APPROACH TO THE PATIENT WITH CHEST PAIN

YEDITEPE UNIVERSITY FACULTY OF MEDICINE PHASE 4 CARDIOLOGY COURSE 2014-2015PROF. MUZAFFER DEGERTEKIN, M.D., PhD.MUSTAFA AYTEK SIMSEK, M.D., Attending

Physician

CAUSES OF ACUTE CHEST PAIN

DIAGNOSTIC CONSIDERATIONS

IMMEDIATE MANAGEMENT

Acute chest pain is one of the most common reasons for presentation to the emergency department

15% to 25% of patients with acute chest pain actually have ACS

The diagnosis of ACS is missed in approximately 2% of patients

Mortality for patients with acute myocardial infarction (MI) who are mistakenly discharged from the ED increases twofold

Myocardial Ischemia or Infarction,

Pericardial Disease,

Vascular Disease,

 Pulmonary Conditions,

 Gastrointestinal Conditions,

 Musculoskeletal and Other Causes,

The most common serious cause of acute chest discomfort

Supply of myocardial oxygen is inadequate compared with the demand

Usually occurs in the setting of coronary atherosclerosis

Coronary spasm Coronary arteritis, Proximal aortitis, Spontaneous coronary dissection, Proximal aortic dissection, Coronary emboli from infectious or noninfectious

endocarditis,thrombus in the left atrium or left ventricle,

Myocardial bridge, Congenital abnormality of the coronary arteries

Classic manifestation of ischemia is angina, which is usually described as a heavy chest pressure or squeezing, a burning feeling, or difficulty breathing

The discomfort often radiates to the left shoulder, neck, or arm. It typically builds in intensity over a period of a few minutes.

The pain may begin with exercise or psychological stress, but ACS most commonly occurs without obvious precipitating factors

Pleuritic pain (i.e., sharp or knifelike pain brought on by respiratory movements or cough)

Primary or sole location of discomfort in the middle or lower abdominal region

Pain that may be localized at the tip of one finger, particularly over the left ventricular apex

Pain reproduced with movement or palpation of the chest wall or arms

Constant pain that persists for many hours Very brief episodes of pain that last a few

seconds or less Pain that radiates into the lower extremities

The visceral surface of the pericardium is insensitive to pain, as is most of the parietal surface (Therefore, noninfectious causes of pericarditis usually cause little or no pain. In contrast, infectious pericarditis almost always involves surrounding pleura)

Pleuritic pain with breathing, coughing, and changes in position (Because the central diaphragm receives its sensory supply from the phrenic nerve, and the phrenic nerve arises from the third to fifth cervical segments of the spinal cord, pain from infectious pericarditis is frequently felt in the shoulders and neck)

Involvement of the more lateral diaphragm can lead to symptoms in the upper abdomen and back (confusion with pancreatitis or cholecystitis)

The sudden onset of excruciating ripping pain

The location of which reflects the site and progression of the dissection (Ascending aortic dissections tend to manifest with pain in the midline of the anterior chest, and posterior descending aortic dissections tend to manifest with pain in the back of the chest).

Dyspnea and pleuritic symptoms

The location of which reflects the site of pulmonary disease

Pneumothorax. sudden in onset and is usually accompanied by dyspnea

Tracheobronchitis…burning midline pain

Pneumonia..pain over the involved lung

Irritation of the esophagus by acid reflux can produce a burning discomfort that is exacerbated by alcohol, aspirin, and some foods

Mallory-Weiss tears of the esophagus prolonged vomiting episodes

Cholecystitis right upper quadrant abdominal pain

Pancreatitis aching epigastric pain

Costochondritis

Cervical disc disease,

Herpes zoster

Heavy exercise affecting the nerves of the chest wall

Major cause of chest discomfort in ED

Chest tightness

Shortness of breath

a sense of anxiety

Evaluation of the patient with acute chest pain

Hemodynamic instability

A 12-lead electrocardiogram (ECG)

History

Physical Examination

Electrocardiography

Chest Radiography

Biomarkers

INITIAL APPROACH: HISTORY

Are you having discomfort? How would you describe the discomfort? Where is the discomfort? Does it radiate anywhere? Any aggravating/alleviating factors? Any associated discomfort?

Diaphoresis, nausea, vomiting, cough, fevers

20

INITIAL APPROACH: HISTORY

Frequency of the discomfort? Time of onset or acute worsening? Has there been any progression? History of Cardiopulmonary disease? Risk factors for cardiopulmonary disease? Family history of cardiopulmonary disease?

21

Vital signs, Examination of the peripheral vessels

Bruits or absent pulses

Identify potential precipitating causes Uncontrolled hypertension, anemia, hyperthriodism

Important comorbid conditions Chronic obstructive pulmonary disease

Evidence of hemodynamic complications Congestive heart failure,

New mitral regurgitation, hypotension

10 minutes after presentation

New persistent or transient ST-segment abnormalities (≥0.1 mV) and T inversion (≥0.2 mV)

During a symptomatic episode at rest and resolve

Usually non-diagnostic

Pulmonary edema (ischemia-induced diastolic or systolic dysfunction)

Pneumothorax, Pneumonia

A cardiac troponins (T or I; cTnT or cTnI)

Creatine kinase MB isoenzyme (CK-MB, less sensitive)

Blood should be obtained for testing at hospital presentation, and at 6 to 9 hours

A normal reference values 0.01 to 0.07 ng/ml

Ultrasensitive assays <0.001 ng/ml or <1 pg/ml

Serial sampling up to 12 hours after presentation %90 to %95

3 hours of the onset of chest pain 80% to 85%

Found in Skeletal muscle, Tongue, Diaphragm, Small intestine, uterus, and prostate

Eleveted Muscular dystrophy High-performance athletics Rhabdomyolysis Alcohol abuse or trauma vs

Shorter half-life Useful for gauging the timing of an MI Diagnosing reinfarction

Serum myoglobin heart-type fatty acid binding protein C-reactive protein serum amyloid A, myeloperoxidase interleukin-6 D-dimer B-type natriuretic peptides

hs-C-reactive protein (prognostic)

D-dimer (PE)

B-type natriuretic peptide (HF, prognostic)

NSTEMI

Presentation

Working Dx

ECG

CardiacBiomarker

Final DxNQMI Qw MI

UA

UnstableAngina

Ischemic Discomfort

Acute Coronary Syndrome

Myocardial Infarction

ST Elevation

No ST Elevation

Non-ST ACS

Libby P. Circulation 2001;104:365, Hamm CW, Bertrand M, Braunwald E, Lancet 2001; 358:1533-1538; Davies MJ. Heart 2000; 83:361-366. Anderson JL, et al. J Am Coll Cardiol. 2007;50:e1-e157, Figure 1. Reprinted with permission.