Evaluation of Chest Pain

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Evaluation of Chest Pain

• Edward Catherwood, MD, MS

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Chest Pain History

• P pattern (temporal sequence)
• A associated features
• SOB, N/V, diaphoresis
• fever, cough, chills
• abdominal pain
• I initiation and improvement
• N nature (quality)

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Chest Pain Physical Exam

• Vital signs and general appearance
• Carotids and JVP
• Lungs
• Cardiac exam
• Thoracic cage
• Abdominal exam
• Periphery (pulses)
• Skin

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Chest Pain Laboratory

• Electrocardiogram
• Chest x-ray
• Blood studies
• CBC
• Cardiac enzymes
• Liver function
• Amylase, lipase
• Imaging Ultrasound, CT, nuclear

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Chest Pain Location
Myocardial ischemia Pericarditis Pleurisy,
Sub-diap abscess
Myocardial ischemia Pericarditis Aortic
dissection Mediastinal lesion Pulmonary
embolism Esophageal spasm
Myocardial ischemia Cervical spine Thoracic outlet
Cholecystitis Hepatic distension Peptic
disease Pancreatitis Myocardial ischemia
Pulmonary embolism Pneumonia Splenic
infarction Subdiap. abscess
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Clinical Spectrum of Acute Coronary Syndromes
Stable angina
Unstable angina
Non-STE MI
STE MI
None
Positive
Positive
ST-segment elevation
ST-segment depression and/or T-wave inversion
ST-segment depression and/or T-wave
inversion
ECG early
ECG late
No Q
No Q
Q develops
Antman EM. In Braunwald E, ed. Heart Disease A
Textbook in Cardiovascular Medicine, 5th ed.
Philadelphia, Pa WB Saunders 1997.
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ACS Clinical Presentation

• Substernal chest pain or pressure (gt20-30 min)
• Localization or radiation to arms, back, throat,
  jaw
• Accompanying features
• Dyspnea
• Nausea/vomiting
• Diaphoresis
• Weakness
• Atypical syncope, CVA, DKA

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ECG Findings in ACS
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ECG Findings in ACS
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ACC/AHA Guidelines
PTCA, percutaneous transluminal coronary
angioplasty CABG, coronary artery bypass graft
ACE, angiotensin-converting enzyme.Adapted from
Ryan TJ, et al. ACC/AHA 1999 Update. Available
at http//www.acc.org/clinical/guidelines and
http//www.americanheart.org. Accessed February
2000.
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Symptoms Suggestive of ACS
Definite ACS
Possible ACS
() ECG Normal biomarkers
ST ?
No ST ?
Reperfuse
ST-T ?s, chest pain, ? markers
Observe repeat ECG, markers at 4-8 hrs
No recurrent pain () follow-up studies
Recurrent pain () follow-up studies
Stress test ? LV function if ischemia
() test
Consider Early Invasive Strategy
() test outpt follow-up
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ECG Findings in ACS
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ECG Findings in ACS
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Cardiac Enzymes
1000
100
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Relative Marker Increase
Upper Reference Interval
1
0
Hours After Chest Pain Onset
Antman EM. In Braunwald E, ed. Heart Disease A
Textbook in Cardiovascular Medicine, 5th ed.
Philadelphia, Pa WB Saunders 1997.
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Secondary Causes of ACS

• Tachyarrhythmias
• Severe anemia
• Medication withdrawal
• Hyperthyroidism
• Sepsis or other toxic state
• Multisystem organ failure

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Post-op Chest Pain and SOB

• 70 yo man 10 days following CABG
• Developed acute dyspnea and right-sided chest
  pain on awakening
• Exam revealed tachypnea and hypoxemia

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Perfusion Lung Scan
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Acute Upper Back Pain

• 49 yo man with long standing HCVD
• Sudden mid back and interscapular pain
• Associated with nausea and sweats
• Unrelieved by change of position
• Some radiation toward the left chest

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Aortic Dissection
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Wrestler with Chest Pain

• 18 yo high school wrestler develops right-sided
  chest pain while pinning his opponent.
• Physical exam reveal decreased breath sounds on
  right

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Alcoholic with Chest Pain and Cough

• 45 yo alcoholic man with fever, chills and
  productive cough over two days

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Smoker with Chest Pain

• 68 yo former smoker with right shoulder and upper
  substernal pain
• History reveals 12 pound weight loss

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Final Caveats

• Nitro response is not diagnostic
• Qualifiers for sharp pain
• Post-prandial pain may be ischemic
• Discomfort thresholds vary
• Patient histrionics may influence you
• Atypical is typical of something
• Value of careful history and physical
• Surveillance is key