approach to chest pain. chest pain table 1-2 differential diagnosis of episodic chest pain...
TRANSCRIPT
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Approach To Chest PainApproach To Chest Pain
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Chest PainChest Pain TABLE 1-2 DIFFERENTIAL DIAGNOSIS OF EPISODIC CHEST PAIN RESEMBLING ANGINA PECTORIS DURATION QUALITY
PROVOCATIONRELIEF LOCATION COMMENT
Effort angina 5-15 minutes Visceral (pres- During effort or Rest, nitroglyc- Substernal, radi- First episode sure) emotion erin ates vivid
Rest angina 5-15 minutes Visceral (pres- Spontaneous (? Nitroglycerin Substernal, radi- Often nocturnal sure) with exercise) ates Mitral prolapse Minutes to Superficial Spontaneous (no Time Left anterior No pattern, vari- hours (rarely visceral) pattern able character Esophageal re- 10 minutes to 1 Visceral Recumbency, Food, antacid Substernal, epi- Rarely radiates flux hour lack of food gastricEsophageal 5-60 minutes Visceral Spontaneous, Nitroglycerin Substernal, Mimics anginaspasm cold liquids, ex- radiates ercisePeptic ulcer Hours Visceral, burning Lack of food, Foods, antacids Epigastric, substernal
‘‘acid’’ foods Biliary disease Hours Visceral (waxes Spontaneous, Time, analgesia Epigastric, ? Colic and wanes) food radiatesCervical disc Variable (gradu- Superficial Head and neck Time, analgesia Arm, neck Not relieved by ally subsides movement, pal- rest pationHyperventilation 2-3 minutes Visceral Emotion, tachy- Stimulus removal Substernal Facial paresthe- pnea siaMusculoskeletal Variable Superficial Movement, Time, analgesia Multiple Tenderness palpationPulmonary 30 minutes + Visceral (pres- Often spontane- Rest, time, bron- SubsternalDyspneic sure) ous chodilator Reproduced with permission from Christie, L.G., Jr., and Conti, C.R.: Systematic approach to the evaluation of angina-like chest pain. Am. Heart J. 1027, 1981.
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Chest PainChest Pain TABLE 1-3 SOME FEATURES DIFFERENTIATING CARDIAC FROM NONCARDIAC CHEST PAIN
FAVORING ISCHEMIC ORIGIN AGAINST ISCHEMIC ORIGIN
Character of Pain
Constricting
Squeezing ‘‘Knife-like,’’ sharp, stabbing
Burning ‘‘Jabs’’ aggravated by respiration
‘‘Heaviness,’’ ‘‘heavy feeling’’
Location of Pain
Substernal In the left submammary area
Across mid-thorax, anteriorly In the left hemithorax
In both arms, shoulders
In the neck, cheeks, teeth
In the forearms, fingers
In the interscapular region
Factors Provoking Pain
Exercise Pain after completion of exercise
Excitement Provoked by a specific body motion
Other forms of stress
Cold weather
After meals
From Selzer, A.: Principles and Practice of Clinical Cardiology. 2nd ed. Philadelphia, W.B. Saunders
Company, 1983, p. 17.
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Patterns of PainPatterns of Pain
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Differential Dx by LocationDifferential Dx by Location
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Chest PainChest PainPhysical ExamPhysical Exam
Vital Signs– Febrile- Endocarditis, Dressler’s, Demand
Ischemia– BP- Hypertensive, Ischemia, Aortic Dissection,
CHF (diastolic dysfxn)– Hypotensive, Cardiogenic Shock, CHF
(systolic dysfxn, AS) – HR- arrhythmia, afib, v-tach, heart block– RR/SaO2- CHF, PE
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Chest PainChest PainPhysical ExamPhysical Exam
Mental Status- alertness (shock), anxiety HEENT: Mucous Membranes, Carotid Upstrokes
(AS, AI, Bisferiens, Alternans), Bruits, Thyroid (CHF, Angina), Cx Tenderness, JVP- CHF,valve disease, Cannon a-waves
Lungs: RR, Rales, Wheezing (Bronchoconstriction or CHF), Pleural Effusion
Extrem: Equal BP’s, pulses (dissection, PVD), femoral/abdominal bruits, perfusion (cool, clammy, shock), Edema-CHF
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Chest PainChest PainCardiac ExamCardiac Exam
Rate/Rhythm- arrhythmia (Afib, V-Tach, Bradycardia), heart block
PMI- displaced, sustained (CHF), palpable S3, S4 Heart Sounds: S1 Loud (MS), Soft (MR, AVB)
Variable(Afib), OS(MS), Mid Sys Click (MVP) Split S2 (BBB, PE, PA HTN, AS, LV Ischemia, Severe MR)
Murmurs- (Separate topic) AS, AI(esp acute), Ischemic MR
S3- CHF, S4-LV Non compliance (Ischemia, HTN)
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ST Elevation Myocardial ST Elevation Myocardial Infarction (STEMI)Infarction (STEMI)
Admit, O2ASASL NTG, +/- IV NTG (SBP>100)MSO4 2-4mg, (MONA)Heparin (UFH or LMW)Beta-blockerCandidate for Thrombolytics
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Definite Indications for PTCA/Thrombolytic Therapy
Consistent clinical syndrome– Chest pain, new arrhythmia, unexplained
hypotension, pulmonary edema
Diagnostic EKG– >1mm ST elevation in >2 contiguous leads– New LBBB
Less than 12 hours since onset of pain
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Relative Indications for PTCA/Thrombolytic Therapy
Consistent Clinical Syndrome
– Chest pain, new arrhythmia, unexplained hypotension or pulmonary edema
Nondiagnostic ECG
– Left bundle-branch block of unknown duration
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Absolute Contraindications for Absolute Contraindications for Thrombolytic TherapyThrombolytic Therapy
History of hemorrhagic stroke Stroke or CVA within 1 year Allergy to the agent Surgery or trauma in past 2 wks Known intracranial neoplasm Suspected aortic dissection Active internal bleeding
(except menstruation)
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Relative Contraindications for Relative Contraindications for Thrombolytic TherapyThrombolytic Therapy
Severe uncontrolled hypertension (>180/110 mm Hg)
History of chronic severe hypertensionCVA or intracerebral pathology > 1 yr agoCurrent anticoagulant useRecent trauma (within 2-4 weeks)Allergy or prior exposure to streptokinase
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Relative Contraindications for Thrombolytic Therapy
Relative Contraindications for Thrombolytic Therapy
Active peptic ulcer disease Significant hepatic dysfunction Recent (2-4 weeks) internal bleeding Bleeding diathesis Noncompressible arterial or central
venous puncture Pregnancy
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PTCA vs. ThrombolysisPTCA vs. Thrombolysis
PAMI Trial Demonstrated Superiority of PTCA over Thrombolysis– Hospital Mortality 6.5% with Thrombolysis vs
2.6% with PTCA– ICH 2% with Thrombolysis vs 0.2% with
PTCA– 90 min Door to Balloon Time– Experienced Operators
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Non-ST Elevation MI Non-ST Elevation MI (NSTEMI)(NSTEMI)
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NSTEMI, Early Invasive NSTEMI, Early Invasive StrategyStrategy
No. Pts
1o Endpoint
Death/MI
Death
MI
Rehosp ACS
P value
1114
7.4
4.7
2.2
3.1
3.4
INV (%)
1106
10.5
7.0
1.6
5.8
5.5
CONS (%)
Cardiac Events at 30 DaysCardiac Events at 30 Days
0.67
0.65
1.40
0.51
0.61
OR
0.009
0.02
0. 29
0.002
0.018
No. Pts
1o Endpoint
Death/MI
Death
MI
Rehosp ACS
P value
1114
7.4
4.7
2.2
3.1
3.4
INV (%)
1106
10.5
7.0
1.6
5.8
5.5
CONS (%)
Cardiac Events at 30 DaysCardiac Events at 30 Days
0.67
0.65
1.40
0.51
0.61
OR
0.009
0.02
0. 29
0.002
0.018
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No. Pts
1o Endpoint
Death/MI
Death
MI
Rehosp ACS
1114
15.9
7.3
3.3
4.8
11.0
1106
19.4
9.5
3.5
6.9
13.7
P valueINV (%)CONS (%)
Cardiac Events at 6 MonthsCardiac Events at 6 Months
0.78
0.74
0.93
0.67
0.78
OR
0.025
<0.05
0.74
0.029
0.054
No. Pts
1o Endpoint
Death/MI
Death
MI
Rehosp ACS
1114
15.9
7.3
3.3
4.8
11.0
1106
19.4
9.5
3.5
6.9
13.7
P valueINV (%)CONS (%)
Cardiac Events at 6 MonthsCardiac Events at 6 Months
0.78
0.74
0.93
0.67
0.78
OR
0.025
<0.05
0.74
0.029
0.054
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CONS CONS INVINV(%)(%) (%)(%)19.419.4 15.315.319.619.6 17.017.0
17.817.8 14.914.921.721.7 17.117.1
27.727.7 20.120.116.416.4 14.214.2
26.326.3 16.416.415.315.3 15.615.6
19.419.4 15.915.9
11OO EndpointEndpoint %Pts%Pts
MenMen (66%)(66%)WomenWomen (34%)(34%)
Age < 65 yrsAge < 65 yrs (57%)(57%)Age Age >> 65 yrs65 yrs (43%)(43%)
DiabetesDiabetes (28%)(28%)No diabetesNo diabetes (72%)(72%)
ST ST ** (38%)(38%)No ST No ST (62%)(62%)
Total PopulationTotal Population
Death, MI, Rehosp ACS at 6 MonthsDeath, MI, Rehosp ACS at 6 Months
*Interaction P=0.006*Interaction P=0.006others P=NSothers P=NS
Subgroups: Primary Endpoint Subgroups: Primary Endpoint
INV Better CONS Better00 0.50.5 11 1.51.5
CONS CONS INVINV(%)(%) (%)(%)19.419.4 15.315.319.619.6 17.017.0
17.817.8 14.914.921.721.7 17.117.1
27.727.7 20.120.116.416.4 14.214.2
26.326.3 16.416.415.315.3 15.615.6
19.419.4 15.915.9
11OO EndpointEndpoint %Pts%Pts
MenMen (66%)(66%)WomenWomen (34%)(34%)
Age < 65 yrsAge < 65 yrs (57%)(57%)Age Age >> 65 yrs65 yrs (43%)(43%)
DiabetesDiabetes (28%)(28%)No diabetesNo diabetes (72%)(72%)
ST ST ** (38%)(38%)No ST No ST (62%)(62%)
Total PopulationTotal Population
Death, MI, Rehosp ACS at 6 MonthsDeath, MI, Rehosp ACS at 6 Months
*Interaction P=0.006*Interaction P=0.006others P=NSothers P=NS
Subgroups: Primary Endpoint Subgroups: Primary Endpoint
INV Better CONS Better00 0.50.5 11 1.51.5
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1 4.5
24 .2
1 6.914 .3
0
5
1 0
1 5
2 0
2 5
3 0
T nT - T nT +
(%)
C O N S IN V
T ro p o n in T : 1 oE P a t 6 m o n th s
T n T cu t p o in t = 0 .01 n g /m l (54% o f P ts T n T + )
D e ath , M I, R eh o sp A C S a t 6 M o n th sD e ath , M I, R eh o sp A C S a t 6 M o n th s
O R = 0 .52O R = 0 .52*p < 0 .00 1*p < 0 .00 1
In terac tio nIn terac tio nP < 0 .0 01P < 0 .0 01
p = N Sp = N S
**
N = 414N = 414 N = 396N = 396 N = 463N = 463 N = 495N = 495
1 4.5
24 .2
1 6.914 .3
0
5
1 0
1 5
2 0
2 5
3 0
T nT - T nT +
(%)
C O N S IN V
T ro p o n in T : 1 oE P a t 6 m o n th s
T n T cu t p o in t = 0 .01 n g /m l (54% o f P ts T n T + )
D e ath , M I, R eh o sp A C S a t 6 M o n th sD e ath , M I, R eh o sp A C S a t 6 M o n th s
O R = 0 .52O R = 0 .52*p < 0 .00 1*p < 0 .00 1
In terac tio nIn terac tio nP < 0 .0 01P < 0 .0 01
p = N Sp = N S
**
N = 414N = 414 N = 396N = 396 N = 463N = 463 N = 495N = 495
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Chest Pain Uncertain EtiologyChest Pain Uncertain Etiology
EKG with Symptoms– 4% of MI’s normal EKG
Non Invasive Imaging :Resting Nuclear Imaging/Echo/Contrast During Symptoms, CT Angio, EBCT, MRI Hyperenhancement
Cardiac EnzymesStress TestingCardiac Catheterization
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Bayes TheroemBayes Theroem
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Predictive ValuePredictive Value
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Predictive Value ETTPredictive Value ETT
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ETT in WomenETT in Women
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Cardiac Stress TestingCardiac Stress TestingNuclearNuclear
TABLE 9-4 SENSITIVITY AND SPECIFICITY FOR DETECTION OF CORONARY ARTERY
DISEASE BY 201Tl SINGLE-PHOTON EMISSION COMPUTERIZED TOMOGRAPHY
NUMBER OF
AUTHOR PATIENTS SENSITIVITY (%) SPECIFICITY
Tamaki et al. 104 91 92 De Pasquale et al. 210 95 71
Borges-Neto et al. 100 92 69
Maddahi et al. 110 96 56
Fintel et al. 112 91 90 Iskandrian et al. 164 88 62
Go et al. 202 76 80 Mahmarian et al. 360 93 87
van Train et al. 242 95 56
Total 1901 91 73
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Stress EchoStress Echo
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Contraindications to ETT Contraindications to ETT
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ETT High Risk FeaturesETT High Risk Features
TABLE 5-4 EXERCISE PARAMETERS ASSOCIATED WITH
AN ADVERSE PROGNOSIS AND MULTIVESSEL CORONARY ARTERY DISEASE Duration of symptom-limiting exercise (< 6 METs) Failure to increase systolic blood pressure ³120 mm Hg, or a sustained decrease ³10 mm Hg, or below rest levels, during progressive exercise ST segment depression ³2 mm, downsloping ST segment, starting at < 6 METs, involving ³5 leads, persisting ³5 min- utes into recovery Exercise-induced ST segment elevation (a Vr excluded) Angina pectoris during exercise Reproducible sustained (> 30 sec) or symptomatic ventricular tachycardia
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EBCTEBCT
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Multislice CTMultislice CTSensitivity Specificity
Segment <50% >50% >75%
Mid/Prox 80 75 88 97
Distal 76 67 60 97
All 79 73 80 97
Leber et al., JACC July 2005
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Diagnostic Accuracy CTADiagnostic Accuracy CTA
Leshka et.al. Eur Heart Journal 2005
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CTA ExclusionsCTA Exclusions
BMI>30 Afib Coronary Calcium Previous Stent HR>75 Hemodynamic Instability, inability to take beta-
blockers Renal Insufficiency, Contrast allergy Coronary Size <3mm
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Coronary AngiographyCoronary Angiography
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Cardiac CatheterizationCardiac Catheterization
Remains the “Gold Standard”High risk patientsNon diagnostic non-invasive testsHemodynamic, Anatomical, Physiological
Assessment– FFR, IVUS
Immediate Intervention if Needed