Chest Pain Evaluation Jimmy Klemis, MD Differential Diagnosis • Cardiovascular – – – – – – Angina (unstable, MI) Aortic dissection Pericarditis PE Pulmonary HTN AS/HOCM • Pulmonary – Pneumothorax – Pleurisy/Pneumonia – Tumor • Other – Herpes Zoster – Anxiety/functional d/o • Gastrointestinal – – – – – – GERD/Esophagitis Esophageal Spasm Mallory-Weiss tear Peptic Ulcer/Gastritis Pancreatitis Biliary dz • Musculoskeletal – – – – costochondritis trauma (rib fx, strain, mets) cervical disk dz arthritis of shoulder/spine Don’t miss • • • • Acute Coronary Syndrome/MI Aortic dissection Pulmonary Embolism Pneumothorax History • “PQRST” – – – – – – – Provokes: exertion/rest, pleuritic, swallowing, positional Palliates: rest, meds(NTG, antiulcer), position Quality: sharp/somatic dull/visceral Region: substernal/epigastric/shoulder/etc Radiation: arm/neck/jaw, back Severity Timing: new, chronic, worsening • Risk factors: CV- age, tobacco, FHx, DM/lipid/ HTN; other- DVT/PE, marfans/pregnant, EtOH, NSAIDs • PMHx: prior CV w/u & Rx, GI hx Physical Exam • General/VS: HR/BP/RR/Sa02/ distress • HNT: jvd/hjr, tracheal dev, carotid pulse • CV: palpation (RV heave/apical impulse/ dyskinetic segments), S1/2, S3/4, murmur (AI,AS, MR, TR, VSD), rub • RESP: symmetry, infiltrate/effusion, rales, wheezing, friction rub, palpation • ABD: ausc/BS, palp/peritoneal signs, bruits/masses • EXT: pulses/symmetry, edema, bruits • Skin: rash/zoster, cool/clammy Aortic Dissection • • Hx: sudden, severe “ripping” pain in ant chest, may radiate to back Etiology – – – – • HTN Trauma (blunt, cath/surgery) Pregnancy Connective tissue (Marfans, Ehlers-Danlos) Clinical: – HTN, BP both arms not equal, distal pulses diminished, AR murmur, cardiac tamponade, neurologic defecits – Mortality high • Diagnosis: – CXR – wide mediastinum – CT, TEE, MRI • Treatment – Beta blockade (Esmolol/Labetalol) + Nipride – Type A/Proximal – surgery Type B/Distal - medical CXR showing wide mediastinum and enlargement of aortic knob c/w interval CXR 3yr prior; CT scan showing flap of aortic dissection Pulmonary Embolus • • Presentation:, dyspnea/tachypnea , tachycardia, pleuritic CP/cough +/hypotension, hemoptysis Risk – – – – – – • • surgery/trauma obesity, smoking oral contraceptives, pregnant/post partum malignancy immobilization/illness (ICU/stroke/CHF/Pneumonia) indwelling central line PE: hypoxia/A-a gradient ( although may be Nl), anxious, RV strain, tachycardia/tachypnea, Diagnosis – ECG S1Q3T3 (<7%) LAB – DDimer (nonspecific); CLINICAL – CXR – oligemia (Westermark’s sign) infarct (Hampton’s hump) – CT (PE protocol), V/Q scan, Pulmonary Angiogram • Treatment – anticoagulation/thrombolysis, interventional/surgical mgmt “Westermarks sign” Oligemia in R Lobe, with angio showing occlusve R PA embolus CT with massive PE in R/L PA “Hampton’s hump” wedge shaped density In lung periphery indicating Pulm infarction Pictures: Braunwauld, Heart Disease, 6th ed PE- ECG S1Q3T3 Pneumothorax • Clinical – dyspnea, pleuritic CP • Physical findings – tracheal deviation, absence of breath sounds • Risk – recent central line, ventilator, trauma, spontaneous/cough/etc • Dx: CXR • Rx: if small, stable can observe; repeat CXR; pneumodart/chest tube Pneumothorax Acute Coronary Syndrome ACS - Evaluation • • • • • History Physical ECG Lab/Cardiac Markers Treatment Myocardial O2 Supply & Demand • Supply – Coronary Blood Flow • diastolic perfusion pressure • coronary vascular resistance – O2 carrying capacity • Demand – Wall Tension • Pressure x radius/2h – Heart Rate – Contractility Unstable Angina/NSTEMI • Causes – nonocclusive thrombus on pre-existing plaque – dynamic obstruction (spasm or constriction) – progressive mechanical obstruction – inflammation +/- infection – “secondary” UA (O2 supply/demand) • supply↓:hypotension/ anemia/ hypoxia • demand↑ : fever/ tachycardia/ HTN History • Chest/epigastric pain/discomfort – pressure/heaviness/tightness/burning – unexplained indigestion/epigastric pain – nausea/vomiting/diaphoresis – dyspnea • Flash Pulmonary edema – should raise susp for ischemia Not characteristic of Angina • • • • • • • • Pleuritic pain (i.e., sharp or knife-like pain brought on by respiratory movements or cough) Primary or sole location of discomfort in the middle or lower abdominal region Pain that may be localized at the tip of 1 finger, particularly over the left ventricular (LV) apex Pain reproduced with movement or palpation of the chest wall or arms Constant pain that lasts for many hours Very brief episodes of pain that last a few seconds or less Pain that radiates into the lower extremities HOWEVER – 7-22% of pt with ACS can have concurrent findings (chest wall tenderness 7% pleuritic 13% sharp/stabbing pain 22%) Source: 2002 ACC/AHA Unstable Angina guidelines Likelihood of ACS 2002 ACC/AHA Unstable Angina guideline UA/NSTEMI - Presentation ECG findings • ST Elevation (injury) – – • • DDx: MI, Pericarditis, early repolarization, vasospasm, LV aneurysm ≥ 2 contiguous leads reperfusion (lytic/PCI) ST Depression (ischemia) T wave abnormalities – hyperacute: hyper K, early MI – inversions: DDx: ischemia, pericardial dz, myocarditis, CNS, drugs (TCA, phenothiazine) • Q waves – – • pathologic: >.04 wide, 25% of total qrs height precordial R wave progression (should increase V1-V5/6) Special – Posterior MI: early transition (tall R V1 or V2, ST depression) – RV infarct: ST elevation V3R V4R – new LBBB – less than 50% of acute MI have clear ECG findings on 1st ECG, 10% of pt with MI may not show ECG changes Acute MI – evolution of ECG Morris, BMJ April 6, 2002 Q waves Pathologic Q waves in inferior and anterior leads; -q waves can occur within 1-2hrs of acute MI but usually 12-24 hrs Morris, BMJ April 6, 2002 T wave abnormalities Channer, et al. BMJ April 27,2002 T wave inversion suggestive of anterior ischemia. TWI may be normal in III, aVR, and V1 if associated with predominantly negative QRS complex. T wave - hyperacute Hyperacute T waves - usually occur early in MI and precede ST elevation; DDx includes hyperK. if uncertain, repeat ECG Morris, BMJ April 6, 2002 ST elevation/reciprocal changes Acute Inferior MI with reciprocal ST depression reciprocal changes seen in 70% inferior and 30% anterior acute MI strongly suggestive of acute MI with PPV 90% source: Morris, BMJ April 6 2002 ST depression ST depression can initially be a subtle flattening of the ST segment, or may present as classic horizontal or downsloping changes with severe ischemia. amount of ST depression usually relates to size of R wave DDx includes LVH and Digoxin Channing, et al. BMJ April 27, 2002 LBBB and Acute MI Acute MI in pt with preexisting LBBB criteria for acute MI in face of old/known LBBB include -ST elevation of >4-5mm -“inappropriate concordance” of ST elevation, seen here in V5-6 (usually ST/T are opposite QRS in LBBB, i.e. discordant) -NEW LBBB is ACUTE MI until proven otherwise Edhouse, et al. BMJ April 20 2002 prev anterior MI with LV aneurysm, seen commonly after ant MI, may be palpable Pericarditis with diffuse ST elevation and PR depression BMJ April 20, 2002 Benign early repolarization in healthy, young, esp AA males. most pronounced in V4 50 WM with severe CP x1hr hyperacute T waves, early MI Cardiac Markers Initial Peak Normal Myoglobin 1-4hr 6-7hr 24hr CK-MB 3-12hr 24hr 48-72hr Also elevated with sk muscle/CPK Troponin I 3-12hr 24hr 5-10d Nonspecific Highly sensitive/ specific Treatment of ACS • Initial – ASA/Plavix – Nitroglycerin • • SLor spray/paste/patch and IV if no relief (5-200mg/min) avoid if hypotensive , viagra w/in 24hr,or RV infarct – Morphine SO4 • 2-4 mg IV – Beta-Blockers • first dose IV if ongoing/recurrent pain; followed by oral dose • avoid if HR <70, acute LV dysfxn,caution with inf MI/RV • can substitute Nondihydro CCB if asthma//cocaine/contra – Heparin/LMWH • Lovenox 1mg/kg SQ q12 (max 120 bid, caution in renal failure) – ACEI • if HTN persists despite above Rx ACS – special considerations • Cocaine/vasospasm – NTG/CCB/Ativan, can also have thrombotic occlusion – clinical/resolution of CP suggests spasm • RV Infarct – R sided ECG V3R V4R – hypotension with NTG/BB – Rx with volume/inotropes Treatment of ACS • Reperfusion eligible – thrombolysis/PTCA • admit telemetry/ICU • monitor for complications – arrythmia • Ventricular tachycardia – (K>4, Mg>2; lidocaine/amiodarone) • Bradycardia/ AV block - (atropine/ pacemaker) – shock • LV dysfxn – inotropes (Dobutamine/Milrinone) + pressors (Dopamine) + IABP if indicated • RV – volume, avoid NTG/BB + above Rx • Cath lab for urgent reperfusion – Mechanical • acute MR, VSD, free wall rupture (3-7d) Acute Reperfusion - Thrombolysis • Criteria – new ST elevation in ≥2 contiguous leads • New LBBB • RV infarct (V3R, V4R elevation) • Post infarct (ST dep anterior segments/early trans) – onset of sxs within 12 hrs (benefit greatest in first 3hrs) Thrombolysis Contraindications ACC/AHA revised guidelines for Acute MI Primary PTCA • same as thrombolysis as well as – – – – sxs >12hrs onset with ongoing chest pain sxs w/in 36hrs + cardiogenic shock if thrombolysis contraindicated (IIa) admission/dx to open artery time 90±30min The real world – 48 F presents to med ER with chest pain x 6 hrs Dx: Acute Inferior MI, reciprocal changes – pt taken for emergent cardiac catheterization and successful PTCA of RCA lesion 81 F Acute/Chronic renal failure, anemia, and dyspnea/confusion and Troponin I of 4 Dx: probable acute coronary syndrome (fellow) LV aneurysm (staff) – emergent cath revealed noncritical 3vCAD, exam c/w LV aneurysm 30 F presents with chest pain x 1 wk Diagnosis: Unstable Angina with ECG suggestive of ischemia with T wave inversions pt had negative enzymes, normal stress test at high level; discharged Differential Diagnosis • Cardiovascular – – – – – – Angina (unstable, MI) Aortic dissection Pericarditis PE Pulmonary HTN AS/HOCM • Pulmonary – Pneumothorax – Pleurisy/Pneumonia – Tumor • Other – Herpes Zoster – Anxiety/functional d/o • Gastrointestinal – – – – – – GERD/Esophagitis Esophageal Spasm Mallory-Weiss tear Peptic Ulcer/Gastritis Pancreatitis Biliary dz • Musculoskeletal – – – – costochondritis trauma (rib fx, strain, mets) cervical disk dz arthritis of shoulder/spine Conclusions • Chest Pain does not necessarily = Acute Coronary Syndrome • Recognize DDx and clinical manifestations • PE/Dissection/PTX • Angina/ACS – myocardial 02 supply and demand; recognize “secondary angina” and treat correctable causes • Reperfusion criteria/contraindications • Call for help if needed