Download Evaluation of Chest Pain

Evaluation of Chest Pain in the
Emergency Department
Rachel Steinhart, MD, MPH
CCRMC Emergency Dept.
5-1-2008
Chest Pain in the ED

There an estimated 4.6 million annual ED
visits for “non-traumatic chest pain” by adults
≥25 in the US


27.7 visits per 1,000 persons annually
Acute Cardiac Insufficiency is estimated
to account for 11% of these non-traumatic
chest pain visits*
Burt CW. Am J Emerg Med. 1999 Oct;17(6):552-9.
Chest Pain in the ED

At SFGH, 2.5% of all visits in patients >35
were for “non-traumatic chest pain”

Of these, 37.6% were hospitalized, 45% of
whom received significant diagnoses
•
10.7% MI
•
•
•
•

22.5% UA or Stable CAD
11.2% Serious Pulmonary Etiology
0.4% Aortic Dissection
0.3% Pulmonary Embolism
Overall, approximately 16% of visits with serious etiology
(Calculated)
Kohn MA, et al. J Emerg Med. 2005;29(4):383-90.
Chest Pain in the ED
Litigation

Missed myocardial infarction represents
approximately 10% of malpractice suits filed

Missed myocardial infarction represents
approximately 30% of the dollars paid out in
malpractice claims
Emerg Med News. 2006: 28(2); 20-7
Proportion of final diagnoses in patients
presenting with CP
Family Practice. 2001;18(6):586-8
Chest Pain: HPI
 P:
pattern (temporal sequence)
 A: associated features
• SOB, N/V, diaphoresis
• Fever, cough, chills
• Neurologic symptoms
 I: initiation and improvement
 N: nature (quality)
Chest Pain: Location
Aortic dissection
Boorhave’s
Myocardial ischemia
Pulmonary embolism
Pericarditis
Myocardial ischemia
Intra-peritoneal fluid
Pericarditis
Pleurisy
Myocardial ischemia
Cervical spine
Thoracic outlet
Myocardial ischemia
CHF
Pancreatitis
Cholecystitis
Peptic disease
Pulmonary embolism
Pneumonia
Myocardial ischemia
Splenic infarction
Intraperitoneal fluid
Peptic disease
Clear cut alternative diagnosis

Patients given a clear-cut alternative noncardiac diagnosis
 At significantly lower risk of
revascularization, MI or death in the
subsequent 30 days
HOWEVER
Still with 4% event rate at 30 days
Acad Emerg Med. 2007 Mar; 14(3):210-5
Character of Chest Pain
Likelihood ratios for MI based on components of the chest pain history
Description of pain
Descriptions increasing the likelihood of MI
Radiation to R arm/shoulder
Radiation to both arms/shoulders
Exertional
Radiation to L arm
Associated with diaphoresis
Associated with nausea or vomiting
Worse than previous angina or similar
to previous MI
Described as pressure
Descriptions decreasing the likelihood of MI
Pleuritic
Positional
Sharp
Reproducible with palpation
Inframammary location
Nonexertional
LR (95%)
4.7 (1.9-12)
4.1 (2.5-6.5)
2.4 (1.5-3.8)
2.3 (1.7-3.1)
2.0 (1.9-2.2)
1.9 (1.7-2.3)
1.8 (1.6-2.0)
1.3 (1.2-1.5)
0.2 (0.1-0.3)
0.3 (0.2-0.5)
0.3 (0.2-0.5)
0.3 (0.2-0.4)
0.8 (0.7-0.9)
0.8 (0.6-0.9)
JAMA 2005; 294:2623.
Nitroglycerine in ER Chest Pain
Annals of Internal Medicine 2003
Improvement in chest pain with nitroglycerine proved:
35% Sensitive
30% Specific
Ann Intern Med. 2003;139:979-986
Canadian Journal of Emergency Medicine 2006
Improvement in chest pain with nitroglycerine proved:
72% Sensitive
37% Specific
Can J Emerg Med 2006;8(3):164-9
Chest Pain: PMH









CAD - self or family
Hypertension
Diabetes
Recent surgery, travel
Substance abuse - alcohol, cigarettes, meth/coke
DVT/PE/Aortic dissection - self or family
Lupus
Marfan’s/connective tissue dz - self or family
Medications - HAART, estrogen
Ann Rheum Dis 2000;59;321-325
N Engl J Med 2007 Apr 26;356(17):1723-35
Chest Pain: Physical Exam









Vital signs - Hypoxia? Tachycardia? Hypertension?
General appearance - Marfanoid?
Carotids and JVP, check neck for crepitus
Lungs
Cardiac exam
Thoracic cage - Trauma? Pectus excavatum?
Abdominal exam - Hepatomegaly?
Periphery - symmetric pulses? edema?
Skin - dermatomal rash?
Physical Signs
Chest Pain: Laboratory

EKG - serial
 Chest x-ray
 Blood studies
• CBC
• Cardiac enzymes
• Liver function
• Lipase
• D-Dimer
• BNP
 Imaging: Ultrasound, CT, Nuclear Study
EKG Findings in Adult Patients with Chest
Pain: Association with Ischemic Events
Interpretation
MI
UA
Other
Total
Normal
1%
4%
95%
114
Nonspecific ST-T-wave changes
3%
23%
75%
150
Abnormal but non-diagnostic of ischemia
4%
21%
75%
72
Ischemia, strain, or infarct pattern OLD
7%
48%
45%
60
Ischemia or strain not known to be old
25%
43%
32%
114
Probable MI
73%
13%
14%
86
TOTAL Number Patients
104
143
349
596
From Aufiderheide TP, Brady WJ: Electrocardiography in the patient with myocardial ischemia or
infarction. In Gilber WB, Aufderheide TP (eds): Emergency cardiac care, St Louis, 1994, Mosby:
adapted from Lee TH, Cook EF, Weisberg M, et al: Arch Intern Med 145:65, 1985
Adverse Cardiac Events
(12 mo out)
Patients discharged with chest pain of unclear origin:
Abnormal ECG
OR 9.5 (2.0 - 45.8)
Preexisting DM
OR 7.1 (1.8 - 27.2)
Preexisting CAD
OR 28.4 (3.5 - 229.0)
Ann Emerg Med. 2004 Jan;43(1):59-67
Potential Underlying Causes of ACS
Tachyarrhythmias
Severe
anemia/acute hemorrhage
Medication withdrawal
Stimulant substance abuse
Hyperthyroidism
Sepsis
Hypotension
Post-op Chest Pain and SOB

70 yo man 10 days
following CABG
 Developed acute
dyspnea and rightsided chest pain on
awakening
 Exam revealed
tachypnea,
tachycardia, and
hypoxemia
Normal
RUL pna
R pl eff
Studies in suspected PE
Initial CXR in PE virtually always NORMAL
Hampton hump – LATE & RARE
Westermark sign - RARE
EKG Evidence:
Atelectasis, small pleural effusion &
Elevated hemidiaphragm may develop
24-72 hours – focal infiltrates
Tachycardia - sinus, afib or aflutter
RV Strain
S1, Q3, T3
Poor R wave prog + TWI V1-4
D-Dimer - Only useful to rule out
PE in LOW RISK
Acute Upper Back Pain





49 yo man with long
standing hypertension
Sudden mid back and
interscapular pain
Associated with nausea
and sweats
Unrelieved by change of
position
Some radiation toward
the left chest
Wide mediastinum - Dissection
Aortic Dissection: clinical presentation
Sudden severe
Migrating pain
Tearing pain
pain
90%
31%
39% (spec. 95%)
Hypertension
Diastolic
murmur
Pulse deficits or BP differential
Focal neurologic deficits
Syncope
ECG criteria for AMI
49%
28%
31%
17%
13%
7%
Klompas et al, JAMA 2002; 287:2262-2272.
Nallamothy et al, Am J Med 2002; 113:468-471.
Aortic Dissection: etiology

Prevalence of major risk factors:
 Hypertension
50-90%
 Bicuspid AoV
9-13%
 Marfan syndrome
3-5%
Radiographic Signs of Thoracic
Aortic Dissection

Studies suggest up to 90% of patients will
have “abnormal” CXR*









Widened mediastinum (>8cm on AP film) [50-65%]
Left pleural effusion (hemothorax)
Ring Sign (displaced intimal calcification >5mm)
Blurred aortic knob
Tracheal deviation to the Right
Esophageal deviation to the Right (seen via NGT)
Left apical cap
Depressed Left mainstem bronchus
Loss of paratracheal stripe
*Hogg K. Sensitivity of a normal chest radiograph in ruling out aortic dissection.
Best Evidence Topics. 9 March 2004.
Aortic Dissection
Classification of Aortic Dissection Type
- Not all require surgical intervention
Wrestler with Chest Pain

18 yo high school
wrestler develops
right-sided chest pain
while pinning his
opponent.
Pneumothorax
Alcoholic with Chest Pain and Cough

45 yo alcoholic
man with fever,
chills and
productive cough
over two days
RUL Pneumonia
Hyperemesis with Chest Pain

26yo G1P0 at 10wks
presents with 4 days
refractory emesis and
12 hours progressive,
severe substernal
chest pain
Pneumomediastinum - Boerhaave’s
Smoker with Chest Pain

68 yo former smoker
with persistant, nonexertional, left
substernal and left
shoulder pain
Summary
 Chest
pain in the ED differs from chest pain
in primary care
 ACS
is not the only cause of potentially life
threatening chest pain
 Diagnosis
of chest pain in the ED is rarely
straight forward
 Chest
pain in the ED is a high-stakes
evaluation
Parting Words

Careful history and physical are imperative

While history or physical exam can suggest likely
alternate diagnoses, none can rule out serious etiology

Neither NTG nor GI cocktail response, nor
reproducibility on palpation are diagnostic

Post-prandial pain may be ischemic

Use caution when diagnosing “non-cardiac” chest pain
in patients with CAD or risk for CAD

Atypical may be typical of something else

Observation can be key