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Page 1: Chest Pain Sumit Bose, MD PGY-3. Objectives Overview of chest pain Differential diagnosis of chest pain Typical vs. atypical chest pain Evaluation of

Chest Pain

Sumit Bose, MDPGY-3

Page 2: Chest Pain Sumit Bose, MD PGY-3. Objectives Overview of chest pain Differential diagnosis of chest pain Typical vs. atypical chest pain Evaluation of

Objectives

Overview of chest pain Differential diagnosis of chest pain Typical vs. atypical chest pain Evaluation of chest pain Review patient cases

Page 3: Chest Pain Sumit Bose, MD PGY-3. Objectives Overview of chest pain Differential diagnosis of chest pain Typical vs. atypical chest pain Evaluation of

Overview Chest pain accounts for 6 million annual

visits to the EDs in the United States Chest pain is the second most common

ED complaint Patients with chest pain present with a

wide spectrum of signs and symptoms It is up to the clinician to recognize the

life-threatening causes of chest pain

Page 4: Chest Pain Sumit Bose, MD PGY-3. Objectives Overview of chest pain Differential diagnosis of chest pain Typical vs. atypical chest pain Evaluation of

Overview

Cayley 2005

Page 5: Chest Pain Sumit Bose, MD PGY-3. Objectives Overview of chest pain Differential diagnosis of chest pain Typical vs. atypical chest pain Evaluation of

Pearl 1

CHEST PAIN ≠ ACSPOSITIVE TROPONIN ≠ ACS

Page 6: Chest Pain Sumit Bose, MD PGY-3. Objectives Overview of chest pain Differential diagnosis of chest pain Typical vs. atypical chest pain Evaluation of

Life-threatening causes of chest pain

Acute coronary syndrome (unstable angina, NSTEMI, STEMI)

Aortic dissection Pulmonary embolism Pneumothorax Tension pneumothorax Pericardial tamponade Mediastinitis (e.g. esophageal rupture)

Page 7: Chest Pain Sumit Bose, MD PGY-3. Objectives Overview of chest pain Differential diagnosis of chest pain Typical vs. atypical chest pain Evaluation of

Differential diagnosis

UpToDate 2012

Page 8: Chest Pain Sumit Bose, MD PGY-3. Objectives Overview of chest pain Differential diagnosis of chest pain Typical vs. atypical chest pain Evaluation of

Typical vs. Atypical Chest Pain

Typical

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

Atypical

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

Page 9: Chest Pain Sumit Bose, MD PGY-3. Objectives Overview of chest pain Differential diagnosis of chest pain Typical vs. atypical chest pain Evaluation of

Typical vs. Atypical Chest Pain

UpToDate 2012

Page 10: Chest Pain Sumit Bose, MD PGY-3. Objectives Overview of chest pain Differential diagnosis of chest pain Typical vs. atypical chest pain Evaluation of

Typical vs. Atypical Chest Pain

Cayley 2005

Page 11: Chest Pain Sumit Bose, MD PGY-3. Objectives Overview of chest pain Differential diagnosis of chest pain Typical vs. atypical chest pain Evaluation of

Evaluation of Chest Pain

Scenario 1 - It’s 2:00 AM and you are the VA NF intern. The nurse pages you and tells you that Mr. S, a 67 yro M with known hx of CAD, who is admitted for ARF is having chest pain after he walked back from the bathroom. What would you do next?

Page 12: Chest Pain Sumit Bose, MD PGY-3. Objectives Overview of chest pain Differential diagnosis of chest pain Typical vs. atypical chest pain Evaluation of

Evaluation of Chest Pain

Scenario 1: Ask nurse for most current set of

vital signs Ask nurse to get an EKG Ask nurse to have the admission

EKG at bedside if available Go see the patient!

Page 13: Chest Pain Sumit Bose, MD PGY-3. Objectives Overview of chest pain Differential diagnosis of chest pain Typical vs. atypical chest pain Evaluation of

Evaluation of Chest Pain

Once at bedside, determine if patient is stable or unstable

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

Page 14: Chest Pain Sumit Bose, MD PGY-3. Objectives Overview of chest pain Differential diagnosis of chest pain Typical vs. atypical chest pain Evaluation of

Evaluation of Chest Pain If patient is stable:

Perform a focused history Does patient have known CAD or other cardiac risk factors? Is the pain typical/atypical? Is the pain similar to prior MI?

Perform a focused physical exam Look for tachycardia, hypertension/hypotension or hypoxia on vital

signs 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

Page 15: Chest Pain Sumit Bose, MD PGY-3. Objectives Overview of chest pain Differential diagnosis of chest pain Typical vs. atypical chest pain Evaluation of

Evaluation of Chest Pain

Labs/imaging/disposition CXR Cardiac biomarkers ABG? Telemetry/ICU

Write a clinical event note!

Page 16: Chest Pain Sumit Bose, MD PGY-3. Objectives Overview of chest pain Differential diagnosis of chest pain Typical vs. atypical chest pain Evaluation of

Evaluation of Chest Pain

Scenario 2 - You are the orphan intern and you get a page from 67121 and the DACR informs you that you have a 45 yro female in the ED who is being admitted to the Hellerstein service for r/o ACS. How would you approach this patient?

Page 17: Chest Pain Sumit Bose, MD PGY-3. Objectives Overview of chest pain Differential diagnosis of chest pain Typical vs. atypical chest pain Evaluation of

Evaluation of Chest Pain

Scenario 2: Get report from ED physician about

the patient Ask ED physician about patient’s

initial presentation Get last set of vital signs Ask ED physician to order EKG and

CXR

Page 18: Chest Pain Sumit Bose, MD PGY-3. Objectives Overview of chest pain Differential diagnosis of chest pain Typical vs. atypical chest pain Evaluation of

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

Review any labs/imaging from current ED visit

Page 19: Chest Pain Sumit Bose, MD PGY-3. Objectives Overview of chest pain Differential diagnosis of chest pain Typical vs. atypical chest pain Evaluation of

CASES

Page 20: Chest Pain Sumit Bose, MD PGY-3. Objectives Overview of chest pain Differential diagnosis of chest pain Typical vs. atypical chest pain Evaluation of

Case 1

You are on the Wearn team and the nurse calls you and tells you that Ms. Z suddenly started having chest pain and her O2 sat went from 94% on room air to 88% on 2L via NC

Page 21: Chest Pain Sumit Bose, MD PGY-3. Objectives Overview of chest pain Differential diagnosis of chest pain Typical vs. atypical chest pain Evaluation of

Case 1 Ms. Z is a 62 yro 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 EKG on admission:

Page 22: Chest Pain Sumit Bose, MD PGY-3. Objectives Overview of chest pain Differential diagnosis of chest pain Typical vs. atypical chest pain Evaluation of

Case 1 You go see the patient. The patient tells you that she was feeling

better after getting duonebs during this admission, but suddenly developed chest pain that is L-sided, 8/10 and worse with breathing. She has never experienced pain like this in the past

Vital signs: Afebrile, HR 120, BP 110/70, RR 28, O2 sat 89% on 2L 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

Page 23: Chest Pain Sumit Bose, MD PGY-3. Objectives Overview of chest pain Differential diagnosis of chest pain Typical vs. atypical chest pain Evaluation of

Case 1

Page 24: Chest Pain Sumit Bose, MD PGY-3. Objectives Overview of chest pain Differential diagnosis of chest pain Typical vs. atypical chest pain Evaluation of

Case 1

Page 25: Chest Pain Sumit Bose, MD PGY-3. Objectives Overview of chest pain Differential diagnosis of chest pain Typical vs. atypical chest pain Evaluation of

Case 1

Page 26: Chest Pain Sumit Bose, MD PGY-3. Objectives Overview of chest pain Differential diagnosis of chest pain Typical vs. atypical chest pain Evaluation of

Case 1 - Pulmonary Embolism

Cayley 2005

Page 27: Chest Pain Sumit Bose, MD PGY-3. Objectives Overview of chest pain Differential diagnosis of chest pain Typical vs. atypical chest pain Evaluation of

Case 1 - Pulmonary Embolism

Diagnostic testing Pulmonary angiography (Gold

standard) Spiral CT (CT-PE protocol) V/Q scan (helpful for detecting chronic

VTE) D-dimer (<500ng/ml helps exclude PE

in patient with low/moderate pre-test probability)

Page 28: Chest Pain Sumit Bose, MD PGY-3. Objectives Overview of chest pain Differential diagnosis of chest pain Typical vs. atypical chest pain Evaluation of

Case 1 - Pulmonary Embolism

Treatment of PE Anticoagulant therapy is primary therapy

for PE Unfractionated heparin LMWH

For unstable patients, catheter embolectomy or surgical embolectomy are options

For patients at risk for bleeding, IVC filter is an alternative

Page 29: Chest Pain Sumit Bose, MD PGY-3. Objectives Overview of chest pain Differential diagnosis of chest pain Typical vs. atypical chest pain Evaluation of

Case 2 24 yro M is being admitted to you from the

ED for chest pain and EKG abnormalities PMHx:

SLE Asthma

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 does report getting over a recent URI few days ago

Page 30: Chest Pain Sumit Bose, MD PGY-3. Objectives Overview of chest pain Differential diagnosis of chest pain Typical vs. atypical chest pain Evaluation of

Case 2 VS: T 38.1 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

Page 31: Chest Pain Sumit Bose, MD PGY-3. Objectives Overview of chest pain Differential diagnosis of chest pain Typical vs. atypical chest pain Evaluation of

Case 2 EKG on admission:

Page 32: Chest Pain Sumit Bose, MD PGY-3. Objectives Overview of chest pain Differential diagnosis of chest pain Typical vs. atypical chest pain Evaluation of

Case 2 - Pericarditis Refers to inflammation of pericardial

sac

Preceded by viral prodrome, i.e. flu-like symptoms

Typically, patients have sharp, pleuritic chest pain relieved by sitting up or leaning forward

Page 33: Chest Pain Sumit Bose, MD PGY-3. Objectives Overview of chest pain Differential diagnosis of chest pain Typical vs. atypical chest pain Evaluation of

Case 2 - Pericarditis

Goyle 2002

Page 34: Chest Pain Sumit Bose, MD PGY-3. Objectives Overview of chest pain Differential diagnosis of chest pain Typical vs. atypical chest pain Evaluation of

Case 2 - Pericarditis

Goyle 2002

Page 35: Chest Pain Sumit Bose, MD PGY-3. Objectives Overview of chest pain Differential diagnosis of chest pain Typical vs. atypical chest pain Evaluation of

Case 2 - Pericarditis

Diagnostic criteria

UpToDate 2012

Page 36: Chest Pain Sumit Bose, MD PGY-3. Objectives Overview of chest pain Differential diagnosis of chest pain Typical vs. atypical chest pain Evaluation of

Case 2 - Pericarditis Treatment

UpToDate 2012

Page 37: Chest Pain Sumit Bose, MD PGY-3. Objectives Overview of chest pain Differential diagnosis of chest pain Typical vs. atypical chest pain Evaluation of

Case 3 You are evaluating a patient on the Carpenter

team with chest pain

Patient is a 67 yro M with PMHx of HTN, HLD, DM-2 and CAD s/p PCI to the LCx in 2007 who is admitted for L leg cellulitis. He develops new onset chest pain that is retrosternal, 7/10, associated with nausea and diaphoresis. Says pain is radiating to his L jaw and is similar to the chest pain he had during his last MI

Page 38: Chest Pain Sumit Bose, MD PGY-3. Objectives Overview of chest pain Differential diagnosis of chest pain Typical vs. atypical chest pain Evaluation of

Case 3 VS: T 37 HR 108 BP 105/60 RR 20 O2 sat

93% on RA Physical exam:

Gen – actively having chest pain, diaphoretic Lungs – rales at bilateral bases Heart – tachycardic, nl s1/s2, no mumurs or

rub Rest of the exam benign

Labs: CBC wnl, RFP wnl, Troponin = 3.2, CKMB = 9, CK = 345

Page 39: Chest Pain Sumit Bose, MD PGY-3. Objectives Overview of chest pain Differential diagnosis of chest pain Typical vs. atypical chest pain Evaluation of

Case 3

Page 40: Chest Pain Sumit Bose, MD PGY-3. Objectives Overview of chest pain Differential diagnosis of chest pain Typical vs. atypical chest pain Evaluation of

Case 3 - NSTEMI

Risk stratification?

Page 41: Chest Pain Sumit Bose, MD PGY-3. Objectives Overview of chest pain Differential diagnosis of chest pain Typical vs. atypical chest pain Evaluation of

Case 3 - NSTEMI

Management of UA/NSTEMI Aspirin

Inhibits platelet aggregation HR control with beta-blocker

Titrate to goal HR ~ 60 beats/min Statin Nitroglycerin SL

Use if patient having active chest pain DO NOT USE if patient is hypotensive and concern

for RV infarct

Page 42: Chest Pain Sumit Bose, MD PGY-3. Objectives Overview of chest pain Differential diagnosis of chest pain Typical vs. atypical chest pain Evaluation of

Case 3 - NSTEMI

Management of UA/NSTEMI Plavix

P2Y12 receptor blocker Inhibits platelet aggregation

Anticoagulation Heparin/LMWH

Inhibits thrombus formation

Oxygen For O2 sat <90%

Morphine For refractory chest pain, unrelieved by NTG SL

Page 43: Chest Pain Sumit Bose, MD PGY-3. Objectives Overview of chest pain Differential diagnosis of chest pain Typical vs. atypical chest pain Evaluation of

Pearl 2

USE THE CHEST PAIN ORDER SET!

Page 44: Chest Pain Sumit Bose, MD PGY-3. Objectives Overview of chest pain Differential diagnosis of chest pain Typical vs. atypical chest pain Evaluation of

Order Set

Page 45: Chest Pain Sumit Bose, MD PGY-3. Objectives Overview of chest pain Differential diagnosis of chest pain Typical vs. atypical chest pain Evaluation of

QUICK CASES

Page 46: Chest Pain Sumit Bose, MD PGY-3. Objectives Overview of chest pain Differential diagnosis of chest pain Typical vs. atypical chest pain Evaluation of

Case 4

Page 47: Chest Pain Sumit Bose, MD PGY-3. Objectives Overview of chest pain Differential diagnosis of chest pain Typical vs. atypical chest pain Evaluation of

Case 4

You find out the patient is having crushing chest pain radiating to the back. His BP in the R arm = 193/112 and in the L arm = 160/99

What diagnosis is on top of your differential?

Page 48: Chest Pain Sumit Bose, MD PGY-3. Objectives Overview of chest pain Differential diagnosis of chest pain Typical vs. atypical chest pain Evaluation of

Case 4 - Aortic Dissection

Stanford Classification Type A – Involves ascending aorta Type B – Involves any other part of aorta

Diagnostic Imaging CXR CT chest with contrast MRI chest TEE

Page 49: Chest Pain Sumit Bose, MD PGY-3. Objectives Overview of chest pain Differential diagnosis of chest pain Typical vs. atypical chest pain Evaluation of

Case 4 - Aortic Dissection

Management of Aortic Dissection Type A dissection – Surgical Type B dissection – Medical

Mainstay of medical therapy Pain control HR and BP control

Goal HR = 60 beats/min, goal SBP = 100-120 mmHg Use IV beta-blockers (i.e. Labetalol, Esmolol) Can also use Nitroprusside for BP control AVOID Hydralazine

Page 50: Chest Pain Sumit Bose, MD PGY-3. Objectives Overview of chest pain Differential diagnosis of chest pain Typical vs. atypical chest pain Evaluation of

Case 5

This is a 45 yro M with PMHx of rheumatoid arthritis who presented 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. Two hours after his procedure, he develops new onset R-sided chest pain

Page 51: Chest Pain Sumit Bose, MD PGY-3. Objectives Overview of chest pain Differential diagnosis of chest pain Typical vs. atypical chest pain Evaluation of

Case 5

Page 52: Chest Pain Sumit Bose, MD PGY-3. Objectives Overview of chest pain Differential diagnosis of chest pain Typical vs. atypical chest pain Evaluation of

Case 5 - Pneumothorax

Management of Pneumothorax Supplemental 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

Page 53: Chest Pain Sumit Bose, MD PGY-3. Objectives Overview of chest pain Differential diagnosis of chest pain Typical vs. atypical chest pain Evaluation of

Pearl 3

ECG Wave-Mavenhttp://ecg.bidmc.harvard.edu/maven/mavenmain.asp

Page 54: Chest Pain Sumit Bose, MD PGY-3. Objectives Overview of chest pain Differential diagnosis of chest pain Typical vs. atypical chest pain Evaluation of

Summary Chest pain is a very common complaint but

has a broad differential Always try to rule out the life-threatening

causes of chest pain It is important to remember that troponin

elevation DOES NOT always mean ACS Use the history, physical exam, labs, EKG and

imaging to commit to a diagnosis Whenever you are stuck, ask for help. Your

seniors are here to help you!

Page 55: Chest Pain Sumit Bose, MD PGY-3. Objectives Overview of chest pain Differential diagnosis of chest pain Typical vs. atypical chest pain Evaluation of

References Cayley, W.E. Diagnosing the cause of chest pain. (2005). American Family Physician, Vol 72

(10), 2012-21. 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. (2012). 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. (2012). 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. (2012). 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. (2012). 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. (2012). UpToDate. http://www.uptodate.com/contents/treatment-of-acute-pericarditis?source=search_result&search=pericarditis&selectedTitle=2%7E150


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