Chest Pain

Things you don’t want to miss (ALWAYS need to rule out either with clinical exam, imaging or labs)

  • Acute coronary spectrum
  • Aortic dissection
  • Pneumothorax
  • Pulmonary embolism
  • Esophageal rupture

Full differential diagnosis

  • Cardiac
    • IHD – from stable angina to STEMI
    • Pericarditis
    • MV prolapse
    • Aortic dissection
  • Respiratory
    • Pneumothorax
    • PE
    • Pneuumonia
    • Pleuritis
  • GI
    • Esophageal rupture (Boerhaave syndrome)
    • Esophageal spasm
    • GERD
  • MSK
    • Costochondritis (Tietze syndrome)
    • Fibromylalgia
  • Skin
    • Shingles



 

History

  • Characterize the pain  (onset, location, duration, frequency, severity, character, alleviating/aggravating factors, radiation, symptoms associated)
  • Personal history of cardiopulmonary conditions
  • IHD risk factors (smoking, DM, HTN, dyslipidemia, FHx – males <55, females <65)
  • Dissection risk factors

Physical exam

  • Cardiac/Vascular
    • Be sure to take bilateral BP if thinking dissection
    • Assess pulse
  • Pulmonary
  • Abdominal/GI

Diagnostics

  • Basic bloodwork: CBCD, lytes, BUN, Cr, Glucose
  • Cardiac enzymes (troponin), CK
  • D-dimer if low probability – if mod/high probability go straight to imaging
  • EKG – with and without pain if possible to assess dynamic changes
  • CXR – looking for pulmonary pathology as well as to assess for signs of dissection

Approach

  • ABC’s
  • Monitors
  • ASA 160 mg to chew
  • Oxygen by NP
  • Appropriate labs, EKGs, upright CXR
  • IV NS kvo
  • Consider nitroglycerine (should improve ACS and esophageal spasm pain – but monitor BP)
  • Consider morphine for pain
  • Depending on findings, may need to consult Cardiology

Ischemic heart disease

  • 1. New – stable angina
  • 2. Unstable angina
  • 3. NSTEMI
  • 4. STEMI

Risk factor for this disease include: male gender, DM, untreated HTN, smoking, dyslipidemia, obesity, females > 30 on OCP, FHx, PVD, stress

Reperfusion strategies:

  • Thrombolytics:
      • Tenecteplase (TNK) – single IV bolus
      • Reteplase (rTPA) in two IV boluses
      • Streptokinase is rarely used
    • Contraindications include: Ao dissection, pericarditis, CVA/TIA, CNS surgery in < 6 mo, any surgery in <4 weeks, severe persistent HTN, significant GI bleed in <6 mo, active bleeding, terminal illness à there is a checklist of these contraindications to complete prior to treatment
  • Angioplasty with coronary stent placement
    • Difficult to accomplish within time limitations

Aortic dissection

  • History
    • Classically a ripping/tearing/searing unbearable pain that may radiate into back (typically worse between scapula) and possibly into the neck.
    • May complain of neurologic symptoms.
    • Risk factors : atherosclerosis, uncontrolled HTN, coarctation, bicuspid aortic valve, aortic stenosis, Marfan’s, Ehler’s Danlos, pregnancy
  • Physical exam
    • Tachycardia
    • Pulse deficit in arms, or BP difference between arms
    • Aortic diastolic insufficiency murmur
    • Maybe tamponade signs
    • Neurological signs: paraplegia, hemiplegia, Horner’s
  • Tests
    • EKG – likely normal, tachycardia, can rarely present like an MI if propagation is backwards and involves Ao outflow tract and thus the coronary artery ostia
    • CXR – widened mediastinum, calcium sign (separation of calcified intima from outer tissue), left apical cap, pleural effusion, obliteration of the aortic knob, depression of the left mainstem bronchus, loss of the paratracheal stripe, tracheal deviation.
    • Diagnostic tests
      • Angiography
      • Spiral CT of chest with contrast
      • TEE
      • MRI of chest

Pulmonary Embolism

  • Well’s Criteria for PE
    • Clinical signs and symptoms of DVT  +3
    • PE most probably diagnosis, or equally likely  +3
    • Heart rate > 100  +1.5
    • Immobilization at least 3 days, or surgery in the previous 4 weeks  +1.5
    • Previous, objectively diagnosed PE or DVT  +1.5
    • Hemoptysis  +1
    • Malignancy w/ Rx within 6 mo, or palliative +1
    • <2 low probability, 2-6 moderate probability, >6 high probability
  • Symptoms of PE
    • Dyspnea, pleuritic chest pain, cough, hemoptysis
  • Signs of PE
    • Tachypnea, tachycardia, fever, crackles, accentuated P2 component of S2, cardiovascular collapse
  • Diagnosis
    • Pulmonary angiography is gold standard
    • Ventilation-perfusion scan or CT angio are now used
    • EKG – may show S1Q3T3 pattern, RBBB, R axis deviation, T wave or ST segment changes, new onset atrial fibrillation
    • ABG – may show A-a gradient
    • CXR – Westermark’s sign (focal oligemia – vasoconstriction distal to embolus), Hampton’s hump (shallow consolidation that looks wedge-shaped against the pleura)
    • 90% of PE originate in lower limbs – do a duplex Doppler to assess
  • Treatment
    • Immediate anticoagulation: unfractionated or LMWH
      • Also start on Warfarin so that heparin may be discontinued after 48 hr of a therapeutic INR (2.0-3.0)
      • Continue to treat for 3-6mo if first event with identifiable, transient risk factor
      • Treat indefinitely if malignancy or recurrent

Pericarditis

  • Historically chest pain that is positional (better when leaning forward), and often pleuritic – but no shortness of breath and stable vital signs
  • EKG will show widespread ST segment elevation and PR depression in lead II
  • Commonly caused by Coxsackie virus
  • Treated with NSAIDs

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