Chest Pain
Intern Bootcamp 2015
Nathan Stehouwer, MD
Objectives: At the end of this
hour you will be able to…
 Provide initial evaluation of a patient with chest
pain
 Know where to find key order sets
 Locate old EKGs
 List the initial management considerations for life
threatening causes of chest pain
 Recite a few key pieces of Cleveland trivia
General approach:
First consider these…
Acute coronary syndromes
Pulmonary embolism
Aortic Dissection
Pneumothorax
Pericarditis with tamponade
Esophageal Rupture
Then take your time sorting out
these
 Cardiac
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
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

MI
Pericarditis
Myocarditis
Aortic Stenosis
Vasospasm
Cocaine chest pain
Cardiac syndrome X
Stress cardiomyopathy
 Pulmonary




PE
PNA
Asthma/COPD
Acute Chest Syndrome
 Pleura
 Pleuritis
 Pneumothorax
 Aorta
 Dissection
 Perforated ulcer
 Chest wall




Costocondiritis/musculoskeletal
Sternitis
Tietze syndrome
Zoster
 Esophagus




Esophageal Spasm
Eosinophilic Esophagitis
Esophageal Rupture/Perforation
GERD
 Mediastinum
 Mediastinitis
 Mediastinal tumors
 RUQ pathology




Pancreatitis
Hepatitis
Cholecystitis
choledocolithiasis
 Panic attack
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
Cayley 2005
Tip:
ALWAYS have the patient point to
the pain!
The 1980 Cleveland Browns were
known by what nickname, after
winning multiple last-second
games?
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:
 While on the phone: Ask nurse for most current
set of vital signs
 Ask nurse to get an EKG
 Obtain the admission EKG from the paper chart or
print baseline EKG from museweb
 Go see the patient!
Evaluation of Chest Pain
 Go to UH Portal->museweb and print
out an old EKG for comparison
 Review prior discharge summaries
Extra prior
“0” before
MRN
 Quickly review
cardiac work
up (9 digits total)
–echo, stress tests and cath reports
 Go see the patient!
Sign in with: UHHS/username
and usual UH system password
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 sick, has a convincing story, or has
concerning EKG findings, call your senior resident
for help/second opinion
 Write a clinical event note
IF THE PATIENT APPEARS UNSTABLE OR VITALS ARE
CONCERNING, CALL A CODE WHITE!
Toolbox for workup of Chest Pain
 EKG
 CXR, unless patient clearly stable, having no dyspnea or
desats, and has pain that is clearly musculoskeletal or GI in
origin
 Cardiac biomarkers, if patient has cardiac risk factors or
typical story
 ABG, particularly if dyspneic or having desaturations
 Therapeutic Trials (if you are not really sure)




Angina/ACS: try some sublingual NTG
GERD: Ranitidine, Maalox, BMX
Anxiety: anxiolytics
Costochondritis/MSK Pain: NSAIDs, ketorolac
 Placement of patient: Telemetry/ICU?
Case 1
 You go see the patient. She had been feeling better after
getting duonebs, but suddenly developed chest pain that is Lsided, 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, JVP at clavicle
sitting upright. Chest pain is not reproducible
 Abd – soft, NT/ND, active BS
 Ext – b/l LEs warm and well perfused
 SKIN – no rash
 What would you order next?
 What is high on your differential?
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
Case 1
Case 1
Modified Wells Criteria







Clinical symptoms of DVT (3 points)
Other diagnoses less likely than PE (3 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
 Or
 >4: likely
 </=4: unlikely
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
Tests for PE
 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 to rule out PE
 CTPE
 Sensitivity 83%
 Specificity 96%
 Moderate - high clinical probability and positive CTPE: 92-96%
chance of PE
Pro Tip #2
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
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 with mod-high bleeding risk
Search “enoxaparin
therapeutic”
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/embolectomy
 For failure of thrombolysis or likelihood of
shock/death before thrombolysis can take effect
(hours)
 Surgical thrombectomy
 Failure of above therapies
Who was the first African-American
player to play in the American
League, joining the Cleveland
Indians in 1947?
Larry Doby
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
 Call to get report from ED physician about the
patient
 Obtain most recent set of vital signs
 Ask about EKG and CXR results
 Ask what meds have been started in ER and how
patient responded
Case 2
Mr. M is a 67 yo man with of hypertension,
dyslipidemia, type II diabetes and coronary
artery disease 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. Began 1 hour ago.
Case 2
VS: T 37 HR 108 BP 105/60 RR 20 O2 sat 93%
on RA
Physical exam:
 Gen – uncomfortable from active chest pain,
diaphoretic
 Lungs – crackles at bilateral bases
 Heart – tachycardic, nl s1/s2, no mumurs or rub
 Rest of the exam benign
Next Steps
Review EKG
Trial SL Nitroglycerin
Administer aspirin
Review CXR
Check Troponin
Case 2 Labs
CBC wnl
RFP wnl
Troponin = 0.05
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
Just a reminder…
Don’t freak out! A positive troponin
does not necessarily equal ACS
Risk Stratification
Figure 2. Algorithm for risk stratification and treatment of patients with UA/NSTEMI.
Christopher P. Cannon, and Alexander G.G. Turpie
Circulation. 2003;107:2640-2645
Copyright © American Heart Association, Inc. All rights reserved.
UA/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 (order under Heparin 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 meds 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
What former Cleveland Public
Safety Director, famed for bringing
Al Capone to justice, has been
honored with his own Great Lakes
Brewing Co. beer?
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


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
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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
Excluding dissection
96% of patients have at least one of:
 Abrupt onset thoracic or abdominal pain that is
sharp/tearing/ripping
 Mediastinal widening
 Variation in pulse or blood pressure >20mmHg
between left and right arms
D-DIMER has a good negative predictive value
in lower risk patients
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
 Avoid Hydralazine
 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
What Cleveland DJ coined the
term “Rock and Roll” in 1952?
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.
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
Classically, patients have sharp, pleuritic
chest pain relieved by sitting up or leaning
forward
Goyle 2002
Differentiation of ST elevations
Acute
Pericarditis
Acute MI
Benign Early
Repolarization
Diffuse ST
segment
elevation
ST elevation in anatomically
contiguous leads; possible
reciprocal ST depression
ST elevation
predominant in V2-V5,
may be widespread
ST elevations
concave
ST elevations convex
ST elevations concave
PR depression
No PR Depression
No PR Depression
T waves upright
T waves invert as infarction
evolves
T wave may be inverted
J point notching/slurring
Goyle 2002
Or, to put it more simply:
Scary
Not Scary
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 and leukocytosis
 Cardiac tamponade or a large pericardial effusion
 Immunosuppressed state
 Warfarin therapy
 Acute trauma
 Failure to respond to NSAIDS
 Elevated cardiac troponin
Case 4 - Pericarditis
UpToDate 2012
Who was the first African-American
mayor of a major U.S. city, elected
by Cleveland in 1967?
Case 5
 You are VA MICU intern, called to assess Mr. Jones. He is a
55 yro M with COPD admitted for exacerbation. On admission
he was given solumedrol, moxifloxacin, scheduled duonebs,
and placed on BiPAP due to CO2 retention.
 He now is complaining of severe R sided chest pain, worse
with breathing.
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
 Tension Pneumothorax – don’t be afraid!
 14G angiocath into 2nd intercostal space in
midaxillary line
Case 6
 45 yo man with 3 days severe gastroenteritis presents with
worsening chest pain
 Pain is 10/10, sharp, retrosternal, constant.
 On exam, he is tachypneic, tachycardic and hypotensive.
 Crepitus is palpated over anterior chest wall
Esophageal rupture
 Precipitating events typically with positive intra-esophageal
pressure but negative intrathoracic pressure (ie retching)
 Up to 25% have no history of vomiting
 May be suggested by subcu emphysema or mediastinal
crackling on auscultation but these are insensitive and take
>1 hour to develop.
 Can be noted by medistainal air on CXR but diagnosis is by
CT or contast esophogram
Esophageal rupture - treatment
 Antibiotics
 IV PPI
 NPO
 Surgical consultation
 Drainage of fluid collections
 Remove necrotic tissue
 Consideration of surgical or endoscopic repair
Pearl
Great EKG Practice Site:
http://ecg.bidmc.harvard.edu/maven/mavenmain.asp