Chest Pain
James Ignatius
Nicole Qaqish
7/19/2010
Classification
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Cardiac Vs Non-Cardiac causes
Cardiac: Ischemic Vs Non-ischemic pathology
Ischemic: Angina, Myocardial Infarction
Non-Ischemic: Pericarditis
Non Cardiac: G.I (GERD, PUD), Pulmonary (PE,
Pneumothorax, Pneumonia, Pleurisy, and Pul.
HTN)
Chest Pain Questions
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“LIQUOR’D” mnemonic
L = location, (retro, substernal…
I Intensity (1 -10)
Q Quality (Sharp, Pressure, dull…)
U Upsetting/Aggravating Factors
O Onset
R Releiving factors + Radiation
D Duration
Angina
• Chest pain that occurs when the coronary
arteries do not deliver an adequate amount of
oxygen-rich blood to the heart
• Categorized as stable, unstable, and Variant
(Prinzmetal’s )
Stable Angina
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Clinical findings of stable angina:
Substernal , high pressure/heavy feeling
Duration from 1 – 5 minutes
Instigated by physical exertion
Relieved with rest or nitrates
Unstable Angina
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Clinical findings of Unstable Angina:
Occurs even at rest
unexpected
More severe and lasts longer than stable
angina, maybe as long as 30 minutes
• May not disappear with rest or use of nitrates
Variant Angina
• Transient coronary vasospasm that is
associated with a fixed atherosclerotic lesion
(75%)
• Pt tends to be younger and in seemingly good
health
• Occurs at rest and and associated with
ventrcular dysrhythmias
• Nitrates and CCB’s are often effective
Diagnosis
• Resting EKG – normal in
pts with Stable Angina,
ST/T wave changes in
unstable Angina and
Variant Angina
• Stress Echo-detect
ischemia, asses LV
function and valve
disease
Treatment
• Lifestyle changes
• Pharmacotherapy – Aspirin, Beta, Blockers,
CCB, Nitrates
• Revascularization (CABG)
Myocardial Infarction
• Interruption of blood supply which causes
necrosis of the myocardium.
• Atheromatous plaque ruptures into lumen and
thrombus forms on top of the lesion causing
occlusion
• MI has a 30% mortality rate.
Myocardial Infarction
• Clinical Features:
• Crushing substernal chest pain(usually >30
minutes)
• Radiation to arms, neck, jaw, back (Left side)
• Diaphoresis, Nausea, Vomiting, Dyspnea,
Syncope
Diagnosis
EKG changes:
ST elevation – transmural injury and can be
diagnostic of acute infarct
ST depression – Sunbendocardial injury
Q wave – evidence for necrosis, usually
indicative of an old MI. Not seen acutely
Diagnosis
Diagnosis
• Cardiac enzymes – Gold Standard.
• 3 sets q8 in 24 hours
• CKMB – increases within 4-8 hours, peaks at
24hrs, and returns to normal 48 -72 hrs later
• Trop I – More specific/sensitive than CKMB.
• TropI falsely increased in Renal failure
Treatment
• Admit pt to CCU, Insert IV, , administer
oxygen, nitrates, morphine
• Aspirin, b-blockers, ACE Inhibitors reduce
mortality
• Lovenox can slow progression of thrombosis.
• Cardiac Rehab- exercise + lifestyle changes
post MI
Pericarditis
• Inflammation of fibrous sac which covers the
heart
• Causes: Viral Infection (Coxsackie B, Echovirus,
Hep. A/B) MI, Uremia,
• Pts usually recover in 1-3 weeks
Pericarditis
• Clinical Features:
• Pleuritic chest pain that is
positional(worsened by lying down,
inspiration). Pain is releived by sitting up +
leaning forward
• Friction Rub – scratching, high-pitched sound
caused by rubbing of visceral and parietal
pleura
Pericarditis
• Diagnosis
• EKG – ST elevation and PR depression , then ST
returns to normal, Twave inverts, then returns
to normal.
• Treatment: Treat underlying cause and offer
NSAIDS for pain
GERD
• Inaappropriate relaxing
of LES causes
backwards flow of
stomach contents into
esophagus.
• Contributing factors:
ETOH, coffee, fatty food
intake, increased age,
and Hiatal Hernia
GERD
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Clinical Features:
Burning, retrosternal pain after meals
Cough, nausea, vomiting
Hoarseness , sore throat
Reflex saliva hypersecretion
GERD
• Diagnosis:
• Endoscopy w/ Biopsy- Can detect cancer
complication or GERD
• 24 hr pH monitoring of LE – Gold Standard.
Highly specific/sensitive
GERD
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Treatment:
Phase I- diet changes + antacids
Phase II – Add H2 blocker (Ranitidine)
Phase III – Switch to PPI if symptoms don’t
resolve
• Phase IV – Add pro – GI motility Agent
(bethanechol/metoclopramide)
• Phase V – combo (H2 or PPI) + BTH/MET
Peptic Ulcer Disease
• A peptic ulcer is erosion in the lining of the
duodenum.
• Causes: H. pylori infection, NSAID, ZollingerEllison syndrome, Smoking, Stress
• Clinical Features:
• Epigastric pain that is achy
• Nausea, vomiting, weight loss, Upper GI bleed
Diagnosis
• Endoscopy is most accurate test
• Histological evaluation of endoscope biopsy –
Gold Standard for H. pylori infection
• Urease Breath Test – Shows active infection,
and efficacy of antibiotic therapy
• Serum gastrin- specific test for ZE Syndrome
Treatment
• Lifestyle mods(Reduce smoking,stress, ETOH,
NSAID) No food before bedtime!
• If H. pylori is present use Triple or Quadruple
therapy
• Triple ( PPI + 2 antibiotics)
• Quadruple (PPI + Peptobismol + 2 Antibiotics)
Treatment
• H2 blockers help with ulcer healing
• Surgical intervention need for complications of
PUD like bleeding, perforation
Case Study
• A 30 year old woman comes to the clinic complaining
of chest pain. For the last 2 years, she has had
intermittent nocturnal chest pain that lasts up to 10
minutes. The pain is substernal and radiates to her
throat. It is 6/10 and wakes her up from sleeping.
She has mild nausea and a clammy feeling. In the
past, she has used antacids and PPI which did NOT
help. Aerobic exercise sometimes instigates this pain.
Case Study
• She reports being quite healthy except for
having Raynauds phenomenon in winter and
migraines treated with sumatriptan. Social
history is remarkable for cocaine use. Vital
signs and physical exam are unremarkable.
Holter monitor study is arranged. What
findings would be most likely evident during
an episode of her chest pain?
Case Study
• A) PR segment depression
• B) Normal electrocardiographic tracing
• C) Prolonged QT interval with increased
duration at night
• D) Transient St elevation in inferior Leads
Answer
• D) This patient has a classic presentation of
Variant Angina, which is caused by coronary
vasospasm that induces transient ischemia
and ST elevations. Patients are usually young
women w/o classic CVS risk factors. It usually
occurs at night and can be worsened by
cocaine and serotonergic agents like
sumatriptan.
Answer
• Vasospams can occur in any distribution but
tend to favor the right coronary artery which
supplies the inferior portion of the heart
• A = Pr depression is indicative of pericardits.
Viral infection in Hx would have been a clue
and leaning forward in bed would have
produced relief.
Answer
• B= ST elevations and T wave changes are
associated with variant angina. EKG can not be
normal
• C= There is no reason to suspect QT interval
prolongation. Pts who have syncopal episodes
may have QT prolongation and it would not
worsen at night.
Respiratory Induced
Chest Pain
By Nicole Qaqish
7/19/2010
Clinical Presentations
• Shortness of breath
• Cough
• Pleuritic chest pain
Initial Approach to Chest Pain
• Ensure adequate A,B,C’s, asses vital signs,
Detailed history on the chest pain
• Rule out Life threatening Lung/ Cardiac
conditions.
• Categorize the chest pain
– Pleuritic ( Pain upon inspiration)
– Visceral ( Dull, Tightness, that is poorly localized)
– Chest wall pain
Approach to Chest Pain
• Many Respiratory induced chest pain have
similar symptoms.
• Evaluate any risk factors the patient might
have.
– Pulmonary embolism ( Hypercougable states, H/O
DVT’s, recent immobilization)
– Pneumothorax ( trauma, recent ventilation)
– Pnuemonia ( age >65, Immune deficient,
Hospitalization causing noscomial pneumonia
The Physical Exam
• Inspection – rate and pattern of breathing
• Palpation – Focal tenderness, rib fractures
• Percussion – Determine Resonance within the
lung tissue
– Hyperresonance (pneumothorax) vs dull percussion
(pneumonia)
• Auscultation – the quality and intensity of breath
sounds. Adventitious sounds such as rales,
rhonchi, friction rubs can also be heard and be
diagnostic for specific lung conditions.
Imagining
• Chest –Xray
– initial diagnostic imaging performed
– Can show consolidation, air/ fluid, opacification
• Further diagnostic imaging
– CT scan
– V/Q scan- to observe the perfusion and ventilation
throughout the pulmonary vasculature.
Most Common Causes of
Respiratory induced chest pain
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Pulmonary Embolism
Pneumothorax
Pleurisy
Pneumonia
Pulmonary Hypertension
Pulmonary Embolism
• Thrombosis from the venous system that embolizes in
the pulmonary vasculature
• Clinical Manifestations
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Dyspnea (73%)
Pleuritic chest pain (66%)
Cough (37%)
Hemptopysis (13%)
Acute Cor Pulmonale
• Physical Exam
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Tachypnea
Tachycardia
Rales
Cyanosis
Pleura friction rub
Pulmonary Embolism
• Imaging:
– CXR- normal
– V/Q scan- Diagnostic imaging in PE
• distribution of blood flow (perfusion scan) and the
distribution of alveolar ventilation (ventilation scan) are
obtained following the inhalation of a radioactive gas
and the IV injection of labeled albumin.
Pneumothorax
• Presence of air between the two layers of pleura,
resulting in partial or complete collapse of the lung.
• Clinical Manifestations:
– Sudden onset of shortness of breath
– Unilateral sharp chest pain
• Physical Exam:
– Tachycardia
– Unilateral Hyperresonance
– Decreased breath sounds
Pneumothorax
• Chest X-Ray- Diagnostic
Pleuritis
• Pleura membrane inflammation.
• Clinical Manifestations:
– Sharp chest pain with inhalation
– Shortness of breath
– Fever/ Chills
• Physical Exam:
– Pluritic friction rub upon auscultation
Diagnosis
• CXR-It may show air or fluid in the pleural
space. It also may show what's causing the
pleurisy –for example, pneumonia, a or a lung
tumor.
• CT- may show pockets of fluid, lung abscess or
pneumonia
• Blood tests can show bacterial or viral infectious
process
• Thoracocentesis and biopsy can be used to
determine the specific cause
Pneumonia
• Inflammation of the parenchyma of the lung due to an
infectious process.
• Clinical Manifestation:
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Fever/ Chills
Shortness of Breath
Pleuritic chest pain
Dry cough
• Physical Exam:
– Pulse- temperature dissociation ( normal pulse with high fever)
– Dull Percussion
– Rales/Rhonchi and decreased breath sounds upon auscultation
Pneumonia
• Chest X-ray can be Diagnostic.
Pulmonary Hypertension
• Increase blood pressure in lung vasculature; Mean arterial
pressure <25mmHg at rest or <30 mmhg during exercise.
• Clinical Manifestations:
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Shortness of Breath
Fatigue
Non productive cough
Angina
Cyanosis
Peripheral edema
Syncope
• Physical Exam:
– JVD
– Parasternal lift due to RV dilation
– Wide Split S2 and loud P2 in pulmonic area upon Auscultation
Pulmonary Hypertension
• ECG- right axis deviation (RVH)
• CXR- Dilated pulmonary vessels with right
ventricle enlargement.
• Echocardiogram- Dilated pulmonary Artery,
Dilation of RA/RV, right heart catherization
reveals increased pulmonary artery pressure
Treatment
• Treat Diagnosed condition:
– Pulmonary Embolism :
• O2 to correct hypoxia
• Anticouglation therapy heparin to prevent another PE and
oral warfarin for long term treatment
• Thrombolytics
• Surgical removal if large enough
• IVC filter if long h/o if DVTs/ PE
– Pneumothorax:
• Primary Pneumothorax – small , observe should resolve by
10 days; Large administer O2 and insert chest tube to allow
lung expansion
• Secondary pneumothorax- chest tube drainage
Continued Treatment
• Pleurisy
– Treat underlying cause
– NSAIDS for symptomatic pain
• Pneumonia
– Antimicrobial Therapy
• Pulmonary hypertension
• Pulmonary vasodilators ( IV prostacylines) and CCB
• Anticougulation due to venous stasis
Musculoskelatal Induced Chest Pain
• Costochondritis– Inflammation of cartilage that conncets rib to sternum
– localized sharp or dull pain
– Tenderness on palpation
• Herpes Zoster– Viral infection that causes painful rash
– Intense unilateral pain along dermatome
• Anxiety– Causes a chest tightness, sweating, hyperventilation
Questions
1. A 24 year old smoking male presents to you with a 2 hour
history of right sided chest pain. He claims that he was
walking and suddenly felt chest pain. He denied any
diaphoresis or radiation of pain. He has no other medical
problems. His father died at the age of 67 from MI. On
examination the individual is a tall male with a thin chest
wall. The best method to make your diagnosis is:
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e.
Cardiac enzymes every 8 hours
CT scan of the chest
ECG
Chest X-ray
Ultrasound of the chest
Answer
D. Spontaneous pneumothorax has no
provoking factors. It usually occurs in tall
males who smoke. The diagnosis can easily
be made by a chest x-ray.
2. A 65 year old female underwent hip replacement surgery 2
days ago. On the third postoperative day, she suddenly
became anxious, dyspneic and tachycardic. She has a
history of anxiety and takes lorazepam for it. Her vital signs
are BP-100/50, Pulse- 120/min RR- 36/min, O2 sat is 86%
on 6 LNC and afebrile. Lung examination is
unremarkable.Chest Xray did not show any abnormalities.
The next step of management is:
a.
b.
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d.
e.
Obtain a ABG
Intubate
Venogram
V/Q scan
Give IV Lorazapam
Answer
D. When PE is suspected Chest X-ray is usually
normal. The initial symptoms are a sudden
onset of hypoxia, tachycardia and tachypnea.
The patient is at high risk for PE due to bed
rest and surgery. The Ventilation Perfusion
scan is the next step in evaluation the patient.
If chest x-ray is negative that rules out
pneumonia, atelectasis, and pulmonary
edema. The next step is to rule out PE
References
• David A. Lipson, Steven E. Weinberger “Harrisons” Chapter
245. Approach to the Patient with Disease of the Respiratory
System
• Steven S. Agabegi, Elizabeth D. Agabegi. “Step up to
Medicine”
• Marc S. Sabetine. “ Pocket Medicine Third Edition”
• Mayo Clinic.com