chest pain 2014.ppt

8/11/2019 chest pain 2014.ppt

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Approach to Chest PainIntern Bootcamp, 2014

Nathan Stehouwer, MD

PGY-4, Internal Medicine & Pediatrics


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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

EsophagealRupture/Perforation

GERD Mediastinitis

RUQ pathology

Panic attack


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Pearl: ALWAYS have the patientpoint to the pain!


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Typical vs. Atypical Chest Pain

Typical

Characterized asdiscomfort/pressure rather than

pain Time duration >2 mins

Provoked by activity/exercise

Radiation (i.e. arms, jaw)

Does not change withrespiration/position

Associated withdiaphoresis/nausea

Relieved by rest/nitroglycerin

Atypical

Pain that can be localized withone finger

Constant pain lasting for days Fleeting pains lasting for a few

seconds

Pain reproduced bymovement/palpation


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UpToDate 2012


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Cayley 2005


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Case 1

You are the orphan intern on Wearn team at 6PM. Youare called by the nurse because Ms. Z has developedchest pain. Ms. Z is a 62 yo F with PMHx of CAD s/premote PCI to the LAD, COPD and right THA 3 weeksago who was admitted for a COPD exacerbation.

What would you do next?


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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!


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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 ifavailable

If patient looks unstable or has concerning EKG findings, callyour senior resident for help

Write a clinical event note!


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focused physical exam for chest painVital 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


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Case 1

You go see the patient. She had been feeling better after gettingduonebs, but suddenly developed chest pain that is L-sided, 8/10and 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


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Case 1


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Case 1


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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


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Next moves

DDIMER: 95% sensitive, VERY nonspecific

ABGElevated A-a gradient fairly sensitive, highly

nonspecific

EKGmost commonly nonspecific changes (ST/T wave

changes, etc)

V/Q scanhelpful 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


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Case 1


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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


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Acute Pulmonary Embolism

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 bleedingrisk

Management


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Search heparin infusion orders


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Pearl: If you have a moderate

or high suspicion of PE, youcan start anticoagulation while

awaiting full diagnostic workup


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Get report from ED physician about the patient

Ask ED physician about patients 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 patientresponded


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Go to UH Portal and print out an oldEKG for comparison

Review prior discharge summaries

Quickly review prior cardiac work upecho, stress tests and cath reports

Go see the patient!


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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 isretrosternal, 7/10, associated with nausea anddiaphoresis.


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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


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Next Steps

Review EKG

Review CXR

Troponin

SL Nitroglycerin


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Case 2


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Case 2 Diagnosis: UA/NSTEMI

EKG changes in Acute Coronary Syndromes:

ST elevations

ST depressions

T wave inversions

pseudonormalizationinversion of previously inverted T waves when

compared with old EKG

New conduction block

Q waves

Importance of serial EKG monitoring: sensitivity of singleEKG is only 50% sensitive for acute MI


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Unstable Angina/NSTEMI: Initial

Management

Stabilizeplaque

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


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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.


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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


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Pearl

Inability to ELIMINATE chest pain in a patient

with ACS using maximal medical therapy

=Urgent call to cardiology for consideration of

immediate catheterization


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Trivia


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What typical ACS med should you

NOT give this patient?


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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 100

SBP


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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 chestpain. 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.


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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


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Thoracic aortic dissection

Hypertension

Atherosclerosis

Preexisting aneurysm (known history in 13% of patients)

Inflammatory conditions affecting aorta (Takayasu, Giant CellArteritis, 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

Risk Factors


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Type A Type B

Thoracic aortic dissection

Surgery!

Do not delay surgery, evenfor LHC

Beta blockers, titrate to HR

50-60 (labetalol, esmolol)

BP control (nitroprusside)

Beta blockers, titrate to HR50-60 (labetalol, esmolol)

BP controladdnitroprusside or similar agentto SBP goal 100-120mmHg

Surgery for those with endorgan damage or those whodo not respond to medicaltherapy

Watch for hypotensiongivefluids if needed, considertamponade, MI, or rupture ascomplications if hypotensive

Management


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Case 4

You are on long call on VA Blue. You are calledto admit a 53 yo M from the ED for chest painand EKG abnormalities

PMHx: HTN Dyslipidemia

You go see the patient and he tells you that

he has had this chest pain for ~2 days, butit has progressively gotten worse. Hischest pain is worse with breathing. Henotes a recent viral URI.


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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 inbed

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


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Case 4

EKG on admission:


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Case 4 - Pericarditis

Refers to inflammation of pericardial sac

Idiopathic pericarditis typically preceded byviral prodrome, i.e. flu-like symptoms

Typically, patients have sharp, pleuriticchest pain relieved by sitting up or leaningforward


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Goyle 2002


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Case 4Pericarditis

Per 2003 ACC guidelines, all patients diagnosed with

pericarditis should receive echocardiogram

High risk features:

Fever (>38C [100.4F]) 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


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Case 4 - Pericarditis

Treatment

UpToDate 2012


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Case 5

This is a 45 yro M with PMHx of rheumatoid arthritis whopresented with progressive sob. He was found to have a R-sided pleural effusion and underwent an US guided

thoracentesis with removal of 1.5 liters of pleural fluid. Twohours after his procedure, he develops new onset R-sidedchest pain


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Case 5


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Case 5 - Pneumothorax

Management of Pneumothorax

100% O2and observation in stable patients for PTX < 3 cm insize

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


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Pearl

Great EKG Practice Site:http://ecg.bidmc.harvard.edu/maven/mavenmain.asp
http://ecg.bidmc.harvard.edu/maven/mavenmain.asphttp://ecg.bidmc.harvard.edu/maven/mavenmain.asp


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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 ofChest Physicians evidence-based clinical practice guidelines. Chest. 2012 Feb;141(2 Suppl):e419S-94S.Cayley, W.E. Diagnosing thecause 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. JACC60 (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 ofacute 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-chest-

pain-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-chest-

pain-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-chest-

pain-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/clinical-

presentation-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-acute-pericarditis?source=search_result&search=pericarditis&selectedTitle=2%7E150

Thanks to Sumit Bose for use of a number of his excellent slides!
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