tenderness
GERD
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Acid irritation/ulceration of esophagus
Burning midsternal pain, worse with GI utilization
Better with GI cocktail (beware of indescriminate use)
Often Dx of exclusion
Workup: CXR and ECG unless young
Rx: Reflux precautions, H2 blockers, proton pump
inhibitors
Shortness of Breath
• Often overlaps with chest pain diagnoses
• Impairment of Oxygenation or Ventilation
• Stimulation of Respiratory Drive
– O2
– CO2
– Pain
• Apprehension/Psychogenic
Shortness of Breath DDx
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Asthma/COPD/Emphysema
CHF
PE
ARDS
Pneumonia/Bronchitis
Restrictive Diseases (CA, Effusion, Collapse)
Anxiety/Hyperventilation/Psychogenic
Upper airway obstructions (croup, angioedema, CA)