Approach to Chest Pain Intern Bootcamp, 2014 Nathan Stehouwer, MD PGY-4, Internal Medicine & Pediatrics Differential Cardiac MI Pericarditis Myocarditis Aortic Stenosis Pulmonary PE PNA Asthma/COPD Acute Chest Syndrome Pleura Pleuritis Pneumothorax Aorta Dissection Perforated ulcer Chest wall Costocondiritis/musculoskeletal Esophagus Esophageal Spasm Eosinophilic Esophagitis Esophageal Rupture/Perforation GERD Mediastinitis RUQ pathology Panic attack Pearl: ALWAYS have the patient point to the pain! Typical vs. Atypical Chest Pain Typical Atypical Characterized as discomfort/pressure rather than pain Time duration >2 mins Provoked by activity/exercise Radiation (i.e. arms, jaw) Does not change with respiration/position Associated with diaphoresis/nausea Relieved by rest/nitroglycerin Pain that can be localized with one finger Constant pain lasting for days Fleeting pains lasting for a few seconds Pain reproduced by movement/palpation Typical vs. Atypical Chest Pain UpToDate 2012 Typical vs. Atypical Chest Pain Cayley 2005 Case 1 You are the orphan intern on Wearn team at 6PM. You are called by the nurse because Ms. Z has developed chest pain. Ms. Z is a 62 yo F with PMHx of CAD s/p remote PCI to the LAD, COPD and right THA 3 weeks ago who was admitted for a COPD exacerbation. What would you do next? Evaluation of Chest Pain Case 1: Ask nurse for most current set of vital signs Ask nurse to get an EKG Obtain the admission EKG from the paper chart Go see the patient! Evaluation of Chest Pain Once at bedside, determine if patient is stable or unstable Perform focused history and physical exam Read and interpret the EKG. Compare EKG to old EKG if available If patient looks unstable or has concerning EKG findings, call your senior resident for help Write a clinical event note! Evaluation of Chest Pain focused physical exam for chest pain Vital Signs: tachycardia, hypertension/hypotension or hypoxia General: Sick appearing, actively having chest pain HEENT: JVD, carotid bruits Chest: Rales, wheezes or decreased breath sounds CVS: New murmurs, reproducible chest pain, s3 gallop Abd: Abdominal tenderness, pulsatile mass Ext: Edema, peripheral pulses Skin: Rash on chest wall Case 1 You go see the patient. She had been feeling better after getting duonebs, but suddenly developed chest pain that is L-sided, 8/10 and worse with breathing. This pain is not like her prior MI. Vital signs: Afebrile, HR 120, BP 110/70, RR 28, O2 sat 89% on 2L (was 95% on RA this morning) Physical exam Gen – in distress, using accessory muscles of respiration Lungs – CTAB, no rales/wheezes Heart – tachycardic, nl s1, loud s2, no mumurs Abd – soft, NT/ND, active BS Ext – b/l LEs warm and well perfused Labs: CBC wnl, RFP wnl, BNP = 520, D-dimer = positive, Troponin = 0.12 Case 1 Case 1 Differential Cardiac MI Pericarditis Myocarditis Pulmonary PE PNA Asthma/COPD Acute Chest Syndrome Pleura Pleuritis Pneumothorax Aorta Dissection Perforated ulcer Chest wall Costocondiritis/musculoskeletal Esophagus Esophageal Spasm Eosinophilic Esophagitis Esophageal Rupture/Perforation GERD Mediastinitis RUQ pathology Panic attack Modified Wells Criteria Clinical symptoms of DVT (3 points) Other diagnoses less likely than PE (1 point) Heart Rate >100 (1.5 points) Immobilization >/= 3 days or surgery within 4 weeks (1.5 points) Previous DVT/PE (1.5 points) Hemoptysis (1 point) Malignancy (1 point) Interpretation: >6: high 2-6: moderate <2: low Next moves DDIMER: 95% sensitive, VERY nonspecific ABG – Elevated A-a gradient fairly sensitive, highly nonspecific EKG – most commonly nonspecific changes (ST/T wave changes, etc) V/Q scan – helpful in patients with HIGH or LOW pretest probabilities in whom a CTPE cannot be obtained (eg CKD) LE Ultrasound: not sensitive CTPE Sensitivity 83% Specificity 96% Moderate - high clinical probability and positive CTPE: 92-96% chance of PE Pearl A CT angiogram (important for evaluating for Pulmonary Embolism or Aortic Dissection) requires EITHER: 1) At least a 20G peripheral IV OR 2) A Power injectable central line Case 1 Diagnostic approach is simple if you suspect PE… Probability low: obtain D-DIMER If positive: obtain CTPE If negative: PE excluded Probability moderate or high: obtain CTPE If positive: treat If negative: PE excluded Acute Pulmonary Embolism Management Stabliize patient oxygen Fluids if hypotensive! Anticoagulants Preferred: LMWH or Fondaparinux Enoxaparin 1.5mg/kg daily or 1mg/kg BID Fondaparinux subcutaneous once daily (weight based) Alternative: UFH (IV or SC) – select high intensity protocol Hemodynamically unstable patients High risk of bleeding (reversible) GFR < 30 Can initiate warfarin on same day IVC filter an alternative in patients with mod-high bleeding risk Search “heparin infusion orders” Pearl: If you have a moderate or high suspicion of PE, you can start anticoagulation while awaiting full diagnostic workup PE with hypotension Thrombolysis Administer over short infusion time Catheter based thrombectomy For failure of thrombolysis or likelihood of shock/death before thrombolysis can take effect (hours) Surgical thrombectomy Failure of above therapies Case 2 You are the long call intern on Hellerstein and get a call to 67121 at 6:58PM. You have a new patient in the ER, being admitted for ACS rule out. What’s your next move? Evaluation of Chest Pain Get report from ED physician about the patient Ask ED physician about patient’s initial presentation Ask for most recent set of vital signs Ask about EKG and CXR results Ask what meds have been started in ER and how patient responded Evaluation of Chest Pain Go to UH Portal and print out an old EKG for comparison Review prior discharge summaries Quickly review prior cardiac work up –echo, stress tests and cath reports Go see the patient! Case 2 Mr. M is a 67 yo man with PMHx of HTN, DLD, DMT2 and CAD s/p PCI in 2007. He presents with new onset chest pain x 2 hours that is retrosternal, 7/10, associated with nausea and diaphoresis. Case 2 VS: T 37 HR 108 BP 105/60 RR 20 O2 sat 93% on RA Physical exam: Gen – actively having chest pain, diaphoretic Lungs – crackles at bilateral bases Heart – tachycardic, nl s1/s2, no mumurs or rub Rest of the exam benign Labs: CBC wnl, RFP wnl, Troponin = 0.05 Next Steps Review EKG Review CXR Troponin SL Nitroglycerin Case 2 Case 2 Diagnosis: UA/NSTEMI EKG changes in Acute Coronary Syndromes: ST elevations ST depressions T wave inversions “pseudonormalization” – inversion of previously inverted T waves when compared with old EKG New conduction block Q waves Importance of serial EKG monitoring: sensitivity of single EKG is only 50% sensitive for acute MI Pearl: Positive Troponin does not equal ACS Risk Stratification Unstable Angina/NSTEMI: Initial Management “Stabilize” plaque Dual antiplatelet therapy Plavix load 600mg followed by daily 75mg ASA 324mg chewable, then 81 daily Anticoagulant UF Heparin at low intensity protocol Statin Atorvastatin 80mg Optimize Myocardial O2 supply/demand Control HR -> Short acting metoprolol, can titrate quickly to HR <60 if BP allows. Give 5mg IV, can repeat at 5-15min intervals. Be wary of patients with heart failure! Supplemental O2 if hypoxemic SL nitroglycerin (0.4mg), repeat every 4-5 minutes Morphine if still having active chest pain Case 2 continued You are now the nightfloat intern, and the patient is signed out to you at 10PM. At midnight, you are called for continued chest pain. Improved from admission but still 5/10 severity. Next steps Vitals Repeat EKG Repeat SL nitro Assess patient in person Call your senior! Dose additional morphine start IV nitroglycerin after 3-4 doses of SL nitroglycerin Start 5 mcg/min Increase by 5mcg/min every 20 minutes Floor maximum: 30mcg/min Pearl Inability to ELIMINATE chest pain in a patient with ACS using maximal medical therapy = Urgent call to cardiology for consideration of immediate catheterization Trivia What typical ACS med should you NOT give this patient? Pearl: Nitroglycerin contraindicated in inferior MI Other contraindications to NG: Preload dependent states Inferior MI Aortic outflow obstruction (HOCM, severe AS) Likelihood of hemodynamic instability HR <50 or >100 SBP<90mmHg or more than 30mmHg below baseline Use of PGE inhibitors Case 3 You are called on Hellerstein to admit a 65 yo man for ACS rule out. Mr Q is a gentleman with a history of DMT2, NASH, remote NSTEMI, and HTN presenting with severe retrosternal chest pain. Pain is different than prior MI but is very severe. Radiates to neck. Began 3 hours ago; has subsided slightly but is still 8/10 in severity. You take report, quickly review chart, and go to assess the patient in the ER. VS: T37.1, HR110, BP145/80 in R arm, RR16, Pox 98%RA Focused Exam: GEN: in discomfort but mentating well HEENT mmm, JVP at clavicle CV normal s1/s2, no murmurs PULM ctab, no w/c/r EXTR: cool Bilateral BP: 145/80R, 110/60L EKG identical to previous EKG which you printed from portal Thoracic aortic dissection Diagnosis CT angiography – first line 83-100% sensitive, specificity 87-100% TEE – second line; good for proximal, cannot visualize descending aorta well MRI – useful for surveillance Images: reference.medscape.com rwjms1.umdnj.eduen.wikipedia.org en.wikipedia.org Thoracic aortic dissection Risk Factors Hypertension Atherosclerosis Preexisting aneurysm (known history in 13% of patients) Inflammatory conditions affecting aorta (Takayasu, Giant Cell Arteritis, RA, syphilis) Collagen disorders (Marfan, Ehlers-Danlos) Bicuspid aortic valve Aortic coarctation Turner syndrome History of CABG, AVR, Cardiac Cath High intensity weight lifting Cocaine use Trauma Thoracic aortic dissection Management Type A Surgery! Do not delay surgery, even for LHC Beta blockers, titrate to HR 50-60 (labetalol, esmolol) BP control (nitroprusside) Type B Beta blockers, titrate to HR 50-60 (labetalol, esmolol) BP control – add nitroprusside or similar agent to SBP goal 100-120mmHg Surgery for those with end organ damage or those who do not respond to medical therapy Watch for hypotension – give fluids if needed, consider tamponade, MI, or rupture as complications if hypotensive Case 4 You are on long call on VA Blue. You are called to admit a 53 yo M from the ED for chest pain and EKG abnormalities PMHx: HTN Dyslipidemia You go see the patient and he tells you that he has had this chest pain for ~2 days, but it has progressively gotten worse. His chest pain is worse with breathing. He notes a recent viral URI. Case 4 VS: T 37.9 HR 104 BP 140/76 RR 20 O2 sat 95% on RA Physical exam: Gen – in mild distress due to chest pain, leaning forward while in bed Lungs – CTAB Chest wall – no visible rash, chest wall NT to palpation Heart – tachycardic, nl s1/s2, no rub Rest of physical exam benign Labs: WBC = 14, RFP wnl, AMI panel x 1 = negative CXR = negative Case 4 EKG on admission: Case 4 - Pericarditis Refers to inflammation of pericardial sac Idiopathic pericarditis typically preceded by viral prodrome, i.e. flu-like symptoms Typically, patients have sharp, pleuritic chest pain relieved by sitting up or leaning forward Goyle 2002 Case 4 - Pericarditis Goyle 2002 Case 4 - Pericarditis Diagnostic criteria UpToDate 2012 Case 4 – Pericarditis Per 2003 ACC guidelines, all patients diagnosed with pericarditis should receive echocardiogram High risk features: Fever (>38ºC [100.4ºF]) and leukocytosis Evidence suggesting cardiac tamponade A large pericardial effusion (ie, an echo-free space of more than 20 mm) Immunosuppressed state A history of therapy with vitamin K antagonists (eg warfarin) Acute trauma Failure to respond within seven days to NSAID therapy Elevated cardiac troponin, which suggests myopericarditis Case 4 - Pericarditis Treatment UpToDate 2012 Case 5 This is a 45 yro M with PMHx of rheumatoid arthritis who presented with progressive sob. He was found to have a Rsided pleural effusion and underwent an US guided thoracentesis with removal of 1.5 liters of pleural fluid. Two hours after his procedure, he develops new onset R-sided chest pain Case 5 Case 5 - Pneumothorax Management of Pneumothorax 100% O2 and observation in stable patients for PTX < 3 cm in size Needle aspiration in stable patients for PTX >3 cm Chest tube placement if PTX >3 cm and if needle aspiration fails Chest tube placement in unstable patients Pearl Great EKG Practice Site: http://ecg.bidmc.harvard.edu/maven/mavenmain.asp References Kearon C, Akl EA, Comerota AJ, Prandoni P, Bounameaux H, Goldhaber SZ, Nelson ME, Wells PS, Gould MK, Dentali F, Crowther M, Kahn SR. Antithrombotic therapy for VTE disease: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2012 Feb;141(2 Suppl):e419S-94S.Cayley, W.E. Diagnosing the cause of chest pain. (2005). American Family Physician, Vol 72 (10), 2012-21. Anderson JL et al. 2012 ACCF/AHA Focuse Update of the Guideline for Management of Patients with Unstable Angina/NSTEMI. JACC 60 (7) 2012. Thrumurthy SG et al. The diagnosis and management of aortic dissection. BMJ 344, 2012. Imazio M, Demichelis B, Parrini I, Giuggia M, Cecchi E, Gaschino G, Demarie D, Ghisio A, Trinchero R. Day-hospital treatment of acute pericarditis: a management program for outpatient therapy. J Am Coll Cardiol. 2004;43(6):1042. Goyle, K.K. and Walling, A.D. Diagnosing pericarditis. (2002). American Family Physician, Vol 66 (9), 1695-1702. Diagnostic approach to chest pain in adults. (2014). UpToDate. http://www.uptodate.com/contents/diagnostic-approach-to-chestpain-in-adults?source=search_result&search=chest+pain&selectedTitle=1%7E150 Differential diagnosis of chest pain in adults. (2014). UpToDate. http://www.uptodate.com/contents/differential-diagnosis-of-chestpain-in-adults?source=search_result&search=chest+pain&selectedTitle=3%7E150 Evaluation of chest pain in the emergency department. (2014). UpToDate. http://www.uptodate.com/contents/evaluation-of-chestpain-in-the-emergency-department?source=search_result&search=chest+pain&selectedTitle=5%7E150 Clinical presentation and diagnostic evaluation of acute pericarditis. (2014). UpToDate. http://www.uptodate.com/contents/clinicalpresentation-and-diagnostic-evaluation-of-acute-pericarditis?source=search_result&search=pericarditis&selectedTitle=1%7E150 Treatment of acute pericarditis. (2014). UpToDate. http://www.uptodate.com/contents/treatment-of-acutepericarditis?source=search_result&search=pericarditis&selectedTitle=2%7E150 Thanks to Sumit Bose for use of a number of his excellent slides!