Chest pain under evaluation

An approach to chest pain

1. Dr Md Seebat Masrur Indoor Medical Officer Department of Cardiology TMC & RCH Chest pain Evaluation ALLPPT.com _ Free PowerPoint Templates, Diagrams and Charts

2. Chest Pain

3. Emergency Physician

4. When a Patient comes in with chest pain Primary Survey ECG

5. Primary Survey Assess vital signs and oxygenation Placing an IV Place on cardiac monitor Focused History & Physical Aim is to determine if the patient is Stable or Unstable If Unstable - Sta bilize the patient: ABCs and reassess

6. Focused History Questions to ask Ref Swap. C. J & Nagurney J T (2005) Element Question Quality In your own word how would you describe the pain ? what adjectives would you use? Location Point your finger to where you are feeling the pain. Radiation If pain moves out of your chest, trace where it travels with your finger. Distribution With your finger, trace the area on your chest where the pain occurs Severity If 10 is the most severe pain you have ever had. On this 10-point scale how severe was this pain? Time of onset & continuity Is the pain still present? Has it gotten better or worse since it began? when did it begin? Duration Second ,Minutes, Hours. How long is a typical episode? First Occurance First time you ever had this pain? Frequency How many times per hour or per day has it been occurring? Similar to previous cardiac ischemic episodes If you have had a heart attack or angina in the past, is this pain similar to the pain you had then?is it more or less severe?

7. Precipitating or Aggravating factors Questions to ask Ref Swap. C. J & Nagurney J T (2005) Pleuritic Is the pain worse if you take a deep breath or cough? Positional Is the pain made better or worse by your changing of body position? If so, what position makes the pain better or worse? Palpable If I press on your chest wall, does it reproduce the pain? Exercise Does the pain come back or get worse if you walk quickly, climb stairs, or exert yourself? Emotional stress Does becoming upset affect the pain? Relieving factors Are there any thing that you can do to relieve the pain, once it has begun? Associated symptoms Do you typically get other symptoms when you get this chest pain?

8. Aetiology

9. Cardiovascular Pericardium -Pericarditis Myocardium -Myocarditis -Heart Failure exacerbation -HOCM - Takotsubo cardiomyopathy Valves -Aortic Stenosis Conducting System -Tachyarrhythmia Vessels -ACS -Aortic Dissection -Hypertensive Emergencies Pulmonary Pleura - Pleuritis -Pneumothorax Airways -Asthma Exacerbation Alveoli -Pneumonia Vessels -Pulmonary embolism -Pulmonary hypertension Lung Cancer

10. GI Esophagus -GERD - Oesophagitis - Oesophageal spasm - Boerhaav`s ( Oesophageal rupture) Stomach -Gastritis -PUD MSK Rib Fractures Costochondritis

11. Miscellaneous Severe Anemia Herpes zoster( a.k.a Shingles) Acute intoxication with cocaine or amphetamines Acute chest syndrome in sickle cell anemia Psychiatric -Panic attack,Somatization

12. Chest Pain:Physical Exam Vital Signs -heart rate, temp, BP in both arms and check for pulsus paradoxus , O2 Sat Chest wall -Palpation, signs of trauma Cardiac Exam -palpation, rhythms, murmurs, gallops, rubs , JVP Pulmonary Exam -Symmetric, wheeze, crackles, focal consolidations Abdomen -Palpation of all quadrants, auscultation for aortic bruit, palpation of liver Extremities - Edema,pulses,pain

13. Investigations ECG CXR Bloods FBC, U&E, LFT, D-dimer (if considering PE and low Wells score), troponin if suspected IHD ABG  if patient acutely unwell or sats under 95% Echo / CT if large proximal PE or aortic root dissection suspected Also can echo for regional wall motion abnormality in MI

14. Rule out Deadly Acute Myocardial infarction Cardiac Temponade Aortic Dissection Pulmonary embolism Tension Pneumothorax Boerhaav`s ( Oesophageal rupture) If they are hemodynamically unstable we need to assume they have one of these problems until proven otherwise The most important consideration is to determine as quickly as possible if the patient might have an emergent life threatening problem specifically

15. So How Do we Diffenrentiate between pain of Most of these deadly causes??? Description of pain,PMH,Physical examination and bed side diagnostic test

16. Acute Coronary Syndrome Acute Coronary Syndrome Description of Chest Pain Onset over mins Substernal /midline Radiation down either arm or to jaw, epigastric region, back Exertional Non- pleuritic ‘’Pressure’’, ‘’tightness’’ Diaphoresis, nausea and vomiting PMH(risk factors) Smoking, DM, HTN, Hyperlipidaemia , Elderly male Exam Often normal, but may have S3, high JVP, and crackles if HF has developed CXR Usually normal ECG ST/T elevations,depression , dynamic ST/T changes or even be unremarable

17. Diagnostic next steps Serial Troponins If troponin elevated, ST segments elevated or dynamic , persistent chest pain or patient unstable  Cath Lab However troponins can be elevated in Pulmonary embolism, myocarditis among other diagnosis.

18. Relieved by Nitroglycerin? Something that you notice is not listed as a feature is that pain related to ACS is relieved with Nitroglycerin. Historically it was thought that a patient presenting to the ED with chest pain was more likely to have myocardial ischemia if the pain was relieved by Nitro. However this is been shown to be untrue. Relief with nitroglycerin is useless as a diagnostic test.

19. Pulmonary Embolism Description of Chest Pain Onset over secs-mins Lateralized to one side No specific radiation Non exertional Pleuritic ‘’Sharp’’ PMH(risk factors) Recent hospitalization Immobilization Malignancy Exam Unremarkable May have evidence of DVT Right sided S3 or RV heave if massive PE CXR Usually normal ECG Classic S1 Q3T3 pattern is much less common than plain sinus tachycardia

20. Diagnostic next steps If clinical suspicion is relatively low d-dimer If clinical suspicion is High or d-dimer elevatedCT angiogram

21. Aortic Dissection Description of Chest Pain Onset over secs-mins Substernal /midline Radiation to back Non- exertional Non- pleuritic ‘’Tearing’ PMH(risk factors) HTN Smoking Exam If not yet ruptured BP elevated If ruptured hypotension May have d iscordant BP between two arms Unequal pulses Focal weakness/numbness CXR May have widened mediastinum ECG No Specific findings

22. Diagnostic next steps If patient relatively stable  CT angiogram If patient unstableTEE at bedside

23. Pneumothorax Description of Chest Pain Onset over secs Lateralized to oneside No specific radiation Non- exertional Pleuritic ‘’Sharp’’ PMH(risk factors) COPD Cystic Fibrosis Recent Trauma Exam Unilateral diminished/absent breath sounds Unilateral hyperresonance Elevated Jugular vein CXR Pneumothorax ECG No Specific findings

24. Cardiac Temponade Description of Chest Pain Acutely or Gradually Crushing, Compression PMH(risk factors) Cancer or Uremia Penetrating chest trauma Exam Beck`s Traid (Hypotension, Distant muffled Heart sound, Jugular Vein Distension) Pulsus Paradoxus (classic Sign) CXR Enlarged Cardiac Silhoutte (water bottle shaped) ECG Low voltage and electrical alternans Bed side ECHO Confirmatory

25. Diagnostic next steps Additional diagnostic work-up usually unnecessary

26. Pericarditis Common distinguishing feature Pleuritic pain that is relieved by sitting up and leaning forward. Percardial friction rub is uncommonly present on exam. Diffuse ST elevations on ECG

27. Myocarditis Common distinguishing feature Mild to moderate Troponin elevation Non- exertional Lasting hours to days

28. Pleuritis Common distinguishing feature Pain lateralizes to affected side, and pleuritic . Pleural friction rub is uncommonly present on exam CXR usually reveals an associated pleural effusion

29. GERD Common distinguishing feature Pain associated with eating specially spicy meal, or onset within minutes to a few hours after lying down

30. Boerhaave`s (Esophageal rupture) Common distinguishing feature Sharp Radiating to abdomen and back Hematemesis Hypotension Hamman's sign   or   Hammond's crunch [

31. MSK Common distinguishing feature Focal chest wall tenderness on exam(reproducible)

32. Zoster Common distinguishing feature Pain described as ‘’burning’’ and limited to single dermatome

33. Now these vast aforementioned causes don’t make the diagnostic algorithm easier to approach, there are still some scoring and pathways and pain rule present to help us guide towards a specific diagnosis as soon as possible

34. Chest pain score overview

35. HEART SCORE

36. HEART PATHWAY

37. VANCOUVER CHEST PAIN RULE