Chest pain

1. Chest Pain
It’s all in the story

2. Everyone has one
Very common
Acute management. Mostly benign, AND
rarely **life-threatening **
Therefore concentrate on the work-up and
treatment of those

3. Roadmap
Context/Background/Epidemiology
DDx
Presentation/History = Workup
AA/Dissection, PTX, PE, SVC Syndrome
ACS
Acute Management

4. Epidemiology
Up to 30% cardiac catheterizations are
negative for CAD*
3.15 million to 1.8 billion $/yr
Low mortality and high morbidity, i.e. the
cause and effect of your hard work
Nevens, F, Janssens, J, Piessens, J, et al. Prospective study on prevalence of esophageal chest pain in patients referred
on an elective basis to a cardiac unit for suspected myocardial ischemia. Dig Dis Sci 1991;36:229–235.
Achem, S, DeVault, K. Recent developments in chest pain of undetermined origin. Curr Gastroenterol Rep 2000;2:201–
209.

5. DDx
mainly cardiac, pulmonary, gastrointestinal,
and psychiatric
Must r/o ACS (angina, NSTEMI, STEMI),
PE, tamponade, Boerhaave’s, aortic
dissection, tension PTX, SVC syndrome

6. Mind your PQRSTs
Provoke, palliation, position
Prior occurrence
Quality
Radiation
Severity
Surgery (PE, CABG)
Timing

7. The Heart
QUALITY: pressure, squeezing, burning
RADIATION to jaw, shoulder, arm
Related to EXERTION?
palpitations, diaphoresis
early am (sympathetic stimulation)
PND (at night)
POSITION
HYPOXIA

8. The Heart
LIMITED FLOW: vasoconstriction, anemia,
hypotention (coronary vasospasm,
arrhythmia, valvular disease, hypertensive
urgency/emergency, cocaine)
Pericarditis, pericardial effusion
CHF

9. Likelihood of ACS
Framingham Cardiac Risk Factors
(intermediate)
History*
ECG (ST deviations)*
Cardiac Biomarkers*
* Any ONE connotes high probability
2002 AHA/ACC USA guidelines

10. The Lung
Pneumonia, URI
- rhonchi
PTX
- absent breath sounds
COPD, sarcoid, pulmonary fibrosis,
pulmonary htn, i.e. increased pulmonary
resistance
- no air movt, wheeze, velcro rales

11. The Upper GI Tract
Boerhaave (esophageal rupture): fever, shock,
odynophagia, tachypnea, hypoxia
EMD and GERD, esophagitis
- Burning, odynophagia, dysphagia,
- POSITIONAL, TEMPORAL
- bad breath in am, or vomit in mouth
- NO RADIATION
- non-exertional
- PILLS: especially clinda, tetracycline,
bisphosphonates

12. GERD, esophagitis
• Can account for >20-65% of UCP
• Diagnostic and Therapeutic: Antacids
- PPI
- H2-blockers
- sucralfate

13. Psychiatric:
dx of exclusion
Panic disorder
Anxiety
Somatization

14. Don’t Forget
AAA/Aortic Dissection
PE
PTX
SVC syndrome

15. Aortic Dissection: High Mortality
Px: ripping quality, may radiate to back
Etiology: surgery, Marfan’s, Ehler-Danlos, htn

16. Aortic Dissection
• PE: discordant bp, neuro
deficits, cardiac tamponade,
faint distal bp, AR murmur (
rapid SOB, CHF, LV failure)
• Austin-Flint, R-sternal border,
widened pulse pressure
• Cxr: widened mediastinum
• TTE, CT

17. Pulmonary Embolus
Px: dyspnea, tachycardia, pleuritic cp, hypoxia,
hypotension
Etiology: surgery, cancer, immobilization, DVT,
indwelling catheter, pregnancy/OCP
S4, RV strain
S1Q3T3 (<7%), A-a gradient, hypoxia, Hampton’s
hump/Westermark sign
Dx: CT Angio, V/Q scan, D-dimer
Tx: Anticoagulation, thrombolysis

18. Pulmonary
Embolus

19. Pneumothorax
 Px: Dyspnea, pleuritic cp
 Etiology: spontaneous, recent
instrumentation or intubation
 PE: tracheal deviation, absent
breath sounds
 CXR
 Minor: observe and o2
 Major: CHEST TUBE >>
needle decompression (mid
clavicular, 2nd ICS)

20. SVC syndrome*
Low-pressure, and thin-walled
Neighbors: trachea, R bronchus, Aorta,
sternum
Head, neck, upper thorax and arms
Etiology: R sided mass – 80% cancer (80%
mostly NSCLCa, 15% NHL), infection (Histo,
TB, syphilis), vasculitides (AA, Takayasu,
mediastinitis).

21. SVC syndrome*
Px: cough, head fullness, SOB, facial swelling,
unilateral arm swelling, dysphagia, dysphonia,
stridor, orthopnea, lightheadedness  worsened
by lying down, bending over

22. SVC Syndrome*
Tx: elevation of head, o2
Steroids, intubation, lasix (cerebral or
laryngeal edema)
consider XRT
Thrombolytics, anticoagulation (cerebral
hemorrhage)
PTA (perc transluminal angio)

23. Other Diagnoses
Malignancy
Musculoskeletal (cough), compression
fracture, rheum diseases, costochondritis,
fibromyalgia
Zoster
Post-radiation

24. Workup
vital signs
O2 sat – how much oxygen is required?
Labs: cardiac biomarkers, lactate, cbc,
BMP, consider coags
ECG
CXR
- mediastinal or aortic widening
ABG
CT angio: if stable

25. The American Journal of Gastroenterology (2001) 96, 958–968; doi:10.1111/j.1572-0241.2001.03678.x

26. Back to the

27. ECG findings
Always look at old ECG

30. ECG findings
LAD – V1-V4, aka “septal, precordial leads”
- Diagonal artery
- supplies LV
LCX – I, L, V5 and V6, aka “lateral leads”
- Obtuse marginal (OM) artery
- reciprocal changes in II, III, F
RCA – II, III, avF, aka “posterior leads”
- posterior descending artery (PDA)
- supplies SA node, and RV  arrythmias
- preload dependent

31. Conduction Pathways

32. ECG findings
ST Elevation (injury)
– DDx: MI, Pericarditis, early repolarization,
vasospasm, LV aneurysm
New LBBB: QRS >120ms, notched R in lateral
leads (no q’s), rS in septal (V1) leads, L axis
deviation
ST Depressions (ischemia)
T wave abnormalities: flattening, inversions,
biphasic

33. T wave abnormalities

34. Evolution
of an MI:
ECG
changes
Peaked T’s
ST elevation
Tombstone
Q wave and
loss of R wave
(usually ~12 h)
T wave
inversion
Morris, BMJ April 6,
2002

35. ECG findings: RV infarct
V1-V3  turn over
and upside down or
ST-depression, R: S
is >1, R may be
broad
V7-V9: place leads
V4-V6 horizontally
at level of V6 (post
axillary, mid
scapula)

36. ECG findings: RV infarct

37. Cardiac Biomarkers
AST: first test, not specific
 CK-MB: 6-12 hours (artifactual if skelatal
muscle is present). Disappears quickly but good
for extension of infarction
 troponin: 12 hours, persists up to 7 days. Can
correlate to size of infarct but can take up to 3
days to result
LDH: 72 hours, not specific

38. Cardiac Biomarkers
Adapted from ACC/AHA Guidelines 2005

39. Treatment
Peripheral iv access
Telemetry
Antiplatelet agents: ecasa 325 chewed or
81mg ecasa + 300mg Plavix (CURE) in NSTEMI
showed dec mortality
Anticoagulant agent: heparin, lovenox
(SYNERGY), Fondaparinux (Xa inhibitor) (OASIS-
5 – 50% less risk of bleeding, decreasing mortality)

40. MONA
M orphine
O xygen
N itrates – SLNTG, paste, po
- iv if pain persists (10 mcg/min)
A sa

41. Armamentarium
Beta- blockers – decrease O2 demand
- no CHF
- can give iv: metoprolol 5mg q5min x 3
Statins (PROVE-IT trial): atorvastatin 80mg
(decreased mortality)
ACEI – if HTN persists, and renal fxn ok
Cardiac catetherization: superior to thrombolysis if
STEMI and w/in 90 minutes of symptom onset.
Ovoid thrombolysis in NSTEMI
- use plt glycoprotein IIb/IIIa inhibitor upfront
(shown to reduce ischemic events by 25%, ISAR-REACT 2)

42. Special Considerations
Cocaine/vasospasm
- NTG/CCB/Ativan, can also have
thrombotic occlusion – clinical/resolution of
CP suggests spasm
RV Infarct: preload dependent
- R sided ECG V3R V4R
- hypotension with NTG/BB – Rx with
volume/inotropes

43. Complications
In-stent Thrombosis (early w/in 24 h, late w/in 1
mo), In-stent Restenosis (6 months)
- latter more likely w/ DES
- latter more likely w/ angioplasty
VSD, MR, free wall rupture (3-7 days)
Arrythmias
- Replete K+, Mg++, Ca++
Bradycardia – atropine/pacemaker

44. Chest Pain DDx: r/o the 5 +1
 Cardiovascular
- Angina (unstable, MI)
- Aortic dissection
- Pericarditis
- Tamponade
- PE
- Pulmonary HTN
- AS/HOCM
- SVC syndrome
 Gastrointestinal
- Boerhaave’s syndrome
- GERD/Esophagitis
- Esophageal Spasm
- Mallory-Weiss tear
- Peptic Ulcer/Gastritis
- Pancreatitis
- Biliary dz
• Pulmonary
- Pneumothorax
- Pleurisy/Pneumonia
- Tumor
• Musculoskeletal
- costochondritis
- trauma (rib fx, strain, mets)
- cervical disk dz
-arthritis of shoulder/spine
- rheumatologic: sarcoid, FM
• Herpes Zoster
• Radiation
• Psychiatric
- Anxiety
- Panic d/o
- Somatization

45. Conclusions
Chest Pain does not necessarily = Acute
Coronary Syndrome
Recognize DDx and clinical manifestations
PE, Aortic Dissection, PTX, Boerhaave’s, (SVC
syndrome)
 Angina/ACS – myocardial 02 supply
insufficient to meet demand; recognize
“secondary angina” and treat correctable
causes
Shock: contractility agents (dobutamine), IVF,
reperfusion,
Call for help if needed