Chest Pain: LSU Medical Student Clerkship, New Orleans, LA

Chest Pain
LSU Medical Student Clerkship,

New Orleans, LA
Chest Pain
Goals
Review the pathophysiology, diagnosis and

treatment of life threatening causes of chest pain.
Chest Pain
Epidemiology
5% of all ED visits
Approximately 5 million visits per year
Chest Pain
Visceral Pain
Visceral fibers enter the spinal cord at several levels leading

to poorly localized, poorly characterized pain. (discomfort,
heaviness, dull, aching)
Heart, blood vessels, esophagus and visceral pleura are
innervated by visceral fibers
Because of dorsal fibers can overlap three levels above or
below, disease of thoracic origin can produce pain anywhere
from the jaw to the epigastrum
Chest Pain
Parietal Pain
Parietal
pain, in contrast to visceral pain, is

described as sharp and can be localized to the
dermatome superficial to the site of the painful
stimulus.
The dermis and parietal pleura are innervated
by parietal fibers.
Chest Pain
Initial Approach
ABCs first, always (look for conditions requiring
immediate intervention)
Aspirin for potential ACS
EKG
Cardiac and vital sign monitoring
Pain relief
Because of the wide differential, H+P will guide the
diagnostic workup
Chest Pain
History
O-
onset
P-provocation /palliation
Q- quality/quantity
R- region/radiation
S- severity/scale
T- timing/time of onset
Chest Pain
History
Change
in pain pattern
Associated symptoms: DOE, SOB,
diaphoresis, vomiting, heart burn, food
intolerance
PHx
Social history
FHx
Chest Pain
Physical Exam
General Appearance and Vitals (sick vs not sick)

Chest exam
-Inspection (scars, heaves, tachypnea, work of
breathing)
-Auscultation (murmurs, rubs, gallops, breath sounds)
-Percussion (dullness)
-Palpation (tenderness, PMI)
Chest Pain
Physical Exam
Neck:
JVD, crepitence, bruits

Abdomen
Extremities: swelling, pulses, tenderness,
Homans
Chest Pain
Differential Diagnoses
Cardiovascular
Acute myocardial infarction, Acute coronary ischemia, Aortic dissection, Cardiac

tamponade, Unstable angina, Coronary spasm, Prinzmetal's angina, Cocaine
induced, Pericarditis, Myocarditis, Valvular heart disease, Aortic stenosis, Mitral
valve prolapse, Hypertrophic cardiomyopathy
Pulmonary
Pulmonary embolus, Tension pneumothorax, Pneumothorax, Mediastinitis,

Pneumonia, Pleuritis, Tumor, Pneumomediastinum
Gastrointestinal
Esophageal rupture (Boerhaave), Esophageal tear (MalloryWeiss), Cholecystitis, Pancreatitis, Esophageal spasm, Esophageal
reflux, Peptic ulcer, Biliary colic
Musculoskeletal
Muscle strain, Rib fracture, Arthritis, Tumor, Costochondritis, Nonspecific chest

wall pain
Neurologic
Spinal root compression, Thoracic outlet, Herpes zoster, Postherpetic neuralgia
Other
Psychologic, Hyperventilation
Chest Pain
Life Threatening Causes of Chest Pain

Acute Coronary Syndromes
Pulmonary Embolus
Tension Pneumothorax
Aortic Dissection
Esophageal Rupture
Pericarditis with Tamponade
Chest Pain
Acute Coronary Syndromes - Epidemiology

In
a typical ED population of adults over the age

of 30 presenting with visceral-type chest pain,
about 15 percent will have AMI and 25 to 30
percent will have UA
Chest Pain
Acute Coronary Syndromes - History

Typical
Chest Pain Story (Pressure-like,

squeezing, crushing pain, worse with exertion,
SOB, diaphoresis, radiates to arm or jaw) The
majority of patients with ACS DO NOT present
with these symptoms!
Cardiac Risk Factors (Age, DM, HTN, FH,
smoking, hypercholesterolemia, cocaine abuse)
Chest Pain
Acute Coronary Syndromes EKG Findings

STEMI
- ST segment elevation (>1 mm) in

contiguous leads; new LBBB
T wave inversion or ST segment depression in
contiguous leads suggests subendocardial
ischemia
5% of patients with AMI have completely normal
EKGs
Chest Pain
Chest Pain
Chest Pain
Acute Coronary Syndromes Cardiac Markers
Marker
Initial
Rise
Peak
Return to
normal
Benefits
Troponin
2-4 hr
10 -24 hr
5 -10 days
Sensitive and specific
CK-MB
3-4 hr
10-24 hr
2 4 days
Unaffected by renal failure
LDH
10 hr
24 -72 hr
14 days
Myoglobin
1-2 hr
4 -8 hr
24 hours
Very sensitive, powerful

negative predictive value
Chest Pain
Acute Coronary Syndromes Cardiac Markers
Chest Pain
Echocardiogram
Wall
abnormalities occur within minutes

Will detect abnormalities in 80% of AMI
Normal resting echo in setting of chest pain
gives low probability
Early screen for AMI complications:
aneurysms, valve abnormalities, other
structural destruction
Chest Pain
Echo
Chest Pain
Acute Coronary Syndromes - Treatment

Aspirin
Nitroglycerin
Oxygen
Analgesia
Chest Pain
Treatment
Beta-Blockers
Anticoagulation
Anti-Platelet
Agents
Thrombolysis
Percutaneous Coronary Interventions
(PCI)
Chest Pain
Stress echocardiograms
Sensitivity
60-90%
Specificity 75% ?
Should be employed with moderate to high
risk stratification
Limitations of reader, image quality, and
previous functional impairment
Negative test has time limited value
Chest Pain
Acute Coronary Syndromes - Treatment

STEMI
(ASA, B-blocker, NTG, anti-platelet,

anticoagulation, thrombolysis, PCI)
NSTEMI
(ASA, B-blocker, NTG, anti-platelet,

anticoagulation, PCI)
Unstable
Angina (ASA, B-blocker, NTG,

anticoagulation, risk stratification)
Chest Pain
Acute Coronary Syndromes - Disposition

Mortality
is twice as high for missed MI

Missed MI is the most successfully litigated
claim against EP's. EPs miss 3-5% OF AMI,
this accounts for 25% of malpractice costs
against EPs
Chest Pain
Acute Coronary Syndromes - Disposition

A
single set of cardiac enzymes is rarely of use

Risk Stratification: goal is to predict the
likelihood of an adverse cardiovascular event
Combination of H+P, EKG, Biomarkers
No single globally accepted algorithm
Mathematical models such as TIMI, GRACE,
PURSUIT, and HEART can be helpful but are no
substitute for clinical judgment
Chest Pain
Pulmonary Embolism - Pathophysiology

Thrombosis
of a pulmonary artery
>90% arise from DVT
Clot from a DVT travels through the venous
system and lodges in the pulmonary vasculature
creating a ventilation/perfusion mismatch
Chest Pain
Pulmonary Embolism History

Dyspnea
is the most common symptom, present

in 90% of patients diagnosed with PE
Sharp pleuritic chest pain, syncope,
Prolonged immobilization, neoplasm, known
hypercoagulable disorder
Chest Pain
Pulmonary Embolism Physical Exam

Tachycardia,
tachypnea, diaphoresis,
hypotension, hypoxia, low grade fever, anxiety,
cardiovascular collapse, right ventricular heave
Chest Pain
Pulmonary Embolism Diagnostic Testing

Sinus
Tachycardia is the most frequent EKG

finding
Classic S1,Q3,T3 finding is seen in less than
20%
ABG plays no role in ruling out PE
D-Dimer in a low risk patient can be used to rule
out PE
Chest Pain
Pulmonary Embolism Wells Criteria
Clinical Signs and Symptoms of DVT? Yes +3

PE is #1 Diagnosis, or Equally Likely? Yes +3
Heart Rate > 100? Yes +1.5
Immobilization at least 3 days, or Surgery in the Previous 4
weeks? Yes +1.5
Previous, objectively diagnosed PE or DVT? Yes +1.5
Hemoptysis? Yes +1
Malignancy w/ Treatment within 6 mo, or palliative? Yes +1
<2 = Low risk, 2.5-6 = moderate risk, >6 = high risk
Chest Pain
Pulmonary Embolism Diagnostic Imaging Algorithm
Chest Pain
Pulmonary Embolism Treatment/Disposition
Unfractionated heparin vs low molecular weight

heparin (some studies suggest superiority of
LMWH)
Thrombolysis (for cardiovascular collapse)
Floor vs ICU
Chest Pain
PE CXR
Chest Pain
Chest Pain
Chest Pain
Chest Pain
Chest Pain
Chest Pain
Aortic Dissection - Pathophysiology
Intimal tear of the aorta leads to dissection of the

layers of the aorta creating a false lumen
Chest Pain
Aortic Dissection - Diagnosis

Tearing chest pain radiating to the back
Risk Factors: HTN, connective tissue disease
Exam: HTN, pulse differentials, neuro deficits
Radiology: Wide mediastinum on CXR, CT angio
chest, echo
Chest Pain
Chest Pain
Aortic Dissection - Classification
De Bakey system: Type I dissection involves both the

ascending and descending thoracic aorta. Type II
dissection is confined to the ascending aorta. Type III
dissection is confined to the descending aorta.
The Daily system classifies dissections that involve the
ascending aorta as type A, regardless of the site of the
primary intimal tear, and all other dissections as type B.
Chest Pain
Chest Pain
Aortic Dissection - Treatment
Patients with uncomplicated aortic dissections confined to the

descending thoracic aorta (Daily type B or De Bakey type III) are
best treated with medical therapy.
Medical Therapy: Goal to decrease the blood pressure and the
velocity of left ventricular contraction, both of which will decrease
aortic shear stress and minimize the tendency to further dissection.
Acute ascending aortic dissections (Daily type A or De Bakey type I
or type II) should be treated surgically whenever possible since these
patients are a high risk for a life-threatening complication such as
aortic regurgitation, cardiac tamponade, or myocardial infarction.
Chest Pain
Tension Pneumothorax - Pathophysiology

Collection
of air in the pleural space causes

collapse of the ipsilateral lung and then
cardiovascular collapse as intrathoracic
pressures increase.
Chest Pain
Tension Pneumothorax - Diagnosis

Risk factors: COPD; connective tissue disease,
trauma, recent instrumentation, positive
pressure ventilation
Absent breath sounds unilaterally, hypotension,
distended neck veins, tracheal deviation
Chest Pain
Chest Pain
Tension Pneumothorax - Treatment

Needle
decompression
Tube thoracostomy
Chest Pain
Esophageal Rupture - Pathophysiology

Tear
in the esophagus leads to leaking of

gastrointestinal contents into the mediastinum
Inflammation followed by infection cause rapid
deterioration, sepsis and death
Chest Pain
Esophageal Rupture - Diagnosis

Rare
but devastating
Risk Factors: Iatrogenic, heavy retching,
trauma, foreign bodies, toxic ingestion
Radiology: Mediastinal air on plain films or CT
scan
Chest Pain
Subtle
Not so subtle
Chest Pain
Imaging
Chest Pain
Esophageal Rupture - Treatment

Antibiotics
Supportive
Care
Small tears with minimal extraesophageal
involvement can be managed conservatively
Surgical consult for all regardless of size
Chest Pain
Take Home Points

ABCs
first
History is key
Have a low threshold for missed MI

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Chest Pain

LSU Medical Student Clerkship,

Review the pathophysiology, diagnosis and

Visceral fibers enter the spinal cord at several levels leading

pain, in contrast to visceral pain, is

General Appearance and Vitals (sick vs not sick)

JVD, crepitence, bruits

Acute myocardial infarction, Acute coronary ischemia, Aortic dissection, Cardiac

Pulmonary embolus, Tension pneumothorax, Pneumothorax, Mediastinitis,

Muscle strain, Rib fracture, Arthritis, Tumor, Costochondritis, Nonspecific chest

Spinal root compression, Thoracic outlet, Herpes zoster, Postherpetic neuralgia

Life Threatening Causes of Chest Pain

Acute Coronary Syndromes - Epidemiology

a typical ED population of adults over the age

Acute Coronary Syndromes - History

Chest Pain Story (Pressure-like,

Acute Coronary Syndromes EKG Findings

- ST segment elevation (>1 mm) in

Sensitive and specific

Unaffected by renal failure

Very sensitive, powerful

Acute Coronary Syndromes Cardiac Markers

abnormalities occur within minutes

Acute Coronary Syndromes - Treatment

Acute Coronary Syndromes - Treatment

(ASA, B-blocker, NTG, anti-platelet,

(ASA, B-blocker, NTG, anti-platelet,

Angina (ASA, B-blocker, NTG,

Acute Coronary Syndromes - Disposition

is twice as high for missed MI

Acute Coronary Syndromes - Disposition

single set of cardiac enzymes is rarely of use

Pulmonary Embolism - Pathophysiology

Pulmonary Embolism History

is the most common symptom, present

Pulmonary Embolism Physical Exam

Pulmonary Embolism Diagnostic Testing

Tachycardia is the most frequent EKG

Pulmonary Embolism Wells Criteria

Clinical Signs and Symptoms of DVT? Yes +3

Pulmonary Embolism Treatment/Disposition

Unfractionated heparin vs low molecular weight

Aortic Dissection - Pathophysiology

Intimal tear of the aorta leads to dissection of the

Aortic Dissection - Diagnosis

Aortic Dissection - Classification

De Bakey system: Type I dissection involves both the

Aortic Dissection - Treatment

Patients with uncomplicated aortic dissections confined to the

Tension Pneumothorax - Pathophysiology

of air in the pleural space causes

Tension Pneumothorax - Diagnosis

Tension Pneumothorax - Treatment

Esophageal Rupture - Pathophysiology

in the esophagus leads to leaking of

Esophageal Rupture - Diagnosis

Esophageal Rupture - Treatment