Approach to the Patient With Chest Pain Diagnostic Workout

1. Approach to the Patient With Chest Pain Diagnostic Workout

2. 5% of ER admissions Much larger proportion in internal medicine-ER section (about 10-20%) Since people are concerned with chest pain

3. 5% of ER admissions Minority: Immediate life-threatening conditions (MI, dissection, PE) Majority: Minor causes or non-urgent significant disorders

4. Among Hospitalized Patients: Inversed Proportion

5. Chest Pain Triage Diagnosis Chest Pain Unit Ward ER Home Sweet Home

6. Chest Pain Diagnostic Challenge UPS…

7. Chest Pain Diagnostic Challenge r/o life threatening conditions: MI, PE, dissection, tension pneumothorax

8. Multiple Potential Origins of Chest pain Superficial (skin and appendices) Musculo-skeketal: chest wall (muscles, ribs) Pleuritic: (parietal pleura, pericardium) Myocardial ischemia Esophageal Aortic Other mediastinal Trachea Vertebral / nerve compression

9. First step: Characterization of pain Defining its origin

10. Skin and appendices Abscess / cellulitis - obvious Mastitis / mastopatia fibrosa cystica – obvious Varicella Zoster – tricky at initial phase (S) Burning pain “superficial” sensitivity affected by dressing (O) Hyperalgesia / disesthesia

11. Chest wall Sensorium by intercostal nerves Sensory fibers in perichondrium and Intercostal muscles Shoulder girdle muscles

12. Chest wall Trauma Tumor Tietze syndrome Myositis / myalgia (strain, immune disease, infection) Infection: most common – viral-influenza peculiar - trichinella Rosaries in rickets

13. Chest wall (S) localized, stab-like, aggravated by breathing (O) Appearance with hand over nipple Local tenderness “Siertze balit”

14. Chest wall Pectoralis M. strain (S) Pain while doing push-ups (O) Trigger points pain intensified while contracting / stretching muscle

15. Pleuritic pain (pleura, pericardium) Inflammation>>Sensorial input from parietal baso-lateral aspects of serosa Phrenic N, Intercostal N. Pleuro-pericartitis Infections (bacterial, viral) Trauma Tumor PE Pneumothorax Immune (SLE, RA, sceroderma) Miscell. (FMF, Dressler’s syndrome)

16. Pleuritic pain (pleura, pericardium) Inflammation>>Sensorial input from parietal baso-lateral aspects of serosa No inflammation – no pain (S) Less localized, stab-like, aggravated by breathing Positional effect ; Effect of swallowing Radiation – shoulder (phrenic), localized (intercostal) Other related complains Pericarditis-some components of anginal pain (O) No local tenderness (unlike musculo-skeletal) Other related physical findings Other related objective indices Gallop +

17. Epidemic Pleurodynia Fever GI symptoms Respiratory symptoms Exanthema Headache, aseptic meningitis Peri-myocarditis Chest pain – pleurisy (Bornholm’s disease) pleuro-pericarditis intercostal myocarditis perichondritis, periosteitis Coxsackie B

18. Anginal pain Sensorium – symathetic nerves along coronary adventitia (sub-epicardial) Reflects Interstitial lactic acidosis? Coronary heart disease Stable AP < - > UAP Narrowing< - > ruptured plaque Lt ventricular strain (subendocardial ischemia) AS HOCM Severe HTN – chronic Severe HTN – acute (pheochromocytoma, sympatomimetic toxidrome) Rt. ventricular strain PE Hypoxia >>>chronic PHTN Acute mountain sickness Others CO poisoning, methemoglobinemia, cyanide poisoning, nitrate withdrawal Tachyarrythmia of any cause, alone or superimposed on CAD (↓diastole, ↓ BP, LVEDP↑)

19. Anginal pain Sensorium – symathetic inflow along coronary adventitia (sub-epicardial) Reflects Interstitial lactic acidosis? (S) Pain type: pressure-like \ heaviness \ burning Acute < - > chronic intermittent Pain radiation Effort-related (differ from enhanced respiration-related musculo-skeletal/pleuritic) Relived by rest (time!), by nitrates Herald symptoms before AMI – milder episodes of pain Associated complains (SOB, orthopnea, cold perspiration, nausea, doom) In chronic pain – specify functional capacity (NYHA) Risk factors (O) …..

20. Esophageal pain Muscular pain (motility disprders) Diffuse esophageal spasm Nutcracker esophagus (S) Much like anginal pain: pressure like, radiation No relation to exrcise Some association with eating/swallowing Relieved by nitrates and CCB Mucosal pain Reflux esophagitis (GERD) Infection (candida, cytomegalovirus etc) Post chemotherapy / irradiation Thermal/acid/alkali burns FB: fishbone (S) heartburn, regurgitation associated with swallowing, aggravated by recumbent position acid taste, night cough, “asthma”, appears after special food or wine, relief by anti-acids

21. Esophageal pain Mixed muscular / mucosal pain Foreign bodies Achalesia (S) Mixed symptoms drooling non-acid reflux

22. Vascular - Aortic pain Aortic dissection (S) Excruciating pain Radiation between scapulae Doom (O) Sympathetic overactivity Unequel pulses / BP AR Bruits Features of “collagen” disease Aortitis / inflammation of major vessels Inflammatory (Takayasu) Infective (S) Less defined, subacute / chronic (O) carotidenia, epigastric tenderness Bruits

23. Other mediastinal pain Infection esophageal rupture (Borhave) post surgical Tumor (S) Ill-defined retrosternal dull / severe pain Many other symptoms

24. Pain originating from airways Sensorium by vagal inflow down to the carina Tracheitis-mucositis Infection Chemical Thermal Irradiation, chemotherapy Post - intubation (S) Retrosternal sharp pain, associated with breathing / cough “as if something is torn from within” aggravated by dry air, improved by humidified air

25. Chest pain - miscellaneous Acute chest syndrome in sickle cell disease (S) Chest pain: pleuritic + anginal type Cough, fever, dyspnea (O) Tachypnea, hypoxia, lobar infiltrate>>> diffuse infiltrates, respiratory failure cardiovascular failure Pain related to pleuritis and PHTN

26. Chest pain - miscellaneous Prolapsed (floppy) mitral valve (barlow’s syndrome) Mechanism of pain ??? (S) “A-typical” stab-like chest pain, lasting seconds “like needle pricks” “Fatigue syndrome”, “neuresthenia” (O) Sometime, some musculo-skeletal components Physical hints for abnormal collagen synthesis Anxiety

27. Origin of Chest Pain Not always within the chest Neck, shoulder girdle Chest structures Referred pain Radicular pain spine Abdominal origin Referred pain Referred pain Gallbladder Liver Pancreas Gastric/duodenal Colon (splenic fl.) Spleen Radicular pain (S) Related to specific movements (O) Triggered by movements Trigger points (S) GIT symptoms Radiation to shoulders (O) Abdominal tenderness and findings

28. Supraspinatus (rotator cuff) Infraspinatus (rotator cuff)

29. Teres minor Subscapularis (rotator cuff)

30. Trapezius

31. Scalenus anterior & posterior (thoracic outlet)

32. Radiated shoulder pain Rotator cuff injury Frozen shoulder Chronic shoulder dislocation

33. Referred pain in the other direction Chest >>>abdomen Basal pneumonia AMI (diaphragmatic wall) Chest>>>neck UL pneumonia Pancoast syndrome

34. Chest Pain Evaluation

35. Chest Pain: Evaluation Medical history Physical examination Initial diagnostic tests Provocative/therapeutic tests Observation period in ER – dynamics Hospitalization Most important Type of pain, duration, location and radiation Associated acute complains: SOB, nausea perspiration,doom perception Association with: exercise, breathing, peculiar movement, swallowing, cough Associated additional symptoms: fever, weight loss… Risk stratification r/o life threatening conditions: MI, PE, dissection acute chest syndrome in a black patient

36. Chest Pain: Evaluation Medical history Physical examination Initial diagnostic tests Provocative/therapeutic tests Observation period in ER – dynamics In-hospital final diagnosis and treatment Vital signs, compare pulses General appearance Hyperalgesia / disesthesia Local tenderness Provocation of pain Signs of DVT r/o life threatening conditions: MI, PE, dissection

37. Chest Pain: Evaluation Medical history Physical examination Assessment: define type of pain Initial diagnostic tests Provocative/therapeutic tests Observation period in ER – dynamics In-hospital final diagnosis and treatment Skin Chest wall (musculo-skeletal) Pleural/pericardial (serositis) Anginal/esophageal-muscular (m. ischemia) Esophageal – mucositis Radicular Other referred pain r/o life threatening conditions: MI, PE, dissection

38. Chest Pain Diagnostic Challenge Medical history Physical examination Assessment: define type of pain Initial diagnostic tests Provocative/therapeutic tests Observation period in ER – dynamics In-hospital final diagnosis and treatment ECG (is it in the presence of pain?) ±CXR ±Basic lab tests, cardiac enzymes, D-dimer, blood gases, surgery protocol, etc. ±echo / spiral CT r/o life threatening conditions: MI, PE, dissection

39. Properties of individual markers Marker Initial Rise Peak Persistence Heart Specificity CK 4 - 6 h 18 - 24 h 24 - 36 h + CK MB 4 - 6 h 16 - 20 h 18 - 30 h ++ Myoglobin 1 - 2 h 4 - 6 h 8 - 12 h + Troponin I 4 - 6 h 18 - 24 h 5 - 7 d ++++ Troponin T 3 - 5 h 18 - 24 h 5 - 7 d ++++ - - 12-24 24-36 24-36 36-48 GOT LDH 8-12 12-24

40. Figure 1. Plot of the appearance of cardiac markers in blood vs. time after onset of symptoms. Peak A, early release of myoglobin or CK-MB isoforms after AMI; peak B, cardiac troponin after AMI; peak C, CK-MB after AMI; peak D, cardiac troponin after unstable angina. Data are plotted on a relative scale, where 1.0 is set at the AMI cutoff concentration.

42. Chest Pain Diagnostic Challenge Medical history Physical examination Assessment: define type of pain Initial diagnostic tests Provocative/therapeutic tests Observation period in ER – dynamics In-hospital final diagnosis and treatment Diagnostic maneuvers Changing position Deep breath Manipulation of neck, shoulder girdle Local pressure Exercise r/o life threatening conditions: MI, PE, dissection

43. Chest Pain Diagnostic Challenge Medical history Physical examination Assessment: define type of pain Initial diagnostic tests Provocative/therapeutic tests Observation period in ER – dynamics In-hospital final diagnosis and treatment Therapeutic trials Nitrate test r/o life threatening conditions: MI, PE, dissection

44. Nitrate Test Be there Pain relief (clinical response) Short time Pharmacologic response Position Test responses Clinical (+), pharmacologic (+) = positive test Clinical (-), pharmacologic (+) = negative test Clinical (+), pharmacologic (-) = placebo effect Clinical (-), pharmacologic (-) = ineffective drug

45. Chest Pain Diagnostic Challenge Medical history Physical examination Assessment: define type of pain Initial diagnostic tests Provocative/therapeutic tests Observation period in ER – dynamics In-hospital final diagnosis and treatment Therapeutic trials Nitrate test (how performed!) Anti-acid with immediate effect (Maalox) Local anestetics Inhalation of humidified air / lidocaine r/o life threatening conditions: MI, PE, dissection

46. Chest Pain Diagnostic Challenge Medical history Physical examination Assessment: define type of pain Initial diagnostic tests Provocative/therapeutic tests Observation period in ER – dynamics In-hospital final diagnosis and treatment Provocative tests Exercise test Bernstein test r/o life threatening conditions: MI, PE, dissection

47. Chest Pain Diagnostic Challenge Medical history Physical examination Assessment: define type of pain Initial diagnostic tests Provocative/therapeutic tests Complementary tests Observation period in ER – dynamics In-hospital final diagnosis and treatment Cardiac echo Spiral CT V/Q scan Ribs X rays Chest X rays on expirium Abdominal US/CT r/o life threatening conditions: MI, PE, dissection

48. Chest Pain Diagnostic Challenge Medical history Physical examination Assessment: define type of pain Initial diagnostic tests Provocative/therapeutic tests Complementary tests Observation period in ER – dynamics In-hospital final diagnosis and treatment The time effect – repeated re-evaluation Change in symptoms Change in objective findings Repeated blood tests (cardiac enzymes) and ECG Exercise test Chest pain units r/o life threatening conditions: MI, PE, dissection

49. Chest Pain Diagnostic Challenge Medical history Physical examination Initial diagnostic tests Provocative/therapeutic tests Complementary tests Observation period in ER – dynamics In-hospital final diagnosis and treatment or Ambulatory final evaluation and treatment Exercise test Thalium scan Cardiac catheterization Endoscopy, esophageal manometry Bone scan r/o life threatening conditions: MI, PE, dissection

50. Treatment Options