Clinical Cases: Chest Pain and Syncope

1. Clinical Cases: Chest Pain and Syncope

2. How do we make diagnoses and decisions?

3. Pattern recognition • An 18 year old college student comes to the ER saying “I’ve had a fever and a terrible headache since this morning, and now my neck is stiff”. • A 7 year old child presents with 3 weeks of blurred vision, polydipsia, polyuria and weight loss.

4. Pattern recognition • Most likely diagnosis based on the patient’s presenting symptoms and your knowledge and experience • History, exam and labs are tested to see if they fit this diagnosis • Alternate diagnoses are excluded • More often used by ‘experts’

5. Logical reasoning • A 62 y.o. woman reports gradually worsening cough and shortness of breath. • A 55 year old man comes in with a 2 month history of diarrhea and weight loss.

6. Data gathered • List of diagnostic possibilities generated and considered • Pathophysiologic: VINDICATE • Organ system • More often used by novices or experts thinking outside of their usual field

7. V Vascular • I Inflammatory • N Neoplastic • D Degenerative • I Intoxication • C Congenital • A Autoimmune/allergic • T Trauma • E Endocrine

8. V CHF • I Tuberculosis • N Lung cancer • D COPD • I Pneumonitis from exposed toxin • C Kyphoscoliosis, congenital heart disease • A Asthma, sarcoidosis • T • E

9. Name the problem Acute - Chronic Sudden - Gradual Onset Intermittent - Continuous Mild - Severe • Identify other key features of patient’s presentation • Test the key features against your differential diagnosis Do these signs and symptoms fit this dx? What doesn’t fit? What else could this be?

10. Case 1 • You are on call on the first night of your medicine rotation. A 62 year old man with no known history of cardiac disease, whom you admitted this morning with a severe cellulitis of the leg, had the sudden onset of substernal chest pain 15 minutes ago.

11. O2 • IV • Request ECG and monitor • Page your resident (or ask the nurse to call a “Rapid Response”)

12. 10 Which feature of his history would most increase the likelihood of MI? • Pain radiating to both arms • Male sex • Hyperlipidemia • Diaphoresis

13. History in acute MI • Increases likelihood of AMI • Pain radiating to both arms > R shoulder > L arm • Syncope (LR 3.0) • Prior MI (LR 1.5-3.0) • Diaphoresis (LR 2.0) • N/V (LR 1.9) • Decreases likelihood of AMI • Pleuritic (LR 0.2) • Reproduced by palpation, sharp or stabbing, or positional (each with LR 0.3)

14. Wooden Pearl: Chest pain that responds to nitroglycerin is cardiac in origin

15. Not so fast… • 459 patients presenting to the ED at Johns Hopkins with acute chest pain treated with NTG with subsequent admission • Nitroglycerin relieved pain (at least 50% decrease within 5 minutes) in • 35% of patients with active coronary disease • 41% without active coronary disease

16. And remember… • 25% of acute infarcts are missed • Atypical symptoms • Dyspnea alone • Indigestion • Atypical chest pain • No symptoms • Elderly • Diabetic • Postoperative

17. Physical Exam in MI • Often normal • S3, rales, elevated JVP with systolic dysfunction • Other evidence of vascular disease • Carotid bruit • Decreased LE pulses

18. Physical Exam in MI • Often normal • S3, rales, elevated JVP with systolic dysfunction • Other evidence of vascular disease • Carotid bruit • Decreased LE pulses

19. Your resident comes in: What else could this be??

20. Common sources of diagnostic error • Availability bias • The diagnosis that springs to mind: the last lecture you attended or the last patient you saw • Premature closure • Stop thinking about alternate diagnoses once a reasonable cause of symptoms is considered

21. Chest pain in the hospital: most likely cause • Unstable angina • Pulmonary embolism • Reflux • Anxiety *personal experience

22. Diagnostic evaluation • VS, heart, lung, LE, screening neuro exam • ECG • Cardiac enzymes • Consider telemetry • Antacid trial • Seriously consider the possibility of pulmonary embolism • Particularly with cancer surgery, ortho surgery • Even more so if not on DVT prophylaxis

23. Case 2 A 72 year old man with a history of diabetes, hypertension and smoking is brought to the ER with sudden, severe chest pain of 25 minutes duration.

24. Based on this, what is most likely? • MI • Aortic dissection • Pericarditis • Non-CV

25. Prevalence in ED patients with Chest Pain • Unstable angina, MI 16-28% • Pericarditis ~2% • Aortic dissection .003% • Non-cardiovascular 72-84%

26. What is most likely? • What else can’t we miss? • High mortality (aortic dissection 1% per hour) • Treatable early (with early surgery, survival ~90%) • 20%+ still missed on initial evaluation

27. Aortic dissection

28. Aortic dissection: History • Tearing or ripping chest pain (LR 10.8) • Migrating chest and back pain (LR 7.6) • Sudden onset pain • Marfan’s syndrome • Hypertension

29. Aortic Dissection: Exam • Any “classic” finding present in only half of all cases • Diastolic murmur (aortic insufficiency) • Unequal blood pressure in limbs (> 20 mm Hg) • Pericardial rub • Elevated JVP (tamponade) • Focal neuro deficit • Shock

30. Chest x-ray findings • Overall sensitivity 90% • Widened mediastinum (Sn ~ 65%) • Abnormal aortic contour (Sn ~ 70%) • Pleural effusion (Sn ~ 15%)

31. Consider aortic dissection: • Sudden, tearing, or ripping chest pain, especially with radiation to back • Migrating chest, back abdominal pain • Neuro deficit, pulse deficit, new AI murmur, tamponade • ECG without ST changes in patient you thought was having an MI

32. Case #3 • A 38 year old woman presents with one day of anterior and left chest pain. • It’s present all the time but is worse with a deep breath. • She is otherwise healthy and has never had anything similar.

33. Acute Pleuritic Chest Pain

34. Which of the following would support a diagnosis of pericarditis? • Hearing this • Muffled heart sounds • Elevated JVP • All 3

35. V Aortic dissection, post-MI • I Viral infection • N Lung, breast, lymphoma, melanoma • D Uremia • I Drug induced lupus • C Congenital • A SLE, RA, FMF • T Trauma - blunt, radiation or procedure • E Hypothyroidism

36. Having detected a pericardial friction rub, which finding would you seek next? • Pulsus alternans • Pulsus paradoxus • Pulsus parvus et tardus

37. Pericardial Tamponade • Fluid increases intrapericardial pressure • With inspiration, venous return to R ventricle increases; it encroaches onto LV • Chest pain/heaviness/tightness • Symptoms & signs of poor cardiac output • Dyspnea • Elevated JVP • Tachycardia then hypotension

38. Pulsus paradoxus • Increased venous return with inspiration • Increased fluid in pericardial space restricts the ability of RV to stretch; excess venous return presses on ventricular septum • Decreased LV filling • Decreased blood pressure with inspiration • Also seen with severe asthma

39. Technique • Inflate BP cuff to above systolic BP and come down veeeerrrrry slowly • Note the pressure at which you begin to hear Korotokoff sounds during expiration • Decreased very slowly • Note the pressure at which you hear sounds in inspiration and expiration • > 10 mm Hg is abnormal

40. Acute Chest Pain: Suggestive History • Unstable angina/MI • Diffuse tightness, pain or pressure • Radiation to both arms more suggestive than 1 • History of CAD • Nausea • Diaphoresis • Aortic dissection • Sudden onset, ripping or tearing pain • Migrating pain in chest, back, abdomen • Pericarditis • Anterior, often pleuritic • Worse with leaning forward

41. Acute Chest Pain: Suggestive Exam • Unstable angina/MI • May be normal • S3, hypotension, elevated JVP with heart failure • Aortic dissection • May be normal • Pulse deficit/unequal BPs > 20 mm Hg • Neuro deficit • Suprasternal mass • Pericarditis • Pericardial friction rub • Tachycardia, elevated JVP, + pulsus paradoxus with tamponade

42. Acute Chest Pain: Next diagnostic steps • ECG • CXR • Cardiac enzymes • Further imaging as guided by history and exam: • Cardiac cath? • Echo to assess wall motion or pericarditis? • CTA or TEE or MRI to assess for dissection?

43. Suggestive of non-cardiac chest pain • Sharp • Pleuritic • Well circumscribed • Lasting seconds at a time • Lasting hours or days at a time • Unchanged by exertion • Associated with waterbrash (acid in mouth)

44. Syncope • Transient loss of consciousness, with associated loss of postural tone and spontaneous recovery. • 3% of ED visits and 1% of hospital admissions • History and exam establish diagnosis in about half • About one-third remain unexplained

45. Key questions in syncope • Is this really syncope? • Seizure will typically have slower return to baseline (postictal state) • Tongue biting, loss of bowel or bladder suggest seizure • Syncope can be associated with tonic clonic movmements • What’s most likely? • What can’t I miss?

46. Have you ever had syncope? • Yes • No • Abstain

47. Most common • Neurocardiogenic AKA vasodepressor AKA vasovagal syncope (25-65%) • Autonomic activation causes decreased BP, bradycardia or both • Emotion, carotid sinus pressure, situational • Medications (5-15%) • Vasodilation, bradycardia, volume depletion • Orthostatic syncope (5-10%) • Volume depletion • Autonomic insufficiency

48. Must not miss • Arrhythmia • Ischemia • Cardiac tamponade • Pulmonary embolism • Major acute blood loss • Valvular disease (aortic or mitral stenosis)

49. Key questions: • Prodrome? Suggests neurocardiogenic - sudden onset without prodrome suggests arrhythmia • Situation? Prolonged standing, physical or emotional stress, cough, micturition, etc all suggest neurocardiogenic. Syncope with exertion suggests limited cardiac output (bad). • Position? Syncope while standing suggests orthostasis, prolonged standing suggests neurocardiogenic, supine suggests arrhthmia • Any chest pain or dyspnea? • History of cardiac disease? • Family history of cardiac disease or sudden death?

50. Key exam • VS • Include orthostatic VS • HEENT - tongue laceration suggests seizure • Cardiac - rate and rhythm, evidence of heart failure, evidence of valvular disease • Lung - evidence of heart failure or PE • Neurologic - evidence of stroke