Approach to Chest Pain
Intern Bootcamp, 2014
Nathan Stehouwer, MD
PGY-4, Internal Medicine & Pediatrics
Differential
 Cardiac
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MI
Pericarditis
Myocarditis
Aortic Stenosis
 Pulmonary
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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
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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
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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
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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
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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:
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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
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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!