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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 • • • • • • • • • • 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 • • • • • • • 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 • • • • • 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) • • • • • • • 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 • • • • • 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) • • • • • • 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) • • • • • • • 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) • • • • • • • • • • 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 • • • • • • • 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 • • • • • • • Previous VTE Malignancy Age > 70 Obesity Prolonged bed rest Severe medical illness Pregnancy / postpartum *“Economy class syndrome” • • • • • • Stroke Myocardial infarction Varicose veins Oral contraceptives Antipsychotic drugs? Travel* VTE/PE Risk Stratification: Patient Factors: Molecular Inherited • • • • • • • • • 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% ? †No previous cardiopulmonary disease • • • • • • 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 • • ELISA D-dimer very sensitive for DVT/ PE • • • 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 • • • 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 + Dopplers D/C + Admit Helical CT Admit + for Admit Angio + Admit Pulmonary Embolus Rx • • • • • 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 - Remodeling and progressive worsening of LV function Heart failure symptoms Causes of CHF • • • • • CAD HTN Valvular Disease (aortic and mitral) Cardiomyopathy (Etoh, amyloid, idiopathic, etc) High Output: – – – – Thyrotoxicosis Anemia AV Fistula Beri Beri, Pagets Causes of Acute CHF Exacerbation • • • • • 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 – – – – – – – – SOB DOE Orthopnea Rales S3 Wheezes Tachycardia Fatigue • Right Heart Failure – – – – – 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 • • • • • • • • 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 • • • • • • 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 • • • • • • 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 • • • • • • • • Asthma/COPD/Emphysema CHF PE ARDS Pneumonia/Bronchitis Restrictive Diseases (CA, Effusion, Collapse) Anxiety/Hyperventilation/Psychogenic Upper airway obstructions (croup, angioedema, CA)
