1. Evaluating Chest Pain
What Are the Risks?
Jeffrey E. Keller MD

2. Badger Correctional Medicine

3. We Belong In Your Jail!

4. The Dilemma of Chest Pain
• On the one hand: I don’t want the words
“Chest Pain” to become a get-out-of-jail-free
card.
• On the other hand: I don’t want to get the
phone call that begins, “Do you remember
that patient you saw yesterday?”

5. Objectives
• Review Pathology and Terminology
• Chest Pain Risk Assessment
– Historical Risk Factors
– Typical Presentation
– Physical Examination

6. Objectives
• How can Cardiac Blood tests help you?
• How can EKGs help you?
• Setting up Chest Pain protocols in your
institution.

7. Atherosclerosis
• The build up of plaque
in the coronary arteries
obstructs flow.

8. Angina
• Coronary flow is
restricted at high flow
states.
• Stable Angina.
– Predictable
• Unstable Angina.
– Pre-MI pain

9. Myocardial infarction
• Coronary flow is
suddenly cut off by a
clot.
• This results in death of
heart muscle.
• STEMI
• NonSTEMI

10. ACS is a process stretching from stable
angina to myocardial infarction.

11. ACS Continuum
Atherosclerosis----
Angina-----
Unstable Angina------
Myocardial Infarction-------
Dead

12. Risk Stratification
• Risk Stratification is the
process by which we
assess the risk involved
in any situation.
• Which of these has the
highest risk of
drowning?
• Swimming the English
Channel.
• Sitting in a bathtub.

13. Risk Stratification
• What is an acceptable “Miss Rate?”
• Ranges between 2-6%
• Cannot do better than 2%
• Attempts to do better than this will harm
more people than help.

14. Risk Assessment Step One
Does the patient have Atherosclerotic
heart disease?
• Known Coronary Heart Disease
• Other Atherosclerotic Process
• Smoking, Age, Family History, Diabetes,
Hypertension
• Male, Obesity, Cholesterol

15. ACS Presentation
Typical MI: Substernal, heavy, radiates to arms
and neck/jaw, sweaty, SOB, nausea, urge to
defecate.
Typical Angina: Comes and goes, precipitated
by heart working harder (exercise, eating,
night), lasts only minutes and goes away.

16. Atypical Presentation
Atypical: Other pain patterns (like not substernal—
off to the side), localized pain, pleuritic pain, no
radiation, no pain, just SOB, exercise
intolerance, weakness, nothing
Who has atypical symptoms? Older, women,
diabetics, chronic disease.
Who is more likely to have typical symptoms?
Young, healthy males—precisely who we tend to
have in correctional facilities

17. Physical Examination
– Ausculation rarely
helpful
– Rarely—pulmonary
edema
– Diaphoresis, gray.
– Overall gestalt of sick
or not sick

18. Assigning Risk—High or Low
• 56 year old who had coronary stents placed
five years ago now states he has substernal
chest pain going into his jaw. He looks grey
and ill.
• 21 year old who complains of stabbing in his
chest “like needles” plus numbness of both of
his legs. No risk factors. His sternum is tender
to palpation.

19. Is H & P Alone Accurate?
• 2-4% miss rate.
• Scoring systems do no
better.
• Goldman’s Criteria.
• Can tests improve on
this?

20. Bayesian Analysis
• How much will a test change probability?
• Sometimes it does, sometimes it does not and
sometimes it makes things worse.
• Assign a probability and then evaluate the
test.

21. Bayesian Analysis
• Step one—assign a risk based on history and
physical
• Step two—do a test and, depending on
whether it is positive or negative, change the
risk assessment.
• Step three. Analyze whether the test has
improved your risk assessment.

22. Tests
– Sensitivity: How accurate is the test at finding
the disease.
– False negative: When a test fails to find the
disease.
– Specificity: How accurate is the test at excluding
the healthy.
– False Positive: When a test is positive in
patients without the disease.

23. Core Concepts
• Tests can be harmful as well as helpful.
• Incidence of false positive and false negative
are related to the overall incidence of the
disease in the community.
• The sensitivity and specificity of a test
determine how much a test will change pre-
test probability.

24. ACS Tests
• Overall incidence of disease in the community.
• Sensitivity and specificity of the test.
• What is the potential harm?

25. Troponin I
• Troponin is released by
damaged heart muscle.
• Levels over 0.5 are
almost always
diagnostic of acute MI.
• It rises around three
hours after the onset of
the MI and stays up for
several days.

26. Troponin
– ER protocol: 3 sets in 6 hours.
– False positive: Intermediate result >0.1 and <0.5
– False negative: Angina. Early MI.

27. Normal Troponin Series
Atherosclerosis----
Angina-----
Unstable Angina------
Myocardial Infarction-------
Dead

28. Troponin case
• 56 year old who had coronary stents placed
five years ago now states he has had
substernal chest pain going into his jaw for the
last 45 minutes. He looks grey and ill.
• Troponin I is negative.
• What have you learned?

29. EKGs
• Normal
• STEMI pattern
• Nonspecific

30. Normal EKG

31. Acute STEMI

32. STEMI?

33. STEMI?

34. Nonspecific EKG

35. Limitations of EKGs
• Sometimes they are normal in people having
an MI.
• Sometimes they are abnormal in people who
are not having heart pain.
• The machine readings are often inaccurate.

36. EKG Summary
• EKGs must be interpreted with the initial Risk
Assessment in mind.
• If a patient initially was high risk and has a
normal EKG, he is still at high risk.

37. Do Chest Pain tests help?
– High Risk patient, positive test: Confirms what
we know. Consult a cardiologist.
– High Risk, negative test. Does not exclude
disease. Does not lower risk much. Still must
pursue further.
– Low risk, negative test: Confirms what we
already knew.
– Low risk, Positive test: Likely a false positive, but
now must pursue further evaluation.

38. Further work up required
• Stress EKG
• Thallium stress EKG
• Angiogram
• CT angiogram
• Cardiology Consultation

39. Documentation
• Historical Risk factors
• History of Typical or Atypical symptoms.
• Physical Exam
• Assessment
• Alternative diagnosis
• Follow-up.

40. Chest Pain
• One of the scariest complaints we confront.
• In actual fact, chest pain carries less long term
risk than do other common jail complaints:
– Alcohol withdrawal
– Drug dependency
– Suicide.

41. Chest Pain in Corrections
• Everyone here can pretty accurately assign
risk based on a patient’s risk factors,
symptoms and physical exam.
• Using EKGs and Cardiac Markers to modify
that assessment is tricky.
• If you are going to use them, you must use
them correctly.

42. Cardiac Marker recommendations
• Use only Troponin I.
• If you order one, you have to order at least
one more at least three hours later.
• If they are negative, you must follow them up
with further testing.

43. EKG in Corrections
Do not make these two mistakes:
Do not assume that a normal EKG means that
the patient has a normal heart.
Do not do EKGs in patients with low risk.

44. Review: Case #1
• 21 year old who complains of stabbing in his
chest “like needles” plus numbness of both of
his legs. He is short of breath.
• Risk assessment for cardiac pain:
• EKG?
• Labs?
• Consult?

45. Review Case # 2
• 56 year old who had coronary stents placed
five years ago now states he has substernal
chest pain going into his jaw. He looks grey
and ill.
• Risk assessment for cardiac pain:
• EKG?
• Labs?
• Consult?

46. Review Case # 3
• A 24 year old comes into the jail high on
Methamphetamine. He complains of chest
pain. His heart rate is 140.
• Risk assessment for cardiac pain:
• EKG?
• Labs?
• Consult?

47. Review case # 4
• A 36 year old man comes to the jail medical
clinic stating that he has had chest pain
steadily for the last four days. He points to his
left sternal border. It hurts worse when he
breathes. The pain radiates to his left arm.
• Risk assessment for cardiac pain:
• EKG?
• Labs?
• Consult?

48. Review case # 4
• A 61 year old diabetic man states that he gets
a little short of breath off an on during the
day. He has no chest pain, but he states that
sometimes he gets a cramp in his jaw. He has
coronary stents placed 7 years ago. He feels
fine right now.
• Risk assessment for cardiac pain:
• EKG?
• Labs?
• Consult?