CHEST PAIN
David Griffen, MD, PhDSouthern Illinois School of Medicine
Chest Pain• Acute Coronary Syndrome• Aortic Dissection• Pulmonary Embolus• Pneumothorax• Boerhaave syndrome• Myocarditis• Pericarditis• Trauma• Peptic ulcer, cholecystitis, pancreatitis• Pleurisy • GERD• Herpes Zoster• Hyperventilation• Costochondral pain• Chest wall strain
Differential DiagnosisLIKELY NOT LIKELY
SERIOUS
NOT SERIOUS
Differential DiagnosisLIKELY NOT LIKELY
SERIOUS
NOT SERIOUS
Chest Pain
• Acute Coronary Syndrome• Aortic Dissection• Pulmonary Embolus• Pneumothorax• Boerhaave syndrome• Myocarditis• Pericarditis
Chest Pain
• Acute Coronary Syndrome• Aortic Dissection• Pulmonary Embolus• Pneumothorax• Boerhaave syndrome• Myocarditis• Pericarditis
Patient #1
• This is a 47 year old male with a history of hypertension presenting to the ED with complaint of chest pain beginning 11 hours prior to arrival.
• The pain is now better but was located in the lower chest and did not radiate. It has been intermittent through the day, at times associated with some mild diaphoresis but no other symptoms.
Patient #1
• The patient did have one episode of transient paresthesias of her left hand and had a brief episode of paresthesia of his left leg without any weakness.
• He stated that this rapidly resolved when she “walked it off”.
• No extremity weakness. • Other than the hypertension, PMH is
unremarkable.
Patient #1• EKG with rate of 64, sinus rhythm, no diagnostic ST
or T wave changes• Laboratory testing negative including cardiac
markers. • The patient had some epigastric discomfort on
palpation which was completely relieved with Mylanta and Viscous xylocine.
• The patient was hypertensive in the ED.• As a precaution he was placed in the chest pain
protocol to have myocardial infarction ruled out and a stress dobutamine echocardiogram performed.
EKG
Patient #1
• Four hours after arrival, the patient complained of chest and epigastric pain. A repeat EKG showed marked bradycardia at 45. The patient was taken out of the chest pain protocol and Cardiology consulted. The patient’s pain became more intense and moved to the upper abdomen, a CT scan of the abdomen with IV and oral contrast was obtained.
Differential?
Patient #1
• The CT showed a dissection of the lower thoracic and abdominal aorta with extension of the dissection into the origin of the superior mesenteric artery and with extensive dissection into the left common iliac artery.
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Chest Pain
• Aortic Dissection
THORACIC AORTIC DISSECTION
• Commonest aortic emergency• Can occur at any age• Males and females
THORACIC AORTIC DISSECTION
• Tear in the intima layer of the artery
• Dissection occurs in the media layer of the artery
• False lumen and a true lumen• Blood from the false lumen
may enter the true lumen again through another tear in the intima, or may escape through a rupture of the adventitia
THORACIC AORTIC DISSECTION
• Risk Factors– Hypertension present in 2/3 of cases– Connective tissue disorders
• Marfan’s• Ehlers-Danlos
– Cocaine– Pregnancy– Associated with congenital cardiovascular
abnormalities• Coarctation of aorta• Patent ductus arteriosis• Bicuspid aortic valve
THORACIC AORTIC DISSECTION
• Classification– DeBakey Classification• Type I – ascending and descending aorta involved• Type II – only ascending aorta involved• Type III – only descending aorta involved
– Stanford Classification• Type A – involves ascending aorta (DeBakey Types I
and II)• Type B – involves descending aorta only (DeBakey
type III)
THORACIC AORTIC DISSECTION
• Complications– Aortic valve incompetence– Rupture• Into pericardium with pericardial tamponade• Into left chest
– Any tributary artery can be occluded by dissection
THORACIC AORTIC DISSECTION
• Symptoms– Pain is usually present
• May migrate as dissection extends• May be absent
– May have episode of syncope– Stroke symptoms– Symptoms consistent with myocardial infarction– Ischemic limb (may mimic arterial embolus)– Abdominal pain– Neurologic symptoms
THORACIC AORTIC DISSECTION
• Signs– May have pulse variations between limbs which may wax
and wane– Murmur of aortic insufficiency may be present (soft
diastolic murmur)– May have left pleural effusion seen on CXR– May see widening of the aorta on CXR– Paraparesis or parapalegia on exam– Cold leg– EKG changes
DIAGNOSIS
• CT WITH CONTRAST• Transesophageal ultrasonography (TEE)• Aortography
THORACIC AORTIC DISSECTION
• Treatment– Blood pressure control
• Nitroprusside plus a beta blocker• Labetalol
– Surgery if the ascending aorta is involved– Medical management if only the descending aorta is
involved
• Prognosis– 75% mortality in 2 weeks if not treated– 60% survival in 5 years if treated
Difficult to Diagnose
• Viljanen, et al 1986– Delay > 24 hours in 31% proximal TAD– Delay > 24 hours in 53% distal TAD
• Bickerstaff, et al 1989. 38% missed.• 1-2% mortality per hour delay in diagnosis.
Januzzi, JL, Sabatine, MS, Eagle, KA, et al. Iatrogenic aortic dissection. Am J Cardiol 2002; 89:623.
6.4 % of patients with TAD had no pain
Litigation in nontraumatic aortic diseases--a tempest in the malpractice maelstrom. - Elefteriades JA - Cardiology - 01-JAN-2008; 109(4): 263-72
SymptomsKlompis, M. 2002 Jama
• Ripping pain LR 10.8• Sudden onset pain LR 1.6• Migrating pain LR 7.6• Pulse deficit LR 5.7• Focal neurologic deficit LR 33• Diastolic murmur LR 1.8
• 12.7 % present with syncope (IRAD study)
D-dimer and TAD?
D-Dimer and TAD
• Controversial• Cutoffs?• Acute intramural hemorrhage
Consider aortic dissection when “north-south” symptoms (above and below diaphragm) are present
Patient #2
Chest Pain
• Aortic Dissection• Acute Coronary Syndrome
ACS
• Cardiac ischemia• Acute coronary syndrome covers the
spectrum of clinical conditions ranging from unstable angina to non-Q-wave myocardial infarction and Q-wave myocardial infarction
Role of ECG in ACS
Classify patients with acute ischemic chest pain into 1 of the 3 groups above within 10 minutes of arrival.
• ST elevation or new or presumably new LBBB:
strongly suspicious for injury
• ST-elevation AMI
• ST depression or dynamicT-wave inversion:
strongly suspicious for ischemia
• High-risk unstable angina/non–ST-elevation AMI
• Nondiagnostic ECG:absence of changes in ST segment or T waves
• Intermediate/low-riskunstable angina
12-Lead ECG Variations in AMI
Baseline
Ischemia—tall or inverted T wave (infarct),ST segment may be depressed (angina)
Injury—elevated ST segment, T wave may invert
Infarction (Acute)—abnormal Q wave,ST segment may be elevated and T wavemay be inverted
Infarction (Age Unknown)—abnormal Q wave,ST segment and T wave returned to normal
LATERAL LEADS = I and AVL, V5 and V6
INFERIOR LEADS = II, III and AVF
ANTERIOR LEADS = V1, V2, V3 and V4
Paper is cheap
Patient #3
• Triage note: “Dyspnea with severe distress”• Presented at noon. Dyspnea and CP started
the previous evening.• VS– RR 48– Pulse rate 36– BP 156/115
• Taken straight back and ED physician called into room
Patient #3
History from husband– PMH positive for “blood clot” in brain (cavernous sinus
thrombosis)– Patient on Lovenox QD– Under treatment for infertility
• Patient mottled, gasping, cyanotic• Becames apneic shortly after arrival• Intubated and ventilated without problems• CT Surgeon consulted and CVOR notified shortly after
patient arrived• Despite ACLS interventions, patient deteriorates to asystole
Patient #3
• CT surgeon arrives but patient in asystole.• Declared expired 1 hour after arrival• Coroner case: autopsy showed bilateral
pulmonary artery thrombosis occluding the pulmonary arteries.
Chest Pain
• Acute Coronary Syndrome• Aortic Dissection• Pulmonary Embolus
Pulmonary Embolism• Notoriously hard to Diagnosis• Symptoms– Dyspnea at rest or with exertion (73 percent) (ONSET USUALLY
WITHIN SECONDS OR MINUTES)– Pleuritic pain (44 percent)– Cough (34 percent)– Orthopnea (28 percent)– Calf or thigh pain (44 percent)– Calf or thigh swelling (41 percent)– Wheezing (21 percent)
Clinical characteristics of patients with acute pulmonary embolism: data from PIOPED II. AU Stein PD; Beemath A; Matta F; Weg JG; Yusen RD; Hales CA; Hull RD; Leeper KV Jr; Sostman HD; Tapson VF; Buckley JD; Gottschalk A; Goodman LR; Wakefied TW; Woodard PK SO Am J Med. 2007 Oct;120(10):871-9.
Pulmonary Embolism
• Signs– Tachypnea (54 percent)– Tachycardia (24 percent)– Rales (18 percent)– Decreased breath sounds (17 percent)– Accentuated pulmonic component of the second heart
sound (15 percent)– Jugular venous distension (14 percent)
Clinical characteristics of patients with acute pulmonary embolism: data from PIOPED II. AU Stein PD; Beemath A; Matta F; Weg JG; Yusen RD; Hales CA; Hull RD; Leeper KV Jr; Sostman HD; Tapson VF; Buckley JD; Gottschalk A; Goodman LR; Wakefied TW; Woodard PK SO Am J Med. 2007 Oct;120(10):871-9.
Pulmonary Embolism Caveats
• Syncope is a well documented presentation of pulmonary embolus– Syncope as an emergency department presentation of pulmonary embolism. AU Wolfe TR; Allen
TL SO J Emerg Med. 1998 Jan-Feb;16(1):27-31.
• May have elevated troponins in PE• Troponin as a risk factor for mortality in critically ill patients without acute coronary syndromes.
AU Ammann P; Maggiorini M; Bertel O; Haenseler E; Joller-Jemelka HI; Oechslin E; Minder EI; Rickli H; Fehr T SO J Am Coll Cardiol 2003 Jun 4;41(11):2004-9.
• Wells and PERC Criteria, and D-dimers, may be useful in non-pregnant patients
Include TAD and PE in your differential for syncope
Chest Pain
• Acute Coronary Syndrome• Aortic Dissection• Pulmonary Embolus
Chest Pain
• Acute Coronary Syndrome• Aortic Dissection• Pulmonary Embolus
Thank you