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Life-Threatening Causes of Chest Pain in the Inpatient Setting

Learn about the life-threatening causes of chest pain in hospitalized patients and evaluate the ACS HEART Score for risk assessment and management. Understand key factors, testing, and treatment options for chest pain emergencies.

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Life-Threatening Causes of Chest Pain in the Inpatient Setting

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  1. Life Threatening Causes of Chest Pain in the Inpatient Matt Johnson, MD

  2. Life Threatening

  3. ACS

  4. HEART Score

  5. HEART Score: History Lower Risk Higher risk • Retrosternal pain • Pressure, radiation to jaw/left shoulder/arms • Duration 5–15 min, • Initiated by exercise/cold/emotion, • Diaphoresis • Nausea/vomiting, • Improves with nitro • patient recognizes symptoms from prior ACS • well localized • sharp • non-exertional • no diaphoresis • no nausea or vomiting • reproducible with palpation.

  6. HEART Score: EKG • Non-specific: • LBBB • Typical changes suggesting LVH • Repolarization disorders suggesting digoxin • Unchanged known repolarization disorders.

  7. HEART Score: ACSRisk Factors:

  8. HEART Score Interpretation • 0-3 (low): MACE 0.9-1.7% - D/C with outpatient f/u • 4-6 (moderate): MACE: 12-16.6% - <5 Stress test, 5+ admitted • >=7 (high): MACE: 60-65% • Stratify those with undifferentiated chest pain, not those already diagnosed with ACS

  9. ACS Work-Up

  10. ACS Treatment

  11. More ACS Treatment

  12. Tips • Relief with NTG does not reliably distinguish between ischemic and non-ischemic causes • Atypical presentations: • Women (epigastric pain, not “classic” chest pain) • Diabetics • Elderly (more likely to c/o fatigue or shortness of breath) • Reproducible pain not rule out ACS – if you push on someone’s chest hard enough it will hurt

  13. Aortic Dissection • Risk Factors: • Hypertension • 7th Decade of life + • Connective Tissue Diseases • Pre-existing Aortic Aneurysm • Bicuspid Aortic valve • Giant Cell arteritis, Takayasu, RA, Syphilis, HIV • Fluoroquinolones • Coarctation • Turner’s Syndrome

  14. Aortic Dissection • Characteristics: • Pain: 90% in chest/back • Abrupt onset • Radiate anywhere • 50% ripping/tearing • Signs: • Pulse deficit • New diastolic murmur • Focal neuro deficit • CVA, Hoarseness, Horners, Paraplegia (spinal cord ischemia) • Hypotension • Syncope • Aortic root widening on US, new pericardial effusion

  15. Aortic Dissection Evaluation:

  16. Aortic dissection detection risk score (ADD-RS) • High risk condition: • Marfan, family history of aortic disease, known aortic valve disease, known thoracic aneurysm, previous aortic manipulation • Pain in the chest, back, or abdomen described as abrupt, of severe intensity, or a ripping/tearing sensation. • Physical examination findings of perfusion deficit, including pulse deficit, systolic blood pressure difference, or focal neurologic deficit, or with aortic diastolic murmur and hypotension/shock. • Score 0/1 and D-dimer <0.5 (500) may rule out (<1 in 300) • Score 2/3: CT Angio

  17. Aortic Dissection Treatment

  18. Pulmonary Embolism:

  19. PE Symptoms:

  20. Decision rules for PE PERC rule out PE: Age <50, HR<100, Sat >95%, no unilateral leg swelling, no hemoptysis, no recent trauma or surgery, no hx PE/DVT, no hormone use AND pre-test probability is <15% Wells Score • Clinical Signs/Symptoms of DVT: +3 • PE is #1 Dx or Equally Likely: +3 • HR >100: +1.5 • Immobilization at least 3 days OR surgery in past 4 weeks: + 1.5 • Previous PE/DVT: +1.5 • Hemoptysis: +1 • Malignancy: +1

  21. Wells’ Score Interpretation

  22. D-Dimer • Age Cut-off • At LAC <0.5mcg/ml is normal (<500ng/ml) • Age (if over 50) x 10 in ng/ml • 55: 550ng/ml = 0.55mcg/ml • 75: 750ng/ml = 0.75mcg/ml

  23. Elevation of D-dimer is anticipated in:

  24. PE Treatment: • Empiric Anticoagulation: • Low Risk for Bleeding: • Wells Score >6 • Wells 2-6 with evaluation to take more than 4 hours • Wells <2 but evaluation to take more than 24 hours • High Risk: • Recent surgery, hemorrhagic stroke, active bleeding • Hold anticoagulation • Moderate Risk: • Clinical Judgement

  25. Risk Factors for Bleeding • Age > 65 • Age >75 • Previous bleeding • Cancer/Metastatic cancer • Renal failure • Liver failure • Thrombocytopenia • Previous stroke • Diabetes • Anemia • Antiplatelet therapy • Poor anticoagulant control • Frequent falls • EtOH abuse

  26. Pericardial Effusion • Build up of pericardial fluid – rate of collection determines potential badness • Infection: viral, bacterial, fungal, TB • Auto-immune • Malignancy • Myocarditis • Trauma • Hypothyroidism • Radiation • Uremia • Post-MI • Post Cath

  27. Pericardial effusion Cardiac Tamponade  Cardiogenic Shock

  28. Tamponade Presentation

  29. Pneumothorax Tension PTX Risk factors: • Trauma • Mechanically ventilated on high PEEP/High TV • Asthma / COPD patients on PPV • Underlying lung parenchymal issues: IPF, blebs Signs: • Decreased breath sounds/Hyperresonance • Hypoxia does not improve with oxygenation • Tracheal deviation • Unequal chest rise

  30. Mediastinitis

  31. Mediastinitis Causes • Consider in post-surgical patients • Boorhave’s • Deep space neck infections extending to chest • Reports of hematogenous spread • Fibrosing mediastinitis • Candida mediastinitis

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