Chest Pain

History

• Age
• When did it start (cardiac cause – morning b/c of circadian rhythms), how did it start, what were you doing when it started
• How long did it last
• Type
• Location, radiation (neck, arm, back)
• Alleviating/aggravating (position – i.e. leaning forward in pericarditis)
• Travel, clots, pregnancy, cancer
• Risk factors (dyslipidemia, hypertension, diabetes, family history, smoking)
• Associated symptoms (nausea, palpitation, diaphoresis, presyncope, SOB, cough, fever, calf pain)

Exam

• Cardiac cause – ↑HR, ↑/↓BP, murmur

Immediate treatment

• #1 ASA 10mg chewed
• Morphine 5/10mg
• O₂ NP 2L
• Nitro SL 0.3mg x 3 (5 minutes) – note: also relieves esophageal spasm
• IV NS (maintenance or ↓)
• Cardiac monitor

Investigations

• EKG → on admission and when pain free (dynamic changes on EKG)
• Troponin I → 6hr after onset of pain
• CK
• CBC – look for WBC
• Lytes – especially K⁺
• Creatinine
• Urea – dehydration
• Chest x-ray

Atypical presentation

• Women
• Elderly
• Diabetics

Unstable Angina

• Recent onset
• Progressive/crescendo
• Occurring ↑ frequency
• Less extertion
• More severe/prolonged pain
• Less response to nitros
• Pain at rest (lasting > 15 minutes)

Differential

• Cardiac:
  • Angina (stable vs unstable)
  • MI
  • Pericarditis
  • Endocarditis
  • Dissection
  • Prinzmetal’s (vasospasm – Tx CCB)
• Respiratory:
  • Pneumoni
  • Pneumothorax
  • Pulmonary embolus
• MSK:
  • Costochondritis
  • Fractures
• GI
  • GERD
  • Peptic ulcer disease (PUD)
  • Spasm, Achalasia, Nutcracker resophagus
  • Gastritis
• Neurology
  • Herpes zoster
  • Neoplasm
• Psychiatry
  • Panic attack

CCS classification for Angina

1 – only with strenuous, rapid or prolonged activity
2 – slightly limiting ordinary activity
3 – level walking at normal pace <1-2 blocks, <1 flight of stairs
4 – inability to carry on physical activity