chest pain 2014.ppt
TRANSCRIPT
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Approach to Chest PainIntern Bootcamp, 2014
Nathan Stehouwer, MD
PGY-4, Internal Medicine & Pediatrics
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Differential Cardiac
MI
Pericarditis
Myocarditis
Aortic Stenosis
Pulmonary
PE
PNA
Asthma/COPD
Acute Chest Syndrome Pleura
Pleuritis
Pneumothorax
Aorta
Dissection
Perforated ulcer
Chest wall
Costocondiritis/musculoskeletal
Esophagus
Esophageal Spasm
Eosinophilic Esophagitis
EsophagealRupture/Perforation
GERD Mediastinitis
RUQ pathology
Panic attack
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Pearl: ALWAYS have the patientpoint to the pain!
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Typical vs. Atypical Chest Pain
Typical
Characterized asdiscomfort/pressure rather than
pain Time duration >2 mins
Provoked by activity/exercise
Radiation (i.e. arms, jaw)
Does not change withrespiration/position
Associated withdiaphoresis/nausea
Relieved by rest/nitroglycerin
Atypical
Pain that can be localized withone finger
Constant pain lasting for days Fleeting pains lasting for a few
seconds
Pain reproduced bymovement/palpation
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Typical vs. Atypical Chest Pain
UpToDate 2012
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Typical vs. Atypical Chest Pain
Cayley 2005
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Case 1
You are the orphan intern on Wearn team at 6PM. Youare called by the nurse because Ms. Z has developedchest pain. Ms. Z is a 62 yo F with PMHx of CAD s/premote PCI to the LAD, COPD and right THA 3 weeksago who was admitted for a COPD exacerbation.
What would you do next?
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Evaluation of Chest Pain
Case 1:
Ask nurse for most current set of vital signs
Ask nurse to get an EKG
Obtain the admission EKG from the paper chart
Go see the patient!
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Evaluation of Chest Pain
Once at bedside, determine if patient is stable or unstable
Perform focused history and physical exam
Read and interpret the EKG. Compare EKG to old EKG ifavailable
If patient looks unstable or has concerning EKG findings, callyour senior resident for help
Write a clinical event note!
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Evaluation of Chest Pain
focused physical exam for chest painVital Signs: tachycardia, hypertension/hypotension or hypoxia
General: Sick appearing, actively having chest pain
HEENT: JVD, carotid bruits Chest: Rales, wheezes or decreased breath sounds
CVS: New murmurs, reproducible chest pain, s3 gallop
Abd: Abdominal tenderness, pulsatile mass
Ext: Edema, peripheral pulses
Skin: Rash on chest wall
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Case 1
You go see the patient. She had been feeling better after gettingduonebs, but suddenly developed chest pain that is L-sided, 8/10and worse with breathing. This pain is not like her prior MI.
Vital signs: Afebrile, HR 120, BP 110/70, RR 28, O2 sat 89% on 2L(was 95% on RA this morning)
Physical exam
Gen in distress, using accessory muscles of respiration
Lungs CTAB, no rales/wheezes
Heart tachycardic, nl s1, loud s2, no mumurs
Abd soft, NT/ND, active BS
Ext b/l LEs warm and well perfused
Labs:
CBC wnl, RFP wnl, BNP = 520, D-dimer = positive, Troponin = 0.12
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Case 1
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Case 1
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Modified Wells Criteria
Clinical symptoms of DVT (3 points)
Other diagnoses less likely than PE (1 point)
Heart Rate >100 (1.5 points)
Immobilization >/= 3 days or surgery within 4 weeks (1.5 points)
Previous DVT/PE (1.5 points)
Hemoptysis (1 point)
Malignancy (1 point)
Interpretation:
>6: high
2-6: moderate
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Next moves
DDIMER: 95% sensitive, VERY nonspecific
ABGElevated A-a gradient fairly sensitive, highly
nonspecific
EKGmost commonly nonspecific changes (ST/T wave
changes, etc)
V/Q scanhelpful in patients with HIGH or LOW pretest
probabilities in whom a CTPE cannot be obtained (eg CKD)
LE Ultrasound: not sensitive
CTPE Sensitivity 83%
Specificity 96%
Moderate - high clinical probability and positive CTPE: 92-96%
chance of PE
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Case 1
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Diagnostic approach is simple if
you suspect PE
Probability low: obtain D-DIMER
If positive: obtain CTPE
If negative: PE excluded
Probability moderate or high: obtain CTPE
If positive: treat
If negative: PE excluded
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Acute Pulmonary Embolism
Stabliize patient
oxygen
Fluids if hypotensive!
Anticoagulants Preferred: LMWH or Fondaparinux
Enoxaparin 1.5mg/kg daily or 1mg/kg BID
Fondaparinux subcutaneous once daily (weight based)
Alternative: UFH (IV or SC)select high intensity protocol
Hemodynamically unstable patients
High risk of bleeding (reversible)
GFR < 30
Can initiate warfarin on same day
IVC filter an alternative in patients with mod-high bleedingrisk
Management
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Search heparin infusion orders
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Pearl: If you have a moderate
or high suspicion of PE, youcan start anticoagulation while
awaiting full diagnostic workup
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Evaluation of Chest Pain
Get report from ED physician about the patient
Ask ED physician about patients initial presentation
Ask for most recent set of vital signs
Ask about EKG and CXR results
Ask what meds have been started in ER and how patientresponded
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Evaluation of Chest Pain
Go to UH Portal and print out an oldEKG for comparison
Review prior discharge summaries
Quickly review prior cardiac work upecho, stress tests and cath reports
Go see the patient!
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Case 2
Mr. M is a 67 yo man with PMHx of HTN, DLD,DMT2 and CAD s/p PCI in 2007. He presents
with new onset chest pain x 2 hours that isretrosternal, 7/10, associated with nausea anddiaphoresis.
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Case 2
VS: T 37 HR 108 BP 105/60 RR 20 O2 sat 93%on RA
Physical exam:Gen actively having chest pain, diaphoretic
Lungs crackles at bilateral bases
Heart tachycardic, nl s1/s2, no mumurs or rub
Rest of the exam benign
Labs: CBC wnl, RFP wnl, Troponin = 0.05
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Next Steps
Review EKG
Review CXR
Troponin
SL Nitroglycerin
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Case 2
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Case 2 Diagnosis: UA/NSTEMI
EKG changes in Acute Coronary Syndromes:
ST elevations
ST depressions
T wave inversions
pseudonormalizationinversion of previously inverted T waves when
compared with old EKG
New conduction block
Q waves
Importance of serial EKG monitoring: sensitivity of singleEKG is only 50% sensitive for acute MI
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Unstable Angina/NSTEMI: Initial
Management
Stabilizeplaque
Dual antiplatelet therapy
Plavix load 600mg followed by daily 75mg
ASA 324mg chewable, then 81 daily
Anticoagulant
UF Heparin at low intensity protocol
Statin
Atorvastatin 80mg
Optimize Myocardial O2 supply/demand
Control HR -> Short acting metoprolol, can titrate quickly to HR
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Case 2 continued
You are now the nightfloat intern, and the patient is signed
out to you at 10PM. At midnight, you are called for continued
chest pain. Improved from admission but still 5/10 severity.
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Next steps
Vitals
Repeat EKG
Repeat SL nitro
Assess patient in person
Call your senior!
Dose additional morphine
start IV nitroglycerin after 3-4 doses of SL nitroglycerin Start 5 mcg/min
Increase by 5mcg/min every 20 minutes
Floor maximum: 30mcg/min
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Pearl
Inability to ELIMINATE chest pain in a patient
with ACS using maximal medical therapy
=Urgent call to cardiology for consideration of
immediate catheterization
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Trivia
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What typical ACS med should you
NOT give this patient?
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Pearl: Nitroglycerin contraindicated
in inferior MI
Other contraindications to NG:
Preload dependent states
Inferior MI
Aortic outflow obstruction (HOCM, severe AS)
Likelihood of hemodynamic instability
HR 100
SBP
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Case 3
You are called on Hellerstein to admit a 65 yo man for ACS
rule out.
Mr Q is a gentleman with a history of DMT2, NASH, remote
NSTEMI, and HTN presenting with severe retrosternal chestpain. Pain is different than prior MI but is very severe.
Radiates to neck. Began 3 hours ago; has subsided slightly
but is still 8/10 in severity.
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You take report, quickly review
chart, and go to assess the patient
in the ER. VS: T37.1, HR110, BP145/80 in R arm, RR16, Pox 98%RA
Focused Exam:
GEN: in discomfort but mentating well
HEENT mmm, JVP at clavicle
CV normal s1/s2, no murmurs
PULM ctab, no w/c/r
EXTR: cool
Bilateral BP: 145/80R, 110/60L
EKG identical to previous EKG which you printed from portal
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Thoracic aortic dissection
Hypertension
Atherosclerosis
Preexisting aneurysm (known history in 13% of patients)
Inflammatory conditions affecting aorta (Takayasu, Giant CellArteritis, RA, syphilis)
Collagen disorders (Marfan, Ehlers-Danlos)
Bicuspid aortic valve
Aortic coarctation
Turner syndrome
History of CABG, AVR, Cardiac Cath
High intensity weight lifting
Cocaine use
Trauma
Risk Factors
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Type A Type B
Thoracic aortic dissection
Surgery!
Do not delay surgery, evenfor LHC
Beta blockers, titrate to HR
50-60 (labetalol, esmolol)
BP control (nitroprusside)
Beta blockers, titrate to HR50-60 (labetalol, esmolol)
BP controladdnitroprusside or similar agentto SBP goal 100-120mmHg
Surgery for those with endorgan damage or those whodo not respond to medicaltherapy
Watch for hypotensiongivefluids if needed, considertamponade, MI, or rupture ascomplications if hypotensive
Management
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Case 4
You are on long call on VA Blue. You are calledto admit a 53 yo M from the ED for chest painand EKG abnormalities
PMHx: HTN Dyslipidemia
You go see the patient and he tells you that
he has had this chest pain for ~2 days, butit has progressively gotten worse. Hischest pain is worse with breathing. Henotes a recent viral URI.
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Case 4
VS: T 37.9 HR 104 BP 140/76 RR 20 O2 sat 95% on RA
Physical exam:
Gen in mild distress due to chest pain, leaning forward while inbed
Lungs CTAB
Chest wall no visible rash, chest wall NT to palpation
Heart tachycardic, nl s1/s2, no rub
Rest of physical exam benign
Labs: WBC = 14, RFP wnl, AMI panel x 1 = negative
CXR = negative
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Case 4
EKG on admission:
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Case 4 - Pericarditis
Refers to inflammation of pericardial sac
Idiopathic pericarditis typically preceded byviral prodrome, i.e. flu-like symptoms
Typically, patients have sharp, pleuriticchest pain relieved by sitting up or leaningforward
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Goyle 2002
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Case 4Pericarditis
Per 2003 ACC guidelines, all patients diagnosed with
pericarditis should receive echocardiogram
High risk features:
Fever (>38C [100.4F]) and leukocytosis
Evidence suggesting cardiac tamponade
A large pericardial effusion (ie, an echo-free space of more than
20 mm)
Immunosuppressed state
A history of therapy with vitamin K antagonists (eg warfarin)Acute trauma
Failure to respond within seven days to NSAID therapy
Elevated cardiac troponin, which suggests myopericarditis
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Case 4 - Pericarditis
Treatment
UpToDate 2012
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Case 5
This is a 45 yro M with PMHx of rheumatoid arthritis whopresented with progressive sob. He was found to have a R-sided pleural effusion and underwent an US guided
thoracentesis with removal of 1.5 liters of pleural fluid. Twohours after his procedure, he develops new onset R-sidedchest pain
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Case 5
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Case 5 - Pneumothorax
Management of Pneumothorax
100% O2and observation in stable patients for PTX < 3 cm insize
Needle aspiration in stable patients for PTX >3 cm
Chest tube placement if PTX >3 cm and if needle aspiration fails
Chest tube placement in unstable patients
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Pearl
Great EKG Practice Site:http://ecg.bidmc.harvard.edu/maven/mavenmain.asp
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References
Kearon C, Akl EA, Comerota AJ, Prandoni P, Bounameaux H, Goldhaber SZ, Nelson ME, Wells PS, Gould MK, Dentali F, Crowther M,Kahn SR. Antithrombotic therapy for VTE disease: antithrombotic therapy and prevention of thrombosis, 9th ed: American College ofChest Physicians evidence-based clinical practice guidelines. Chest. 2012 Feb;141(2 Suppl):e419S-94S.Cayley, W.E. Diagnosing thecause of chest pain. (2005).American Family Physician, Vol 72 (10), 2012-21.
Anderson JL et al. 2012 ACCF/AHA Focuse Update of the Guideline for Management of Patients with Unstable Angina/NSTEMI. JACC60 (7) 2012.
Thrumurthy SG et al. The diagnosis and management of aortic dissection. BMJ 344, 2012.
Imazio M, Demichelis B, Parrini I, Giuggia M, Cecchi E, Gaschino G, Demarie D, Ghisio A, Trinchero R. Day-hospital treatment ofacute pericarditis: a management program for outpatient therapy. J Am Coll Cardiol. 2004;43(6):1042.
Goyle, K.K. and Walling, A.D. Diagnosing pericarditis. (2002).American Family Physician, Vol 66 (9), 1695-1702. Diagnostic approach to chest pain in adults. (2014). UpToDate. http://www.uptodate.com/contents/diagnostic-approach-to-chest-
pain-in-adults?source=search_result&search=chest+pain&selectedTitle=1%7E150 Differential diagnosis of chest pain in adults. (2014). UpToDate. http://www.uptodate.com/contents/differential-diagnosis-of-chest-
pain-in-adults?source=search_result&search=chest+pain&selectedTitle=3%7E150 Evaluation of chest pain in the emergency department. (2014). UpToDate. http://www.uptodate.com/contents/evaluation-of-chest-
pain-in-the-emergency-department?source=search_result&search=chest+pain&selectedTitle=5%7E150 Clinical presentation and diagnostic evaluation of acute pericarditis. (2014). UpToDate. http://www.uptodate.com/contents/clinical-
presentation-and-diagnostic-evaluation-of-acute-pericarditis?source=search_result&search=pericarditis&selectedTitle=1%7E150
Treatment of acute pericarditis. (2014). UpToDate. http://www.uptodate.com/contents/treatment-of-acute-pericarditis?source=search_result&search=pericarditis&selectedTitle=2%7E150
Thanks to Sumit Bose for use of a number of his excellent slides!
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