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Approach to Chest Pain in the ED

Approach to Chest Pain in the ED. Anthony Carrozza, M.D. DMS-Emcare, Las Vegas. Epidemiology. 6 million visits/yr 2nd most common complaint Wide range of causes High Morbidity/Mortality/Liability. The Big 7. ACS PE Aortic Dissection Pneumothorax Pericardial Tamponade Pneumonia

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Approach to Chest Pain in the ED

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  1. Approach to Chest Pain in the ED Anthony Carrozza, M.D. DMS-Emcare, Las Vegas

  2. Epidemiology • 6 million visits/yr • 2nd most common complaint • Wide range of causes • High Morbidity/Mortality/Liability

  3. The Big 7 • ACS • PE • Aortic Dissection • Pneumothorax • Pericardial Tamponade • Pneumonia • Mediastinitis/Borhavve’s Syndrome

  4. Cardiac GI Lungs/Pleura Musculoskelelal Derm Panic The Others

  5. Goals of CP Evaluation • R/O STEMI/NSTEMI • R/O other Life Threatening Causes • R/O Low risk ACS • 1-2% risk < NEED FURTHER WORKUP

  6. Pretest Probability • The probability of having the target disorder BEFORE a diagnostic test result is known. • Interpreting test result • EKG-- STE and AMI • Test Selection • PE-- Dimer vs. CT

  7. SPin (+) test rules dz in a / (a+c) SNout (-) test rules dz out d / (b+d) Specificity Sensitivity

  8. Acute Coronary Syndrome • #1 Killer in developed countries • Approx 15% of Adult CP = ACS • Supply and Demand of Blood/Myocardium • Stable Angina -- Predictable, increase in demand • UA/AMI-- Acute decrease in Supply

  9. Diagnostic Workup • STEMI • +EKG • NSTEMI • +Enzymes, +/- EKG • UA- ACS with Negative Enzymes • EKG/Labs - Nondiagnostic • History - Is the Key! …or is it?

  10. What’s a good story? • Visceral Pain- not well localized • SS Chest “Tightness” “Pressure” “Aching” • Gradual onset • Peaks in 2-3 min • Exertional • Radiation • Does a “good story” predict ACS?

  11. Comparison of frequency of inducible myocardial ischemia in Patients Presenting to ED with Typical vs. Nonanginal Chest Pain. Hermann LK, Weingart SD, et al. Am J Cardiology, June 2010 105(11) 1561-1564,. • Retrospective study - 2525 CP pts • Patients admitted to CPOU/no CAD • Divided into 2 groups • SS+Exertional+Relieved by rest/NTG -- 231 pt • Atypical Sx (Nonanginal/no CP)-- 2293 • No significant difference in inducible ischemia

  12. Diaphoresis Vomiting Radiation Sharp Stabbing Positional Likelihood Likelihood

  13. ACS without Pain • Dyspnea • Vomiting • Dizziness • AMS • Weakness

  14. h/o CHF h/o CVA Age > 75 Women Diabetics 51% 47% 45% 39% 38% RF for Painless AMI

  15. Pitfalls • 7% of patients with AMI/UA have fully reproducible CP • Nitro relieves Cardiac and Noncardiac pain equally • Response to GI cocktail should not influence your disposition

  16. EKG • Sensitive enough? • Initial EKG catches only about 50% AMI • Not Sensitive enough • A normal EKG does not rule out ACS-- • It does decreases likelihood

  17. Biomarkers • Trop I • Very High Sp/Sn for AMI/myocardial cell death • Not sensitive enough for UA • Rises over 3-6hrs back to baseline in 7-10days • CK-MB -- High Sn, moderate Sp • Rises over 4-6hrs back to baseline 3-4 days • Myoglobin-- Low Sp • BNP

  18. Single Set of Enzymes • Inadequate to R/O infarct • Provides NO information about possibility of ischemia • Can not base disposition decisions on result

  19. Threshold for ACS workup • Difficult to decide who needs a workup • Ekg/History/Labs - Not accurate enough • Who does not need a work up? • Very Low Pretest Probability< 1-2% • Based on clinical suspicion • ACS work up not indicated

  20. The Limited Utility of Routine Cardiac Stress Testing in ED Chest Pain Younger Than 40 Years. Herrman LK, Weingart S, et al. Ann Emerg Med 54(1), 2009 • Retrospective • Included • 220 low risk CP patients aged 23 to 40 • All patients had Obs/serial enzymes/Stress • Excluded • Ischemic EKG, Known CAD/CHF, Hypotensive • 6 pts had Positive Stress • 4 Cath-- all negative

  21. Is it ok to miss ACS? • No, but inevitable • No test rules out ACS with 100% certainty • Diagnosing higher than 98-99% • Number of workups rise exponentially • Overtesting • False positives • Risks outweigh benefits

  22. Bottom Line • 1-2% < risk of ACS = Work up • Workup = Obs/2-3 sets enzymes/stress • One set of negative enzymes is not a workup

  23. Stress test/Myocardial Perfusion Scanning • A risk stratification tool to aid in safely dispositioning patients • Purpose not to rule CAD out • Purpose is to rule out clinically significant stenoses • Normal Stress testing highly correlated with excellent short term cv prognosis

  24. Pulmonary Embolism • Significant Morbidity/Mortality • ?500,000/yr in US • Unknown Incidence - Most PE are undiagnosed! • Difficult to diagnose • Obstruction of Pulmonary Artery • Clot/Air/Fat • Massive vs. Submassive

  25. Pathophysiology • DVT migrates through R heart into the Lungs • Lower Ext • Pelvic Veins • Right heart • Upper Ext • Renal Veins

  26. Risk Factors In Women: • Pregnancy • Heavy Smoking • Obesity • OCPs • HTN • Immobilization • Surgery within 3 mos • Stroke • Malignancy • Central Line Placement • Blood Disorders

  27. Symptoms Associated with PE • Dyspnea at rest/exertion -- 73% • Pleuritic CP -- 44% • Leg Pain -- 44% • Leg Swelling -- 41% • Cough -- 34% • Wheezing -- 21%

  28. Atypical Presentations • Syncope • Cough • Mimic Pneumonia- cough/fever/infiltrate

  29. Diagnosis of PE • ABG -- limited utility • 6% normal • 25% pO2 greater than 85 = O2 sat over 95% • CXR -- limited utility • Abnormalities similar to patients without PE • EKG -- Limited utility • Nonspecific Precordial T wave Abnormalities-- 68% • Sinus Tach -- not reliable 6-67%

  30. EKG/PE

  31. D-Dimer • Fibrin Degradation Product • Rules out PE in patients with LOW PRETEST PROBABILITY ONLY! • High Dimer at baseline • Elderly • Cancer • Sepsis • Pregnant

  32. Lower Extremity US • Many pts with PE -- Negative US • As high as 60% may be negative • Including Calf veins may improve diagnostic accuracy • Negative LE US does not rule out PE

  33. Spiral CT Scan • Sn varies according to Study (70%-100%) • Newer Generation Scanners 90%< • Newer Data focuses on High NPV • tn/tn+fn • Very few False negative test • Negative CT = <1% Clinically significant disease

  34. Spiral CT • Other Advantage • Rules out other causes for CP • Disadvantage • Radiation • Dye reaction • Nephrotoxicity

  35. V/Q Scan • Low suspicion PE + Low Prob/Normal Scan • <4% • High/Mod suspicion PE + High Prob Scan • 96%/88% • Nondiagnostic in 75% cases • Higher in patients with Chronic V/Q mismatches • High Variability in reads

  36. Take Home Points • Chest pain is a very high risk CC. • Hx/EKG/Labs do not always give us answers. • If not Very Low risk/No clear Dx -- Need Workup. • PE can present with very nonspecific sx. • D-dimer is only for Low Prob Patients

  37. References • “Diagnostic approach to chest pain in adults” Uptodate.com • “Evaluation of patients with chest pain at low or intermediate risk for acute coronary syndrome” Uptodate.com • Mattu, A. Emergency Medicine: Avoiding the pitfalls and improving the outcomes. BMJ Books 2007.

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