Chest Pain

Dr. Rakesh Gupta MD

Specialist: Pulmonologist
Lifecare Hospital: Musaffah
 Objectives
• Describe various etiologies for chest pain
• Review approach to chest pain
• Focus on life threatening causes of Chest
Pain
 Chest Pain
Common complaint in ED
5% of all ED visits or 5 million visits per year
2 million hospitalizations annually
2% of patients with acute MI are unrecognized
and discharged from the ED
Wide range of etiologies
WHAT LIES IN THE CHEST?
 Common causes of chest pain?
• Skin: Herpes zoster
• Breast
– Fibroadenomas
– Mastitis
– Gynecomastia
• Musculoskeletal
– Costochondritis
– Precordial catch syndrome
– Pectoral muscle strain
– Rib fracture
– Cervical or thoracic spondylosis (C4–T6)
– Myositis
• Esophageal
– Spasm
– Rupture
– Esophagitis
• Reflux
• Medication-related
– Neoplasm
• Gastrointestinal (GI)
– Peptic ulcer disease
– Gallbladder disease
– Liver abscess
– Subdiaphragmatic abscess
– Pancreatitis
• Pulmonary
– Pleura
• Pleural effusion
• Pneumonia
• Neoplasm
• Viral infections
• Pneumothorax
– Lung
• Neoplasm
• Pneumonia
– Pulmonary vasculature
• Pulmonary embolism  Mediastinal structures
• Pulmonary hypertension  Lymphoma
• Cardiac  Thymoma

– Pericarditis
– Myocarditis
Psychiatric
– Myocardial ischemia (stable angina, myocardial infarction,
or unstable angina)
• Vascular: Thoracic aortic aneurysm or aortic dissection
What are the 6 cause of chest pain
………………….Can be fetal

 Acute Coronary Syndromes

 Pulmonary Embolism
 Aortic Dissection
 Esophageal Rupture
 Pneumothorax
 Pneumonia
…..So how to reach to a conclusion
 What are the key parts
of the HPI in the Chest pain patient?
 History matters!
• Location: Central, left, or right
• Associated symptoms: SOB, sweating, nausea
• Timing: Gradual or sudden onset
• Provocation: What makes worse or better?
• Quality: Visceral vs somatic
• Radiation: Back, neck, arm
• Severity: Scale of 1-10
 The Rest of the History
• PMH – HTN, Diabetes, etc any recent
intervention
• Meds – Cardiac meds? Nitro? ASA? Plavix?
Coumadin?
• Allergies – Always important!
• Social – Smoker? Alcoholic? Cocaine?
• Family – Sudden Death? Early MI? DVT? PE?
What are the key parts of the
Physical?

What can you exam in only 2 minutes?

 Emergency Physical
• General Appearance
• Vital Signs (BP in both arms, Pulsus paradoxus)
• Heart (Muffled? Regular? Fast?)
• Lungs (Equal? Wet? Tympanitic?)
• Neck (JVD?)
• Abdomen (Distention?)
• Lower Limb (Edema? calf tenderness?)
 Key Investigations
• ECG
• Cardiac enzymes
• X ray chest
• USG
• CT Scans
• ECHO
• MRI
This guy is rushed back
by EMS, what do you do?
Approach to Chest Pain
INITIAL GOAL in ED is to identify life threats
– MI, PE, aortic dissection
Remember abcs always first

What are the pt’s vital signs?

Brief history and quick physical examination

ECG and X Ray Chest and order blood work

Medications if needed
 Stabilized

Secondary survey
 Case 1
• 40 years male
• History of DM and HTN
• History of dyslipidemia
• On irregular treatment
• Severe left sided chest pain
radiates to the left jaw
• Associated with profuse sweating
 Case 1

What do you do if you see this?

Case 1 - ACS
• CXR
– To look for failure and evaluate for
other cause of chest pain
• Cardiac Enzymes
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
ANGINA vs DYSPEPSIA

• Sometimes difficult to differentiate

• Both cause central chest pain with similar
accompanied symptoms
• Nitrate will relieve both pain
• Ground rule : Exclude angina first
 Remember

• That diabetics and elderly

patients are prone to silent
ischemia with minimal
symptoms. May not complain
of chest pain.
• STEMI/NSTEMI
Unstable Angina/NSTEMI/STEMI:
Initial Management
• “Stabilize” plaque
– Dual antiplatelet therapy
• Plavix load 600mg followed by daily 75mg
• ASA 324mg chewable, then 81 daily
– Anticoagulant
• UF Heparin at low intensity protocol
– Statin
• Atorvastatin 80mg
• Optimize Myocardial O2 supply/demand
– Control HR -> Short acting metoprolol, can titrate quickly
to HR <60 if BP allows. Give 5mg IV, can repeat at 5-15min
intervals. Be wary of patients with heart failure!
– Supplemental O2 if hypoxemic
– SL nitroglycerin (0.4mg), repeat every 4-5 minutes
– Morphine if still having active chest pain
 Case 2
30 years Male had an ORIF of ankle fx 2 weeks ago,
c/o sudden onset of chest pain.

What are the signs/symptoms of this disease?

What are the risk factors for this disease?
 PE Diagnosis
 Symptoms
 SOB or dyspnea- Present in 90%
 Chest pain (pleuritic)- 66% of patients with PE
 Cough with or without hemoptysis
 Sudden onset

 Signs
 Tachycardia > 100 beats per minute
 Tachypnea > 20 breaths per minute
 Hypoxia < 95% on RA (no other cause)
 Lower extremity swelling
Pulmonary Embolus Risk Factors

• Hypercoaguability
– Malignancy, pregnancy, estrogen use, factor V Leiden,
protein C/S deficiency
• Venous stasis
– Bedrest > 48 hours, recent hospitalization, long distance
travel
• Venous injury
– Recent trauma or surgery
Criteria
 PE Diagnosis
 D-dimer
 Very sensitive in low to moderate probability
 Not specific (Lots of false positives)
 Spiral CT
 Current gold standard
 Quick and available
 Caution if impaired creatinine clearance
 V/Q
 Many studies will be “Indeterminate”
 US doppler lower limb
 Surrogate maker, but DVT is treated in similar.
Management:
• Shift to ICU
• Anticoagulation
• Thrombolysis
 Case 3
• 35 years old M with sudden sharp
chest pain
• Radiating to back.
• Asymmetric pulses
 Aortic Dissection
• Blood violates aortic intimal
and adventitial layers
• False lumen is created
• Dissection may extend
proximally, distally, or in both
directions
Aortic Dissection: Risk Factors

• Bimodal distribution
– Young: Connective tissue (Marfan) or pregnancy
– Older: Most commonly > 50 (mean age 63)
• Risk factors
– Male: 66% of patients
– Hypertension: 72% of patients
– Connective tissue disease
• 30% of Marfan’s patients get dissections
– Cocaine Use
– Syphilis
Aortic Dissection Diagnosis
 CXR- Widened mediastinum, abnormal aortic knob,
pleural effusions
 Not sensitive (25% have wide mediastinums)

 Chest CT- Very sensitive and specific

 Quickly obtained
 Must think about kidney + contrast

 Angiography- Gold standard

 Most reliable anatomy of dissection

 Bedside ECHO – evaluate aorta and look at heart to

r/o tampanode.
How do you manage this
disease?
Blood pressure control
Goal SBP 120-130 mmHg
Beta blockers are first line (Labetalol and Esmolol)
Can add vasodilators i.e. nitroprusside
Admission to ICU
Involve CT surgery early
 Case 4
• 55 yo alcoholic with persistant vomiting
presents with sudden onset of Chest pain
followed by hemetemisis.
 Management
• Antibiotics
• NPO
• Shift to ICU
• Referred to Gastroenterology
 Case 5

• 18 years old healthy male was lifting

weights when he had sudden onset of
sharp Chest Pain + SOB.
• HR 122, RR 34, BP 70/P, Sat 88%
• Decreased breath sounds on right.

What do you do first?

 Case 6
• 32 f
• Sharp chest Pain
 Case 6
VS: T 37.4 HR 104 BP 140/76 RR 20 O2 sat 97% on RA
Physical exam:
Gen – in mild distress due to chest pain
Lungs – normal
Chest wall – no visible rash, chest wall Not tender to palpation
Heart – tachycardic, Normal S1/S2
Rest of physical exam Normal
Labs:
WBC = 12, RFP wnl, AMI panel x 1 = negative, D Dimer - Normal
CXR = negative
ECG=No significant changes
• Analgesic given in ER : Pain Better
• Diagnosis – Musculoskeletal pain and
discharged on analgesic

• Returned to ER
Missing history: Pain relieves by bending
forward
 Pericarditis
• Refers to inflammation of pericardial sac

• Idiopathic pericarditis typically preceded by

viral prodrome, i.e. flu-like symptoms

• Typically, patients have sharp, pleuritic chest

pain relieved by sitting up or leaning forward
Goyle 2002
 Case 6
• EKG on admission:
Pericarditis

Goyle 2002
Pericarditis
• Treatment
MUSCULOSKELETAL CHEST PAIN

• Vary with posture

• Arthritis
• Costocondritis (teitze`s syndrome )
• Intercostal muscle injury
• Coxsackie viral infection
• Minor soft injuries
• Rib fracture
 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
 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

Kearon C, Akl EA, Comerota AJ, Prandoni P, Bounameaux H, Goldhaber SZ, Nelson ME, Wells PS, Gould MK, Dentali F, Crowther M,
Kahn SR. Antithrombotic therapy for VTE disease: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of
Chest Physicians evidence-based clinical practice guidelines. Chest. 2012 Feb;141(2 Suppl):e419S-94S.Cayley, W.E. Diagnosing the
cause of chest pain. (2005). American Family Physician, Vol 72 (10), 2012-21.
Anderson JL et al. 2012 ACCF/AHA Focuse Update of the Guideline for Management of Patients with Unstable Angina/NSTEMI. JACC 60
(7) 2012.
Thrumurthy SG et al. The diagnosis and management of aortic dissection. BMJ 344, 2012.
Imazio M, Demichelis B, Parrini I, Giuggia M, Cecchi E, Gaschino G, Demarie D, Ghisio A, Trinchero R. Day-hospital treatment of acute pericarditis: a
management program for outpatient therapy. J Am Coll Cardiol. 2004;43(6):1042.
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. (2014). 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. (2014). 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. (2014). 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. (2014). 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. (2014). UpToDate. http://www.uptodate.com/contents/treatment-of-acute-
pericarditis?source=search_result&search=pericarditis&selectedTitle=2%7E150
Thanks to Sumit Bose for use of a number of his excellent slides!
THANKS