Download Chest Pain - UNC School of Medicine

Chest Pain and
Shortness of Breath
Brett Sheridan, M.D., F.A.C.S
Assistant Professor
Cardiothoracic Surgery
Department of Surgery
Causes of Chest Pain and SOB
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Myocardial Infarction
Pulmonary Embolism
Pneumothorax
Hemopneumothorax
Thoracic Aortic Dissection
Esophageal Rupture
Gastro-esophageal Reflux
Empyema
47 y/o man is jogging with his daughter when he
suddenly collapses unconscious……
Most common causes of death in the US…
1) Heart Disease
2) Cancer
3) Stroke
How many people in the US died from
cardiovascular disease in 2001?
Do more men or women die from
cardiovascular disease?
Acute coronary syndrome (ACS) is defined by
EITHER acute myocardial infarction OR
unstable angina.
These patients are divided into 3 subsets:
ST elevation myocardial infarction
non-ST elevation MI
Unstable angina
(STEMI)
Describe the initial stabilizing treatment for symptomatic
ischemic heart disease presenting in the ER
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ECG within 10 minutes
Supplemental O2
IV access continuous ECG monitoring
Sublingual NTG if SBP > 90 mmHG
Morphine
ASA (chewed)
Labs
If ST elevation > 1mV or LBBB then reperfusion
(fibrinolysis or PTCA)
What is AMI management in first 24 hours?
• Limited activity 12 hrs and monitor 24 hrs
• No prophylactic antiarrythmics
• IV heparin if:
– large anterior MI,
– PTCA, LV thrombus or
– thrombolytics administered
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SQ heparin for all others
ASA indefinitely
IV NTG x 24 hrs
IV beta-blocker if stable
ACE inhibitor if BP permits
Statin therapy
Acute coronary Syndrome:
On-going myocardial ischemia despite initial Rx
Thrombolytics
Revascularization
PCI
CABG
Why are patients referred for CABG instead of
undergoing a PCI approach to coronary artery
disease?
Percutaneous coronary angioplasty
(PTCA, PCI,…)
Percutaneous coronary angioplasty (PTCA,
PCI,…)
Percutaneous coronary angioplasty (PTCA,
PCI,…)
Natural history of percutaneous coronary
angioplasty…..uh-oh!
Cite 2 prospective randomized trials comparing
PCI vs CABG for the treatment of multivessel CAD
• Inclusion Criteria
– Symptomatic
– Multivessel CAD
– LVEF > 30%
• Baseline Characteristics
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Class III/IV angina - 66%
Previous MI - 42%
3 vessel CAD - 30%
mean LVEF = 60%
Comparison of Coronary-Artery Bypass Surgery and Stenting for
the Treatment of Multivessel Disease
(Arterial Revascularization Therapies Study Group)
CABG
Patients (n)
Late outcome
Death
MI
CVA
Revascularization *
Event-free survival *
Symptom-free *
Cost *
PCI
605
600
---------------------1 year----------------2.8%
2.5%
4.0%
5.3%
2.0%
1.5%
4%
17%
88%
74%
90%
79%
$13,638
$10,665
Event –free Survival: CABG vs PCIS
14% benefit w/ CABG!
Risk of Repeat Revascularization
16 % benefit w/ CABG!
Risk of Death
3.7 % SURVIVAL benefit w/ CABG!
Conclusions-SoS Trial
• Again, repeat revascularization remains more
common after PCI (with or without a stent) in
multivessel CAD.
• In this study, higher rate of all cause mortality
with PCI
Contrast the difference between
“off-pump” CABG versus the typical
cardiopulmonary bypass supported CABG.
Traditional CABG
• General anesthetic
• Median sternotomy
• Conduit harvest (LITA,
radial, vein)
• Institution of
cardiopulmonary bypass
(CPB)
• Cardiac arrest
• Placement of aorto-coronary
grafts
• Seperation from CPB
• Close
Advantages - Traditional CABG
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Still Heart
Exposure and access
Visualization
The most intensely scrutinized procedure in
US medicine
SAFETY
Disadvantages - Traditional CABG
• Proinflammatory response to CPB
• Suggestion of end-organ injury
– CNS
– Pulmonary
– Renal
• Increased fluid shifts
Off-Pump Stabilizer
Off-Pump- Snare
Off-Pump Stabilizing Devices
Off-Pump Exposure of PDA
List 10 complications of CABG and there
relative frequency
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Death
Stroke
Bleeding requiring re-op
Wound Problems
Myocardial infarction
Arrhythmias
Pneumonia
Pneumothorax
Cardiac Tamponade
Pericardial Inflammation
Renal Insufficiency
3%
1-2%
3-5%
0.5-5%
2-30%
10-60%
4%
1-2%
3-6%
18%
15-20%
What four medications prevent MI and death
following a myocardial infarction.
“Class I” Indications
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ASA
Beta-blockers
ACE inhibitor
Statins
Risk Of Pneumothorax
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Pain
SOB ( dyspnea)
Hypoxia
Hypotension (embarrassed CO)
Death
DDX of Underlying Pulmonary Pathology
Spontaneous
• Primary
– Subpleural bleb
• Secondary
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Chronic Obstructive lung disease
Bullous disease
Cystic fibrosis
Pneumocystis-related
Idiopathic pulmonary fibrosis
Pulmonary embolism
Catamenial
Esophageal perforation
• Neonatal
Acquired
• Trauma
• Iatrogenic
Treatment options
• Observation
• Tube thoracostomy
• Surgery
• Other “dated” options
– Needle aspiration
– Chemical pleurodesis
Observation
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Asymptomatic
Pneumothorax less than 20%
ER for 4-6 hours w/ repeat CXR
F/U within 48 hours and CXR
Any doubts --admit
Tube Thoracostomy
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Primary Method of Management
Prompt re-expansion of lung
Prevents life-threatening sequelae
Allows pleural-pleural apposition –sealing
injured lung
• Tube removed once air leak resolves for 12
hours
Prognosis
• Usually resolves within 1-2 days
• 30% chance of recurrence
• Increases to 60-70% if second pneumothorax
Surgery- Indications
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Recurrent pneumothorax
Persistent air leak or incomplete expansion
Massive air leak with incomplete expansion
History of bilateral pneumothoraces
Occupational hazard or lack of access
Hemopneumothorax
Surgery-Procedure
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Video-assisted thorascopic surgery (VATS)
Resection of offending bleb
Mechanical pleurodesis
Tube thoracostomy
Chemical pleurodesis
– Tetracycline
– Talc
Treatment of Secondary Pneumothoraces
• Usually associated with significant comorbid
disease and debilitated patients
• Individualize treatment (less is more)
• AIDS and Pneumocystis carinii
• COPD
• Cystic fibrosis
Hemothorax - Etiologies
Pulmonary
Bullous emphysema
Necrotizing Infections
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PE with lung infarction
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Tuberculosis
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AV malformation
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Hereditary hemorrhagic telangiectasia
Pleural
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Neoplasm (mesothelioma)
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Endometriosis
Pulmonary Neoplasm
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Primary
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Metastatic
– Melanoma
– Trophoblastic tumors
Blood Dyscrasia
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Thrombocytopenia
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Hemophilia
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Complication of systemic anticoagulation
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Von Willebrand’s disease
Abdominal Pathology
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Pacreatic pseudocyst
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Splenic artery aneurysm
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Hemoperitoneum
Thoracic Pathology
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Ruptured thoracic aortic aneurysm
Top Causes
Trauma
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Cancer
Pulmonary embolism
Hemothorax- What to do?
• Traumatic
– Tube thoracostomy- large bore
– IF more than 1500 mL or more than 200 mL/hour
x 3 hours THEN surgical exploration
• Non-Traumatic
– Needle aspiration
– Cytology
– Tube thoracostomy if HCT > 50%
Aortic Dissection…What is it?
• A bad problem to have
• A sudden (usually) intimal tear of the aorta
creating a true lumen and a false lumen
• Consequences of this tear are variable
depending on location and progression of
the dissection
Classification-DeBakey
Histology and Structure
• Normal aorta- 3 layers
– intima
– tunic media
– adventitia
Histology and Structure
• Media- strongest
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usually 1.2 mm
most affected by dissection
elastic collagen fibers 20-30 % of aortic wall
smooth muscle cells 5 %
Microfibrils contain the glycoprotein “fibrillin.”
These act as scaffolding for deposition of
elastin to produce concentric rings of tunica
media.
more….Histology
and Structure
• Aortic dissection denotes one or more tears
b/w the the aortic lumen and a medial
cleavage plane
• May be localized to the point of “primary
tear” but often extends.
• Rarely circumferential
• Re-entry tears occur often… providing
communication b/w true and false channels.
even more….Histology and Structure
• The dissection usually splits the outer layers of the
media and weakens the external coat. The false
channel may dilate or rupture.
• The false channel eventually develops an
endothelial lining but may contain extensive
thrombus.
• Acute stage –14 days
• Subacute - 2 months
• Chronic - after 2 months
Incidence
• Annual estimated @ 2-5 cases per million
• Pathology series the prevalence ranged from
0.2 to 0.8% in Chicago and Boston
• Males > Females 2:1
• Type A - 50-55 years
• Type B - 65 years
Risk Factors
pregnancy
Marfan’s
hypertension
aortic coarctation
congenital aortic valve anomalies
Presentation- acute dissection
• Sudden severe chest pain (90%) worst at onset
not previously experienced …adjectives such
as “ripping” and “tearing”
Presentation- acute dissection
• Sudden severe chest pain (90%) worst at
onset not previously experienced
…adjectives such as “ripping” and “tearing”
• History of hypertension
• Type A- pain mid-sternal
• Type B-pain inter-scapular
• If extension… neurologic deficit, abdominal
pain, or peripheral extremity ischemia
Differential Dx- acute dissection
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Coronary ischemia/ myocardial infarction
Aortic aneurysm w/o dissection
Musculoskeletal
Pericarditis
Biliary colic
Pulmonary embolism
Physical exam- acute dissection
• Blood pressure usually elevated
• Hypotension associated w/ pericardial tamponade,
rupture, aortic insufficiency, or massive MI
• New pulse deficit- 60%
• Diastolic decrescendo murmur @ LSB- aortic
regurgitation
• Diminished left-sided breath sounds- hemothorax
• Neurologic exam
– mental status,
– focality --peripheral vs central
Diagnostic studies- acute dissection
• CXR
– deformity of Aortic knob,
– widened mediastinum,
– left pleural effusion, etc.
• EKG- chest pain w/ normal EKG sine qua non
Diagnostic studies- acute dissection
Echocardiography currently thought to be the preferred
diagnostic test –rapid and accurate. Evaluates aortic valve,
segmental wall function, pericardial effusion.
Unfortunately operator dependent.
Diagnostic studies- acute dissection
CT- expeditious w/ reasonable sensitivity and specificity
Diagnostic studies- acute dissection
MRA-excellent sensitivity and specificity but slow
Diagnostic studies- acute dissection
Aortography - lacks sensitivity as imaging requires blood flow which
may not occur in false lumen. Indication for coronary angiogram
remains controversial.
DeBakey, Surgery, 1982
Medical Treatment
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24 hrs
2 wks
5 yrs
10 yrs
Type A
72%
43%
34%
28%
Type B
100%
92%
76%
56%
Masuda, Circulation, 1991
Medical Treatment- Aortic Dissection
Masuda, Circulation, 1991
Medical vs Surgical - Type B Ao Dissection
Glower, Ann Surg, 1991
Conclusion
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Aortic dissection is a bad problem to have
High index of suspicion
Control heart rate and blood pressure URGENTLY
Type A requires immediate surgery
Type B - best served w/ medical treatment
If ischemic complications, the patient faces a grim
prognosis with (or without) surgery therefore a surgical
approach may be advocated.
Esophageal Rupture- Causes
• Iatrogenic
– Esophageal endoscopy /dilation
– Paraesophageal surgery
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Boerhaave syndrome
Trauma
Foreign Body
Caustic
Esophageal RuptureMost common sites of iatrogenic perforation
• Proximal to the upper esophageal sphincter
• Gastric cardia
• Esophageal stricture
Untreated perforation
• Medianstinitis
• Death
Nonoperative Management of
Esophageal perforation
Criteria
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Disruption contained within the mediastinum
Free drainage back into the esophagus
Minimal symptoms
Minimal signs of sepsis
Nasogastric decompression
Percutaneous drainage
IV antibiotics (oral flora)
Parenteral nutrition
Esophageal RupturePrinciples of surgical treatment
• Debridement
• Treat the underlying problem
– Cancer
– Stenosis
– Reflux
• Repair of perforation
• Drainage
Gastroesophageal Reflux Disease
• 50% of asthma patients
have objective evidence
of esophageal reflux
• Pathophysiology:
Reflux vs Reflex
• Anti-reflux surgery
improves asthma
symptoms
– 90% of children
– 70% of adults
GERD – Diagnostic evaluation
• History and Physical Exam
• Tests
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24 hour ambulatory pH Monitoring
Manometry
Barium swallow
Upper endoscopy
GERD- Complications
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Stricture
Barrett’s esophagus
Esophageal ulcer
Hemorrhage
4-20%
10-15%
2-7%
2%
GERD- Pathophysiology
• More frequent and prolonged relaxations of the
lower esophageal sphincter
• Increased exposure of esophageal mucosa to
acid, pepsin and bile salts
• Hiatal hernia ???
GERD- Goals of treatment
• Heal the injured mucosa
• Eliminate symptoms
• Prevent or treat complications of GERD
GERD – Treatment Options
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Lifestyle modifications
H2 Blockers
Proton Pump Inhibitors
Surveillance for persistent symptoms
Endoscopy
Anti-reflux surgery
Empyema
• Infection of the pleural space
• Usually a complication of a bacterial
pneumonia or lung abscess
Empyema- Common organisms
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Staphylococcus aureus (most common)
Streptococcus
Pseudomonas
Klebsiella pneumoniae
E. Coli
Proteus
Bacteroides
Empyema - Diagnosis
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History and Physical Exam
Chest radiograph
Chest CT scan
Needle aspiration
Empyema- Treatment Goals
• Resolve sepsis
• Complete expansion of lung
• Antibiotics
• Drain the space (abscess) – Chest tube
– Child vs Adult
• Decortication
– VATS
– Thoracotomy