Chest Pain

Objectives

Overview of chest pain

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

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

Overview

Cayley 2005

Pearl 1

CHEST PAIN ACS

POSITIVE TROPONIN ACS

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)

Differential diagnosis

UpToDate

Typical vs. Atypical Chest

Pain
Atypical

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

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

Typical vs. Atypical Chest

Pain

UpToDate

Typical vs. Atypical Chest

Pain

Cayley 2005

Evaluation of Chest Pain

Scenario 1 - Its 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?

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!

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

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

Evaluation of Chest Pain

Labs/imaging/disposition

CXR
Cardiac biomarkers
ABG?
Telemetry/ICU

Write a clinical event note!

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?

Evaluation of Chest Pain

Scenario 2:
Get report from ED physician about
the patient
Ask ED physician about patients
initial presentation
Get last set of vital signs
Ask ED physician to order EKG and
CXR

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

CASES

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

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:

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

Case 1

Case 1

Case 1

Case 1 - Pulmonary
Embolism

Cayley 2005

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)

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

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

Case 2

VS: T 38.1 HR 104 BP 140/76 RR 20 O2 sat 95% on RA

Physical exam:

Labs:

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
WBC = 14, RFP wnl, AMI panel x 1 = negative

CXR = negative

Case 2

EKG on admission:

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

Case 2 - Pericarditis

Goyle 2002

Case 2 - Pericarditis

Goyle 2002

Case 2 - Pericarditis

Diagnostic criteria

UpToDate 2012

Case 2 - Pericarditis

Treatment

UpToDate 2012

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

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

Case 3

Case 3 - NSTEMI

Risk stratification?

Case 3 - NSTEMI

Management of UA/NSTEMI

Aspirin

HR control with beta-blocker

Inhibits platelet aggregation

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

Case 3 - NSTEMI

Management of UA/NSTEMI

Plavix

P2Y12 receptor blocker

Inhibits platelet aggregation

Anticoagulation

Heparin/LMWH

Oxygen

Inhibits thrombus formation

For O2 sat <90%

Morphine

For refractory chest pain, unrelieved by NTG SL

Pearl 2
USE THE CHEST PAIN ORDER SET!

Order Set

QUICK CASES

Case 4

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?

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

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

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

Case 5

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

Pearl 3

ECG Wave-Maven
http://ecg.bidmc.harvard.edu/maven/mavenma
in.asp

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!

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-acutepericarditis?source=search_result&search=pericarditis&selectedTitle=1%7E150
Treatment of acute pericarditis. (2012). UpToDate. http://www.uptodate.com/contents/treatmentof-acute-pericarditis?source=search_result&search=pericarditis&selectedTitle=2%7E150