APPROACH TO CHEST PAIN

Dr .Hanan AlBackr

18/10/1429

(18/10/2008)

APPROACH TO CHEST PAIN Objectives: • 1. Establish a differential diagnosis for chest pain

• 2. Know what clues to obtain on history to rule-in or out MI, PE, pneumothorax and pericarditis.

• 3. Identify risk factors for MI and PE

• 4. Know how to do a focused physical exam, identifying features that would distinguish between MI, PE, pneumothorax, pericarditis, tamponade, pneumonia, and aortic dissection.

• 5. Identify investigations required in diagnosing MI, PE, pneumothorax and pneumonia and how to interpret results.

• 6. Outline management strategy in MI, PE, peumothorax and pneumonia

Chest Pain

• Common presentation to A&E

• Trivial to life-threatening causes

• Key to diagnosis is history

• Negative baseline investigations DO NOT ruleout serious conditions

Life-threatening Causes ofChest Pain

• Myocardial infarct• Unstable angina• Thoracic aortic dissection• Pulmonary embolus• Tension pneumothorax• Oesophageal rupture

Other Differentials

• Costochondritis• Herpes Zoster• Musculoskeletal• Pancreatitis• Anxiety

CHEST PAIN ASSESSMENT

• History Vitally Important

• Pain -Nature• Site• Severity• Radiation• Onset• Exac/relieving factors• Associated features• Duration• Previous similar pains

CHEST PAIN ASSESSMENT

• RISK FACTORS

• Family history• Smoking• Raised BP• Raised cholesterol• Past Medical History (IHD,diabetes)

Initial Approach

• Assume the worst!• 100% Oxygen• IV access• Monitoring• ECG quickly• Done in tandem with history taking

Chest Pain Assessment

ExaminationGeneral Examination (sweaty clammy pale cyanosed, anaemic etc pulse BP)

Cardiovascular /Respiratory examination ? Failure ( crackles ,oedema, raised

JVP)Heart Sounds - rate , nature ,?quiet ? added heart

sounds, ?murmurs

CHEST PAIN INVESTIGATIONS

• 12 Lead ECG

• Cardiac Enzymes (incl Troponins)

• CXR

Investigations

• ECG most important

• 20% of patients having an MI will have a normal ECG initally

• Negative cardiac enzymes in A&E are not helpful

• CXR useful to rule out other causes

CXR Pneumothorax

Case 1

A 65 year-old male presents with a 2-hour history of central chest pain. He describes it as “though an elephant is sitting on my chest”. He gets similar symptoms when walking 2 blocks and is relieved with rest. Today’s episode began after he walked to the bathroom and was not relieved by rest.

• 1) What is the most likely diagnosis? What other clues in his history would support the diagnosis?

• 2) What is the difference between stable angina and unstable angina?

• The patient’s BP is 140/75 and his HR is 110 and regular. His JVP

is at 3 cm ASA, he has no crackles, no murmurs and no peripheral edema. His EKG is EKG #1.

• 3) How would you manage this patient?

• 4) Would your management strategy change if he presented with EKG #2?

• 5) Outline the indications and contraindications to thrombolysis

• The patient stabilizes and is admitted to the CCU. He develops chest pain again 2 days later but of a different quality. The pain is worse when he is supine and improves when he sits up.

• 6) What is a possible diagnosis? • 7) What clinical and diagnostic clues would help

confirm the diagnosis? • 8) What is the management? What should you look

out for?

APPROACH TO CHEST PAIN

• 1) Myocardial ischemia or infarction • History:

– - pressure-type of chest pain – - generally involves central to left-sided pain with

radiation to jaw or arms – - exacerbated by activity, relieved with rest – - relieved with nitro spray – - associated with nausea, diaphoresis, syncope,

shortness of breath – - enquire about cardiac risk factors: age, sex, smoking

history, diabetes, hypertension, hyperlipidemia, previous myocardial infarction and family history

Physical exam: • - Does the patient look distressed? • - ↓BP indicates cardiogenic shock • - ↓HR may indicate block or increased vagal tone, ↑HR

may indicate an ischemia-related tachyarrhythmia • - ↑JVP, pulsatile liver and peripheral edema seen in right-

sided heart failure • - oxygen desaturation, crackles, S3 seen in left-sided heart

failure • - new murmurs: mitral regurgitation murmur in papillary

muscle dysfunction • - Look for other signs of vasculopathy (carotid, abdo,

femoral bruits, peripheral pulses)

Investigations: • - EKG (should be knee-jerk reflex in chest pain

scenario!) – see section on approach to EKG • - CXR to look for signs of congestive heart failure • - Cardiac enzymes: CK (will begin to rise 6 hours after

infarct and remain elevated for 24-48 hours), troponin (will begin to rise 12 hours after infarct and remain elevated for 2 weeks). Need to follow serially if first set negative.

• - Exercise-stress test, dobutamine stress echo, myocardial perfusion scan: useful to look for inducible ischemia if unsure

• - Coronary angiography: gold-standard

Management: • Morphine for pain • Oxygen if hypoxic • Nitro spray/drip for pain • Aspirin • Lasix if in congestive heart failure • Inotropes if in cardigenic shock • Streptokinase (thrombolysis-TPA or TNK more

commonly used) • Anticoagulation • Also, think of beta-blockers (reduce heart rate and

contractility but beware of worsening of CHF). Statins and Ace-inhibitors should be added as indicated.

• Primary angioplasty may be indicated.

Case 2

A 78 year-old woman presents with sudden-onset, sharp right-sided chest pain. She has been coughing since the onset of her pain and has noted that she is dyspneic. Her pain significantly worsens with inspiration.

• 1) What diagnoses are you considering?

• 2) What clinical clues can help?

• She reports some hemoptysis and has a documented fever. Her CXR shows some changes likely consistent with atelectasis in the right lower lung field.

• 3) What is your next step?

• On further questioning you get a history of calf tenderness just prior to the onset of chest pain.

• 4) What test would you order?

• 5) What is your management strategy?

• 2) Pulmonary Embolus History: • - Sudden-onset sharp chest pain • - exacerbated by inspiratory effort • - can be associated with hemoptysis, sycope, dyspnea, calf swelling/pain

from DVT • - risk factors: immobilization, fracture of a limb, post-operative

complications, hypercoagulable states (underlying carcinoma, high-dose exogenous estrogen administration, pregnancy, inherited deficiencies of antithrombin III, activated protein C, S, lupus anticoagulant, prior history of DVT/PE [Virchow’s triad]

Physical: • - Anxious patient, sense of impending doom • - Tachycardia, tachypnea, hypoxia • - If severe, can get hypotension, syncope, and RV failure (↑JVP, RV heave

and loud/palpable P2)

Investigations: • - ↓PaO2 and ↓PaCO2 from increase in overall minute ventilation • - Increased A-a gradient • - D-dimer is sensitive but has a low specificity. Do NOT order it to rule-in a

PE! • - CXR:

– a. Frequently normal – b. Often non-specific (atelectasis, pleural effusion) – c. May see Hampton’s hump (area of infarction), Westermark’s sign (area of

oligemia/decreased vascular markings)

• - EKG: sinus tachycardia most common, S1Q3invertedT3 with large embolus (classic, but rare!), look for right-axis deviation

• - Echo: if large embolus, can see signs of right-sided compromise • - V/Q scan very sensitive but not specific • - Spiral CT with contrast show large, central emboli • - Pulmonary angiogram is gold standard but carries risk • - Consider Doppler U/S of legs

Management: • - Anticoagulation to prevent further

thrombus (heparin initially and then coumadin with therapeutic INR level of 2-3 for 6 months – length of therapy still controversial)

• - Thrombolysis if hemodynamically unstable

• - Supportive treatment with oxygen, and fluids

Case 3

A 23 year-old man with Marfanoid appearance presents to the ER with acute onset of sharp right-sided chest pain and SOB. His BP is 80/60 and he has decreased breath sounds on the right side.

• 1) What is the most likely diagnosis?

• 2) What is your next step?

• The patient is appropriately managed but continues to be hypotensive. On further questioning he remarks that his chest pain radiates to his back between his shoulder blades.

• 3) What additional diagnoses should be considered now?

• 4) What investigations would help confirm the diagnosis?

• 5) How would you manage this patient?

3) Pneumothorax History: • - can be asymptomatic or present with acute pleuritic

chest pain and dyspnea • - primary pneumothorax predominantly in healthy young

tall males • - secondary

– a. due to trauma (MVA accidents – associated with rib fractures, iatrogenic – during line placement, thoracentesis)

– b. increased alveolar pressure from asthma or barotraumas (BiPAP, ventilator-associated)

– c. rupture of bleb in COPD patients – d. necrosis of tissue in pneumonia, empyema, cancers

Physical: • - decreased expansion of chest, decreased breath

sounds and decreased tactile/vocal fremitus on side of pneumothorax

• - hyperresonant percussion note • - In tension pneumothorax, where pleural injury

produces a one-way valve, increased positive pressure can cause tracheal deviation away from the side of the pneumothorax, mediatinal shift with compression of contralateral lung, decreased venous return and CO and BP. This is an emergency.

Investigations: • - CXR: fine line of visceral pleural detached from parietal

pleura seen on ipsilateral side • - In large pneumoathoraces, mediastinal shift and

contralateral compression of lung can be seen

Management: • - watchful wait for small pneumothoraces – repeat CXR • - chest tube insertion for large, hemodynamically

unstable pneumothoraces • - In emergent situation, insert large bore needle in 2nd

ICS, midclavicular line, followed then by chest tube insertion