chest pain icu 2012

8/13/2019 Chest Pain Icu 2012

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CHEST PAIN

Mohamed Elsawy


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CHEST PAIN Accounts for 5% of all ED visits per yearDifferential diagnosis is extensive


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CHEST PAIN ANATOMYDIFFERENTIAL DIAGNOSISBRIEF OVERVIEW OF DISEASEPROCESSES CAUSING CHEST PAIN

APPROACH TO CHEST PAIN


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ANATOMY In devising a differential diagnosis forchest pain, it becomes essential toreview the anatomy of the thorax.The various components of the thoraxcan all be responsible for producing

chest pain


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ANATOMY

SKIN MUSCLES


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ANATOMY

BONES


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ANATOMY

PULMONARY SYSTEM


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ANATOMY

HEART


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ANATOMY

VASCULATURE AND GI SYSTEM AORTA AND ESOPHAGUS


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DIFFERENTIAL DIAGNOSIS OF CHEST PAIN

CHEST WALL PAINPULMONARY CAUSESCARDIAC CAUSESVASCULAR CAUSESGI CAUSESOTHER (PSYCHOGENIC CAUSES)


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DDX: CHEST PAIN CHEST WALL PAIN

-Skin and sensory nerves- Musculoskeletal system


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DDx: CHEST PAIN CHEST WALL PAIN

-Skin and sensory nerves

-Herpes Zoster- Musculoskeletal system

- Isolated Musculoskeletal Chest Pain Syndrome*Costochondritis

*Xiphoidalgia*Precordial Catch Syndrome*Rib Fractures

- Rheumatic and Systemic Diseases causingchest wall pain


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DDX: CHEST PAIN PULMONARY CAUSES

- Pulmonary Embolism

- Pneumonia- Pneumothorax/ Tension PTX- Pleuritis/Serositis

- Sarcoidosis- Asthma/COPD- Lung cancer (rare presentation)


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DDx: CHEST PAIN CARDIAC CAUSES

- Coronary Heart Disease

*Myocardial Ischemia*Unstable Angina*Angina

- Valvular Heart Disease*Mitral Valve Prolapse*Aortic Stenosis

- Pericarditis/Myocarditis


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DDX: CHEST PAIN Vascular Causes:

-Aortic Dissection


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DDX: CHEST PAIN GI CAUSES

-ESOPHAGEAL

*Reflux* Esophagitis* Rupture (Boerhaave Syndrome)* Spasm/Motility Disorder/Foreign Body

Secondary to Stricture/Web/Etc

-OTHER*Consider Pain referred from PUD, BiliaryDisease, or Pancreatitis


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DDX: CHEST PAIN PSYCHIATRIC- PANIC DISORDER- ANXIETY- DEPRESSION- SOMATOFORM DISORDERS


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CHEST PAIN BRIEF OVERVIEW OF DISEASEPROCESSES CAUSING CHEST PAIN


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CHEST WALL PAIN

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CHEST WALL PAIN HERPES ZOSTER

-Reactivation of Herpes Varicellae

- Immunocompromised patients oftenat risk for reactivation.

- 60% of zoster infections involve the trunk- Pain may precede rash


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HERPES ZOSTER Clusters of vesicles(with clear or purulentfluid) grouped on an

erythematous base.Lesions eventuallyrupture and crust.Dermatomal distribution.Usually unilateralinvolvement that halts atmidline


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CHEST WALL PAIN Musculoskeletal Pain

- Usually localized, sharp, positional

- Pain often reproducible by palpation- At times reproduced by turning or armmovement

- May elicit history of repetitive or

unaccustomed activity involving trunk/arms- Rheumatic diseases will causemusculoskeletal pain via thoracic jointinvolvement


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MUSCULOSKELETAL PAIN DIAGNOSISCOSTOCHONDRITIS

TIETZE SYNDROMEXIPHODYNIA

PRECORDIAL CATCHSYNDROME

RIB FRACTURE

CLINICAL FEATURESInflammation of costal cartilages+/- sternal articulations. NoswellingPainful swelling in one or moreupper costal cartilages.Discomfort over xyphoidreproduced by palpationSharp pain lasting for 1-2 minepisodes near the cardiac apexand associated with inspiration,poor posture, and inactivity

Pain over involved rib


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PULMONARY CAUSES OF CHESTPAIN

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PULMONARY EMBOLISM RISK FACTORS: VIRCHOWS TRIAD - Hypercoagulability

*Malignancy*Pregnancy, Early Postpartum, OCPs, HRT*Genetic Mutations: Factor V Leiden, Prothrombin, Protein C

or S deficiencies, antiphospholipid Ab, etc

- Venous Stasis* Long distance travel

* Prolonged bed rest or recent hospitalization* Cast

- Venous Injury* Recent surgery or Trauma


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PULMONARY EMBOLISM CLINICAL FEATURES- Shortness of breath- Chest pain: often pleuritic- Tachycardia, tachypnea, hypoxemia- Hemoptysis, Cough- Consider diagnosis in new onset A fib- Look for asymmetric leg swelling (signs of

DVT) which places patients at risk for PE- If massive PE, may present with hypotension, unstable

vital signs, and acute cor pulmonale. Also may present withcardiac arrest (PEA >>asystole).


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PE: DIAGNOSTIC TESTS EKG:

-Sinus tachycardia most common- Often see nonspecific abnormalities- Look for S1Q3T3

(S wave in lead I, Q wave in lead III,inverted T wave in lead III)


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PE: S1Q3T3


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PE: DIAGNOSTIC TESTS CHEST XRAY- Normal in 25% of cases

- Often nonspecific findings- Look for Hamptons Hump (triangular pleuralbased density with apex pointed towards hilum):sign of pulmonary infarction

-Look for Westermarks sign: Dilation ofpulmonary vessels proximal to embolism andcollapse distal


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CXR: Hamptons Hump and

Westermarks Sign


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PE: DIAGNOSTIC TESTS ABG:

*Look for abnormal PaO2 or A-a gradient

D Dimer:*Often elevated in PE.* Useful test in low probability patients.

*May be abnormally high in various conditions:(Malignancy, Pregnancy, sepsis, recent surgery)


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Interpretation of Results

Estimation of the pretest probability isimperative for proper application of resultsVarious methods:

Wells et al (Canada) Wicki et al (Switzerland) Kline et al (USA)


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Wells Criteria

Criteria Points

Suspected DVT 3.0

Alternative Dx less likely 3.0

Heart rate >100 bpm 1.5

Immobilization/surgery 1.5

Previous DVT/PE 1.5

Hemoptysis 1.0

Malignancy 1.0


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Wells Criteria: Risk Interpretation

Score Probabilityof PE, %

% with thisscore

Risk

0-2 points 3.6 40 Low

3-6 points 20.5 53 Moderate

>6 points 66.7 7 High


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Low Probability

D-dimer

Negative Positive

STOP V/Q Scan

Normal High Non-high

STOP US Legs Pulm Angio

DVT Normal

US 1 week TREAT

Positive Normal

STOP TREAT


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Moderate Probability

D-dimer

Negative Positive

STOP V/Q scan

Non-High High

Normal

TREAT

US legs

Normal DVT

US in 1 week

Pulm angio TREAT


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High Probability

V/Q scan

Normal Non-High High

TREAT US legs Pulm angio Pulm angio

DVT Normal

TREAT Pulm angio US 1week


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PE: DIAGNOSTIC TESTS VQ SCAN (Ventilation-Perfusion scan)-use in setting of renal insufficiency

Helical CT scan with IV contrastPulmonary angiography: Gold Standard


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PNEUMONIA CLINICAL FEATURES- Cough +/- sputum production- Fevers/chills- Pleuritic chest pain- Shortness of breath- May be preceded by viral URI symptoms- Weakness/malaise/ myalgias

- If severe: tachycardia, tachypnea, hypotension- Decreased sats-Abnormal findings on pulmonary auscultation: (rales,

decreased breath sounds, wheezing, rhonchi)


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PNEUMONIA: DIAGNOSIS CXR

If patient is to be hospitalized,Consider CBC (to look for leukocytosis)Consider sputum culturesConsider blood culturesConsider ABG if in respiratory distress


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SPONTANEOUS PNEUMOTHORAX RISK FACTORS:-Primary

* No underlying lung disease* Young male with greater height to weight ratio* Smoking: 20:1 relative risk compared to nonsmokers.

-Secondary* COPD* Cystic Fibrosis* AIDS/PCP* Neoplasms


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PNEUMOTHORAX CLINICAL FEATURES- Acute pleuritic chest pain: 95%

- Usually pain localized to side of PTX- Dyspnea- May see tachycardia or tachypnea- Decreased breath sounds on side of PTX

- Hyperresonance on side of PTX- If tension PTX, will have above findings + tracheal

deviation + unstable vital signs. This is rare complication withspontaneous PTX


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PLEURITIS/SEROSITIS Inflammation of pleura that covers lungPleuritic chest pain

Causes:- Viral etiology- SLE- Rheumatoid Arthritis- Drugs causing lupus like reaction:

Procainamide, Hydralazine, Isoniazid


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COPD/ASTHMA EXACERBATIONS CLINICAL FEATURES:- Decrease in O2 saturations- Shortness of Breath- May see chest pain- Decreased breath sounds, wheezing, or prolonged

expiratory phase on exam- Look for accessory muscle use (nasal flaring, tracheal

tugging, retractions).

Order CXR to r/o associated complications: PTX, pneumonia thatmay have led to exacerbation


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CARDIAC CAUSES OF CHESTPAIN

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RISK FACTORS FOR CAD AgeDiabetesHypertensionFamily HistoryTobacco UseHypercholesterolemiaCocaine use


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ISCHEMIC CHEST PAIN CLINICAL FEATURES- Chest pain: often described as pressure, heaviness,

tightness, squeezing- Pain usually substernal or in left chest- Pain can radiate to neck, jaw, arm- Associated symptoms: nausea, vomiting, diaphoresis,

shortness of breath, lightheadedness, palpitations- In appropriate setting, consider above associated symptoms,

as well as neck/jaw/arm pain, and epigastric pain as ischemicequivalents.

- Pain may be associated with activity- Symptoms may improve with rest or NTG


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ISCHEMIC CHEST PAIN EXERTIONAL ANGINA* BRIEF EPISODES BROUGHT ON BY EXERTION AND

RELIEVED BY REST ON NTG

UNSTABLE ANGINA* NEW ONSET* CHANGE IN FREQUENCY/SEVERITY* OCCURS AT REST

AMI* SEVERE PERSISTENT SYMPTOMS* ELEVATED TROPONIN


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ACUTE INFERIOR MI

ST ELEVATION II, III, AVF


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ISCHEMIC CHEST PAIN:

DIAGNOSTIC TESTS CARDIAC ENZYMES- Myoglobin

* Will rise within 3 hours, peak within 4-9hours, and return to baseline within 24 hrs.

- CKMB* Will rise within 4 hours, peak within 12- 24

hours and return to baseline in 2-3 days- TROPONIN I

* Will rise within 6 hours, peak in 12 hoursand return to baseline in 3-4 days


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KINETICS OF CARDIAC MARKERSAFTER AMI

MARKER DETECTION PEAK DISAPPEARANCE

Myoglobin 1 4 h 6 7 h 24 h

CK-MB mass 3

12 h 12

18 h 2

3 daysTotal CK 4 8 h 12 30 h 3 4 dayscTnI 3 12 h 12 24 h 5 7 days

These values represent averages.


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Stefan Blankenberg, MD; Renate Schnabel, MD; Edith Lubos, MD, et al., Myeloperoxidase Early Indicator of Acute Coronary Syndrome and Predictorof Future Cardiovascular Events 2005


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BIOCHEMICAL CARDIAC MARKERS IN

PTS WITH SUSPECTED ACS WITHOUT STE

CK-MB

1. Rapid, cost-efficient, accurate assays

2. Ability to detectearly reinfarction

Myoglobin

1. High sensitivity

2. Useful in earlydetection of MI

3. Detection ofreperfusion

4. Most useful inruling out MI

Troponins

1. Powerful forstratification

2. Greater sensitivity andspecificity than CK-MB

3. Detection of recent MIup to 2 weeks after onset

4. Useful for selection oftherapy

5. Detection of

Advantages

UA/NSTEMI 9/00

BIOCHEMICAL CARDIAC MARKERS IN PTS


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BIOCHEMICAL CARDIAC MARKERS IN PTS

WITH SUSPECTED ACS WITHOUT STE

CK-MB

1. Lack ofspecificity withskeletal muscledisease/injury

2. Low sensitivityduring early MI (36 h) aftersymptom onset andfor minor myocardialdamage

Myoglobin

1. Very lowspecificity withskeletal muscle injuryor disease

2. Rapid return tonormal

Troponins

1. Low sensitivityin early phase of MI(


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high sensitive Troponin I


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Timing of Trop I in Acute Coronary Syndrom (ACS)


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High sensitive Troponin update : hs TropI assays detect normal levelsof troponin


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Sensitivity and specificity of central lab Trop assays

High sensitive assays

Conventional assays

High sensitive assays allow faster diagnosis of ACS


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RTH, 09..2011

Troponin update : New IFCC listing from 2011

Guidelines acceptable high sensitive Troponin assays


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VALVULAR HEART DISEASE AORTIC STENOSIS

*Classic triad: dyspnea, chest pain, and syncope

* Harsh systolic ejection murmur at right 2nd intercostal space radiating

towards carotids* Carotid pulse: slow rate of increase* Brachioradial delay: Delay in pulses between right brachial and right radial

arteries* Try to avoid nitrates: Theses patients are preload dependent

MITRAL VALVE PROLAPSE* Symptoms include atypical chest pain, palpitations, fatigue, dyspnea

* Often hear mid-systolic click* Patients with chest pain or palpitations often respond to beta blockers.


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ACUTE PERICARDITIS

CLINICAL FEATURES- Sharp, stabbing chest pain

- Pleuritic chest pain- Pain often referred to left trapezial ridge- Pain more severe when supine.- Pain often relieved when sitting up and leaning

forward- Listen for pericardial friction rub


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ACUTE PERICARDITIS COMMON CAUSES* IDIOPATHIC* INFECTIOUS* MALIGNANCY* UREMIA* RADIATION INDUCED* POST MI (DRESSLER SYNDROME)

* MYXEDEMA* DRUG INDUCED* SYSTEMIC RHEUMATIC DISEASES


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ACUTE PERICARDITIS: DIAGNOSTIC TESTS

EKG*Look for diffuse ST segment elevation and PR depression.* If large pericardial effusion/tamponade, may see low voltage and

electrical alternansCXR* Of limited value.* Look at size of cardiac silhouette

ECHO*To look for pericardial effusion


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ACUTE PERICARDITIS

Diffuse ST segment elevation


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TAMPONADE

ELECTRICAL ALTERNANS


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MYOCARDITIS Inflammation of heart muscleFrequently accompanied by pericarditisFeverTachycardia out of proportion to feverIf mild, signs of pericarditis +fevers, myalgias,rigors, headache

If severe, will also see signs of heart failureMay see elevated cardiac enzymes


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VASCULAR CAUSES OF CHESTPAIN

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AORTIC DISSECTION

RISK FACTORS- UNCONTROLLED HYPERTENSION

- CONGENITAL HEART DISEASE- CONNECTIVE TISSUE DISEASE- PREGNANCY- IATROGENIC ( S/P AORTIC CATHETERIZATION

OR CARDIAC SURGERY)


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AORTIC DISSECTION CLINICAL FEATURES* Abrupt onset of chest pain or pain between scapulae

* Tearing or ripping pain

* Pain often worst at symptom onset* As other vessels become affected, will see- Stroke symptoms: carotid artery involvement- Tamponade: Ascending dissection into aortic root- New onset Aortic Regurgitation- Abdominal/Flank pain/Limb Ischemia: Dissection into abdominal

aorta, renal arteries, iliac arteries- AMI

* Decreased pulsations in radial, femoral, carotid arteries* Significant blood pressure differences between extremities* Usually hypertension (but if tamponade, hypotension)


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DIAGNOSIS: AORTIC DISSECTION

CXR: Look for widened mediastinumCT SCAN:

ANGIOGRAPHYTEE

** SUSPECTED DISSECTONS MUST BECONFIRMED RADIOLOGICALLYPRIOR TO OPERATIVE REPAIR.


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GI CAUSES OF CHEST PAIN

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ESOPHAGEAL CAUSES

REFLUXESOPHAGITIS

ESOPHAGEAL PERFORATIONSPASM/MOTILITY DISORDER/


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OTHER GI CAUSES In appropriate setting, consider PUD, BiliaryDisease, and Pancreatitis in differential of chestpain.


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PSYCHOLOGIC CAUSES

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PSYCHOLOGIC

Diagnosis of exclusion


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APPROACH TO THE PATIENT WITHCHEST PAIN

PUTTING IT ALL TOGETHER


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CHEST PAIN: ANCILLARY TESTING

LABS: Consider. * Baseline labs: CBC, BMP, PT/PTT* D dimer (PE)* Blood cultures (pneumonia)

* Sputum cultures (pneumonia)* Peak flow (Asthma)* ABG* Cardiac Enzymes ( MI)* Urine tox (cocaine- MI)* ESR (pericarditis)

EKG


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CHEST PAIN: ANCILLARY TESTS

IMAGING: CONSIDER * CXR

- Rib fractures

- Hamptons Hump/ Westermarks sign: PE - Infiltrates: Pneumonia- Widened mediastinum: Aortic dissection- Pneumothorax- Cardiac size: enlarged silhouette without CHF: pericardial effusion

* CT CHEST if suspect PE or Aortic Dissection

* VQ SCAN: PE* STRESS TESTS: Angina* CATH: Ischemia* ECHO* EGD: Esophageal disease

chest pain icu 2012

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