Clinical Approach to Chest Pain

September 8, 2011

Dr. Scott McKay, M.D., C.C.F.P. Assistant Professor Department of Family Medicine

Im sure youve heard it already

Welcome to clerkship! This will be your most exciting year of medical school! Dont stress (too much) and enjoy!

Objectives
By the end of this lecture, you will:
Be able to identify common causes of chest pain Be familiar with the evaluation and diagnostic approach to a patient with chest pain Be familiar with the emergent care of a patient with acute coronary syndrome

Case 1
You are working in a rural ER in northern Ontario and the local EMS radios in They are 3 minutes out coming in Code 4 CTAS 2 with a 63 year old male having chest pain Your preceptor just ran across the street to the local diner to buy lunch

Case 2
A 50 year old female presents to the family medicine office you are working at Shes anxious and complaining of chest pain and palpitations x 1 hour She was widowed 8 months ago and lost her job 2 weeks ago (and now worried she cant afford her daughter's medical school tuition)

Case 3
Your first night on general surgery call, the floor calls you at 2 A.M. to assess a patient POD #4 (left hemicolectomy for colon cancer) with shortness of breath and chest pain

As we discussed before
(remember spectrum/consolidation week?)

HUGE differential diagnosis

?CARDIAC ?RESPIRATORY ?MUSCULOSKELETAL ?GASTROINTESTINAL ?PSYCHOGENIC

Esophagitis (GERD) - Esophageal spasm Peptic ulcer disease - Angina Myocardial Infarction - Rib Fracture Costochondritis/MSK - Pericarditis Aortic dissection - Pleurisy Pulmonary embolus - Pulmonary hypertension Pneumothorax - Radiculopathy Shoulder arthropathy - Cholecystitis Pancreatitis - Pneumonia Psychological: Anxiety and panic disorders Gastritis or nonulcer dyspepsia

As we discussed before
HUGE differential diagnosis

You MUST identify and rule out life threatening causes of chest pain

Life Threatening causes of Chest Pain

Acute coronary syndrome Aortic dissection Pulmonary embolism Tension pneumothorax Pericardial tamponade Mediastinitis (eg, Esophageal rupture)

Acute Coronary Syndromes (ACS)

Unstable Angina (UA) Non-ST Elevation Myocardial Infarction (Non-STEMI) ST Elevation Myocardial Infarction (STEMI)

As we discussed before
HUGE differential diagnosis You MUST identify and rule out life threatening causes of chest pain

The differential depends on the setting

Primary Care

Other settings
Hospital in-patients
Co-morbidities Post-operative

Emergency room
More serious causes? Up to 20-33% of patients presenting to ER could have CP attributable to a psychiatric diagnosis

Evaluation of Chest Pain

Systematic approach needed! Description of chest pain Quality of the pain Region/location of pain Radiation Temporal elements Provocation Palliation Severity Associated symptoms Risk factors Physical examination Investigations
ECG Chest X-ray Blood work Other

Cardiac Risk Factors

Hypertension
>140/90 or treated

Diabetes
More than doubles cardiac risk

Hyperlipidemia
LDL > 3.5 mmol/L or treated

Tobacco use
current or within 5 yrs, > 40 pack-years ++ significant

Family History
1st degree male or female relative < 60 yrs

Cumulative Absolute Risk of CVD at 5 Years

(Up to Date Online v19.2; Adapted from Jackson, R, Lawes, CM, Bennett, DA, et al, Lancet 2005; 365:434)

Algorithm for diagnosis

(Adapted from: Diagnostic approach to chest pain in adults. UpToDate Online 19.2)

History (focused) and physical is the best place to start! ECG is quick and easy VITALS! Look at the patient
Do they look well or ill? The cause may be obvious!

Algorithm for diagnosis

(Adapted from: Diagnostic approach to chest pain in adults. UpToDate Online 19.2)

Step 1 (Evaluate need for emergent care)

Consider potentially life-threatening causes of chest pain If acute coronary syndrome suspected start emergent care If emergent and not ACS, start appropriate emergent care

Emergent Care Initial Steps...

GET HELP! Have staff physician or more senior team member called/paged Dont forget nurses and RTs

Emergent Care Initial Steps...

Airway, Breathing, and Circulation assessed 12-lead ECG obtained Resuscitation equipment brought nearby Cardiac monitor attached Oxygen given IV access and blood work obtained Aspirin 160 to 325 mg given Nitrates and morphine given (unless contraindicated)

ACS Emergent Care

M orphine
2 4 mg IV q5-15 min

O xygen N itro
0.4 mg SL q5min x 3

A spirin
160-325 mg chewed

Algorithm for diagnosis

(Adapted from: Diagnostic approach to chest pain in adults. UpToDate Online 19.2)

Step 2 (Emergent care not needed)

If cardiac cause likely based on symptoms that are suggestive of angina and/or a history of cardiac risk factors, proceed to Step 3 Otherwise, proceed to Step 4

Step 3 (Symptoms consistent with stable angina)

Evaluate the patient for cardiac disease and consider starting outpatient management (aspirin, beta blockers, nitroglycerin, and education ) If the results of the evaluation do not demonstrate cardiac disease, proceed to Step 4

Step 4 (Evaluation for cardiac disease was negative)

Evaluate the patient for other causes of chest pain gastrointestinal disease, respiratory disease, musculoskeletal disease, psychogenic disease

Important points on history

Worsening in the frequency, intensity, duration, and timing (eg, nocturnal pain, rest pain) of prior anginal or anginal equivalent symptoms New onset symptoms of shortness of breath, nausea, sweating, extreme fatigue in a patient with a known history of cardiovascular disease Onset of typical anginal symptoms in a patient without a history of cardiovascular disease Age greater than 70 years Diabetes mellitus Women Extracardiac vascular disease (PVD, PAD, CVA)

Arguments against cardiac pain

Pain less than 30 seconds or lasting weeks If the pain can be localized with one finger If the pain is immediately severe with no crescendo pattern If the pain occurs only at rest

Investigations
12 Lead ECG
Findings depend on
Duration hyperacute/acute versus evolving/chronic Size amount of myocardium affected Localization
Lateral = Leads I, AVL, V5, & V6 Inferior = Leads II, III, & AVF Anterior = Leads V1-4 Posterior = Leads V4R, V8, V9 (need 15 lead ECG)

ECG
Possible findings in ACS
ST segment elevation or depression Q-waves New conduction defect T-wave inversion

NORMAL ECG!

T-wave inversion

Inferior myocardial infarction (Q waves and ST elevations)

Anterior ischemia (ST depressions in leads V2 and V3)

Points to remember for ECGs

Initial ECG is often NOT diagnostic in patients with ACS
In patients who ended up with an MI, initial ECG was nondiagnostic in 45 percent and normal in 20 percent

Dont assume a normal ECG obtained while patient having chest rules out ACS

Investigations
Chest x-ray
Usually non-diagnostic in ACS Helps to identify other important conditions
Congestive heart failure Pnuemonia Pnuemothorax Pleural effusion Widened mediastinum (aortic dissection)

Normal CXR!

Left lower lobe pneumonia

1. Interstitial pulmonary edema 2. Bilateral perihilar alveolar edema 3. Bilateral pleural effusions.

Investigations
Blood work
Standard sets of blood work will be done in ER In other locations, you may have to decide Troponin-T (@ LHSC) and CK most important for myocardial infarction Other hospitals may use Troponin-I

Cardiac Enzymes
Cardiac Troponins
Blood levels rise after 3-6 hours (can be negative at initial assessment!) Peak at 12-20 hours

Creatine Kinase (CK)

May rise earlier than troponin, but less specific for cardiac muscle

ALWAYS repeat in 6-8 hours if suspicious for acute cardiac event (ie, non-STEMI)

Other treatment options...

Thrombolytics (fibronolysis) Beta-blockers Anticoagulant therapy

Thrombolytic/Fibrinolytic Therapy
(ACC/AHA guidelines)

Primary percutaneous coronary intervention (PCI) is preferred If no PCI available & no contraindications
STEMI patients with symptom onset within the prior 12 hours and ST elevation greater than 0.1 mV in at least 2 contiguous precordial leads or at least 2 adjacent limb leads OR STEMI patients with symptom onset within the prior 12 hours and new or presumably new LBBB

Beta-Blockers
Reduce short term complications and increase longterm survival Oral = IV administration Start within 24 hrs of MI (if no contra-indications) IV if hypertensive at presentation
Metoprolol 5 mg (slow push over 1-2 min) q5min x 3 doses max

PO: 25 50 mg of metoprolol or atenolol

DO NOT USE in cocaine-related ACS

Anticoagulant therapy
Low Molecular Weight Heparin (LMWH)
ie, enoxaparin, dalteparin, tinzaparin

Can be used in UA, NSTEMI, or STEMI NOT an emergent treatment Regimen depends on diagnosis, prior treatment, and future treatment

BACK TO THE CASES

Case 1
You are working in a rural ER in northern Ontario and the local EMS radios in They are 3 minutes out coming in Code 4 CTAS 2 with a 63 year old male having chest pain Your preceptor just ran across the street to the local diner to buy lunch

Canadian Triage Acuity Scale

CTAS 1 - cardiac arrest, unconscious, near death asthma, severe respiratory distress, major trauma, etc. CTAS 2 head injury (w. altered mental state), severe trauma, severe allergic reaction, chest pain, severe asthma, difficulty breathing, etc. CTAS 3 head injury (alert w. vomiting), moderate trauma, moderate asthma, GI bleed with normal vitals, seizure, etc. CTAS 4 - head injury (alert no vomiting), earache, minor trauma, chest pain, vomiting and diarrhea, minor allergic reaction, corneal foreign body CTAS 5 minor trauma, sore throat, minor symptoms, etc.

AMBULANCE CALL CODES

Code 1
deferrable call - non-emergency

Code 2
scheduled call - prearranged one day in advance non-emergency

Code 3
prompt call emergency

Code 4
life threatening emergency call

Case 1 Discussion
WHAT DO YOU DO??? Pulse check... ...your own!

Case 1 Discussion
ABCs 12-lead ECG obtained Resuscitation equipment brought nearby Cardiac monitor attached Oxygen given IV access and blood work obtained

While you get the ECG...

Non-radiating central chest pressure Onset 20 min ago while digging trench CRF
+ve smoker +ve chol -ve htn -ve DM -ve FH

+ diaphoresis No history of similar or known CAD

ST segment depression in leads I, aVL, and V4-V6

Now What?
M orphine
2 4 mg IV q5-15 min

O xygen N itro
0.4 mg SL q5min x 3

A spirin
160-325 mg chewed

Beginning of the end...

Pain resolved after nitro x 2 Repeat ECG shows resolved changes 1st set of cardiac enzymes pending Will monitor/admit for second set and further investigations
Angiogram/PCI Exercise stress testing

Case 2
A 50 year old female presents to the family medicine office you are working at Shes anxious and complaining of chest pain and palpitations x 1 hour She was widowed 8 months ago and lost her job 2 weeks ago (and now worried she cant afford her daughter's medical school tuition)

Case 2 cont
PMH = diabetes mellitus type II, smoker (recently increased due to stress), hypertension, high cholesterol, and generalized anxiety disorder Medications = metformin, ramipril, simvastatin, citalopram, clonazepam

Now What?
Vitals ECG (if available) (brief) History Then... 911 or continue office assessment

Case 3
Your first night on general surgery call, the floor calls you at 2 A.M. to assess a patient POD #4 (left hemicolectomy for colon cancer) with shortness of breath and chest pain

Case 3 Discussion
Doing it all right! Start initial care over phone
IV access, O2 ECG CXR (portable) Bloodwork (incl. cardiac enzymes)

Call your resident Rush to the floor to assess (thinking of differential)

Classic S1Q3T3 findings of... ...pulmonary embolism!

Risk factors for PE

Immobilization Surgery within the last three months Stroke/ paresis/ paralysis History of venous thromboembolism Malignancy Central venous instrumentation within the last three months Chronic heart disease

Additional risk factors identified in women Obesity (BMI 29 kg/m2) Heavy cigarette smoking (>25 cigarettes per day) Hypertension

Take home points...

Think about common causes of chest pain first Develop a systematic (and consistent) approach to the evaluation of a patient with chest pain Know the emergent/initial care of a patient with acute coronary syndrome

Questions? smckay28@uwo.ca

THANKS & GOOD LUCK!