Chest Pain and Shortness of Breath

Brett Sheridan, M.D., F.A.C.SAssistant Professor

Cardiothoracic SurgeryDepartment of Surgery

Causes of Chest Pain and SOB

• Myocardial Infarction• Pulmonary Embolism• Pneumothorax• Hemopneumothorax• Thoracic Aortic Dissection• Esophageal Rupture• Gastro-esophageal Reflux• Empyema

47 y/o man is jogging with his daughter when he suddenly collapses unconscious……

1) Heart Disease

2) Cancer

3) Stroke

Most common causes of death in the US…

How many people in the US died from cardiovascular disease in 2001?

Do more men or women die from cardiovascular disease?

Acute coronary syndrome (ACS) is defined by EITHER acute myocardial infarction OR unstable angina.

These patients are divided into 3 subsets:ST elevation myocardial infarction (STEMI)non-ST elevation MIUnstable angina

• ECG within 10 minutes• Supplemental O2• IV access continuous ECG monitoring• Sublingual NTG if SBP > 90 mmHG• Morphine• ASA (chewed)• Labs• If ST elevation > 1mV or LBBB then reperfusion

(fibrinolysis or PTCA)

Describe the initial stabilizing treatment for symptomatic ischemic heart disease presenting in the ER

What is AMI management in first 24 hours?

• Limited activity 12 hrs and monitor 24 hrs• No prophylactic antiarrythmics • IV heparin if:

– large anterior MI, – PTCA, LV thrombus or – thrombolytics administered

• SQ heparin for all others• ASA indefinitely• IV NTG x 24 hrs• IV beta-blocker if stable• ACE inhibitor if BP permits• Statin therapy

Why are patients referred for CABG instead of undergoing a PCI approach to coronary artery disease?

Acute coronary Syndrome:On-going myocardial ischemia despite initial Rx

Thrombolytics Revascularization

PCI CABG

Percutaneous coronary angioplasty (PTCA, PCI,…)

Percutaneous coronary angioplasty (PTCA, PCI,…)

Percutaneous coronary angioplasty (PTCA, PCI,…)

Natural history of percutaneous coronary angioplasty…..uh-oh!

Cite 2 prospective randomized trials comparing PCI vs CABG for the treatment of multivessel CAD

• Inclusion Criteria – Symptomatic– Multivessel CAD

– LVEF > 30% • Baseline Characteristics

– Class III/IV angina - 66%– Previous MI - 42%– 3 vessel CAD - 30% – mean LVEF = 60%

Comparison of Coronary-Artery Bypass Surgery and Stenting for the Treatment of Multivessel Disease

(Arterial Revascularization Therapies Study Group)

CABG PCI

Patients (n)                                    605                                      600

Late outcome                              ---------------------1 year-----------------Death                                           2.8%                                  2.5%MI                                                4.0%                                   5.3% CVA 2.0% 1.5%

Revascularization *                    4 %                               17%Event-free survival *                  88%                                74%Symptom-free *                          90%                                    79%

Cost *                            $13,638                              $10,665

14% benefit w/ CABG!

Event –free Survival: CABG vs PCIS

16 % benefit w/ CABG!

Risk of Repeat Revascularization

Risk of Death

3.7 % SURVIVAL benefit w/ CABG!

Conclusions-SoS Trial

• Again, repeat revascularization remains more common after PCI (with or without a stent) in multivessel CAD.

• In this study, higher rate of all cause mortality with PCI

Contrast the difference between “off-pump” CABG versus the typical

cardiopulmonary bypass supported CABG.

Traditional CABG

• General anesthetic• Median sternotomy• Conduit harvest (LITA,

radial, vein)• Institution of

cardiopulmonary bypass (CPB)

• Cardiac arrest• Placement of aorto-coronary

grafts• Seperation from CPB• Close

Advantages - Traditional CABG

• Still Heart

• Exposure and access

• Visualization

• The most intensely scrutinized procedure in US medicine

SAFETY

Disadvantages - Traditional CABG

• Proinflammatory response to CPB

• Suggestion of end-organ injury– CNS – Pulmonary – Renal

• Increased fluid shifts

Off-Pump Stabilizer

Off-Pump- Snare

Off-Pump Stabilizing Devices

Off-Pump Exposure of PDA

List 10 complications of CABG and there relative frequency

• Death 3%• Stroke 1-2%• Bleeding requiring re-op 3-5%• Wound Problems 0.5-5%• Myocardial infarction 2-30%• Arrhythmias 10-60%• Pneumonia 4%• Pneumothorax 1-2%• Cardiac Tamponade 3-6%• Pericardial Inflammation 18%• Renal Insufficiency 15-20%

What four medications prevent MI and death following a myocardial infarction.

“Class I” Indications

• ASA

• Beta-blockers

• ACE inhibitor

• Statins

Risk Of Pneumothorax

• Pain

• SOB ( dyspnea)

• Hypoxia

• Hypotension (embarrassed CO)

• Death

DDX of Underlying Pulmonary Pathology

Spontaneous• Primary

– Subpleural bleb

• Secondary– Chronic Obstructive lung disease– Bullous disease– Cystic fibrosis– Pneumocystis-related – Idiopathic pulmonary fibrosis– Pulmonary embolism– Catamenial– Esophageal perforation

• NeonatalAcquired• Trauma• Iatrogenic

Treatment options

• Observation

• Tube thoracostomy

• Surgery

• Other “dated” options– Needle aspiration– Chemical pleurodesis

Observation

• Asymptomatic

• Pneumothorax less than 20%

• ER for 4-6 hours w/ repeat CXR

• F/U within 48 hours and CXR

• Any doubts --admit

Tube Thoracostomy

• Primary Method of Management

• Prompt re-expansion of lung

• Prevents life-threatening sequelae

• Allows pleural-pleural apposition –sealing injured lung

• Tube removed once air leak resolves for 12 hours

Prognosis

• Usually resolves within 1-2 days

• 30% chance of recurrence

• Increases to 60-70% if second pneumothorax

Surgery- Indications

• Recurrent pneumothorax

• Persistent air leak or incomplete expansion

• Massive air leak with incomplete expansion

• History of bilateral pneumothoraces

• Occupational hazard or lack of access

• Hemopneumothorax

Surgery-Procedure

• Video-assisted thorascopic surgery (VATS)

• Resection of offending bleb

• Mechanical pleurodesis

• Tube thoracostomy

• Chemical pleurodesis– Tetracycline– Talc

Treatment of Secondary Pneumothoraces

• Usually associated with significant comorbid disease and debilitated patients

• Individualize treatment (less is more)

• AIDS and Pneumocystis carinii

• COPD

• Cystic fibrosis

Hemothorax - EtiologiesPulmonary

Bullous emphysemaNecrotizing Infections

• PE with lung infarction• Tuberculosis• AV malformation• Hereditary hemorrhagic telangiectasiaPleural• Neoplasm (mesothelioma)• EndometriosisPulmonary Neoplasm• Primary• Metastatic

– Melanoma– Trophoblastic tumors

Blood Dyscrasia• Thrombocytopenia• Hemophilia• Complication of systemic anticoagulation• Von Willebrand’s diseaseAbdominal Pathology• Pacreatic pseudocyst• Splenic artery aneurysm• HemoperitoneumThoracic Pathology• Ruptured thoracic aortic aneurysm

Top Causes

Trauma...

CancerPulmonary embolism

Hemothorax- What to do?

• Traumatic– Tube thoracostomy- large bore– IF more than 1500 mL or more than 200 mL/hour

x 3 hours THEN surgical exploration

• Non-Traumatic– Needle aspiration– Cytology– Tube thoracostomy if HCT > 50%

Aortic Dissection…What is it?

• A bad problem to have

• A sudden (usually) intimal tear of the aorta creating a true lumen and a false lumen

• Consequences of this tear are variable depending on location and progression of the dissection

Classification-DeBakey

Histology and Structure

• Normal aorta- 3 layers – intima – tunic media – adventitia

Histology and Structure

• Media- strongest – usually 1.2 mm – most affected by dissection – elastic collagen fibers 20-30 % of aortic wall – smooth muscle cells 5 %– Microfibrils contain the glycoprotein “fibrillin.”

These act as scaffolding for deposition of elastin to produce concentric rings of tunica media.

more….Histology and Structure

• Aortic dissection denotes one or more tears b/w the the aortic lumen and a medial cleavage plane

• May be localized to the point of “primary tear” but often extends.

• Rarely circumferential

• Re-entry tears occur often… providing communication b/w true and false channels.

even more….Histology and Structure

• The dissection usually splits the outer layers of the media and weakens the external coat. The false channel may dilate or rupture.

• The false channel eventually develops an endothelial lining but may contain extensive thrombus.

• Acute stage –14 days• Subacute - 2 months• Chronic - after 2 months

Incidence• Annual estimated @ 2-5 cases per million

• Pathology series the prevalence ranged from 0.2 to 0.8% in Chicago and Boston

• Males > Females 2:1

• Type A - 50-55 years

• Type B - 65 years

Risk Factorspregnancy

Marfan’s

hypertension

aortic coarctation

congenital aortic valve anomalies

Presentation- acute dissection

• Sudden severe chest pain (90%) worst at onset not previously experienced …adjectives such as “ripping” and “tearing”

Presentation- acute dissection

• Sudden severe chest pain (90%) worst at onset not previously experienced …adjectives such as “ripping” and “tearing”

• History of hypertension

• Type A- pain mid-sternal

• Type B-pain inter-scapular

• If extension… neurologic deficit, abdominal pain, or peripheral extremity ischemia

Differential Dx- acute dissection

• Coronary ischemia/ myocardial infarction

• Aortic aneurysm w/o dissection

• Musculoskeletal

• Pericarditis

• Biliary colic

• Pulmonary embolism

Physical exam- acute dissection

• Blood pressure usually elevated• Hypotension associated w/ pericardial tamponade,

rupture, aortic insufficiency, or massive MI• New pulse deficit- 60%• Diastolic decrescendo murmur @ LSB- aortic

regurgitation• Diminished left-sided breath sounds- hemothorax• Neurologic exam

– mental status, – focality --peripheral vs central

Diagnostic studies- acute dissection

• CXR

– deformity of Aortic knob,

– widened mediastinum,

– left pleural effusion, etc.

• EKG- chest pain w/ normal EKG sine qua non

Diagnostic studies- acute dissection

Echocardiography currently thought to be the preferred diagnostic test –rapid and accurate. Evaluates aortic valve, segmental wall function, pericardial effusion. Unfortunately operator dependent.

Diagnostic studies- acute dissection

CT- expeditious w/ reasonable sensitivity and specificity

Diagnostic studies- acute dissection

MRA-excellent sensitivity and specificity but slow

Diagnostic studies- acute dissection

Aortography - lacks sensitivity as imaging requires blood flow which may not occur in false lumen. Indication for coronary angiogram remains controversial.

DeBakey, Surgery, 1982

Medical Treatment

Type A• 24 hrs72%• 2 wks 43%• 5 yrs 34%• 10 yrs28%

Type B

100%

92%

76%

56%

Masuda, Circulation, 1991

Medical Treatment- Aortic Dissection

Masuda, Circulation, 1991

Medical vs Surgical - Type B Ao Dissection

Glower, Ann Surg, 1991

Conclusion

• Aortic dissection is a bad problem to have

• High index of suspicion

• Control heart rate and blood pressure URGENTLY

• Type A requires immediate surgery

• Type B - best served w/ medical treatment

• If ischemic complications, the patient faces a grim prognosis with (or without) surgery therefore a surgical approach may be advocated.

Esophageal Rupture- Causes

• Iatrogenic– Esophageal endoscopy /dilation– Paraesophageal surgery

• Boerhaave syndrome

• Trauma

• Foreign Body

• Caustic

http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=%5Cwebsites%5Cemedicine%5Cmed%5Cimages%5CLarge%5C672esophagealperforation1.jpg&template=izoom2

• Proximal to the upper esophageal sphincter

• Gastric cardia

• Esophageal stricture

Esophageal Rupture- Most common sites of iatrogenic perforation

Untreated perforation

• Medianstinitis

• Death

Nonoperative Management of Esophageal perforation

Criteria– Disruption contained within the mediastinum– Free drainage back into the esophagus– Minimal symptoms– Minimal signs of sepsis

• Nasogastric decompression• Percutaneous drainage• IV antibiotics (oral flora)• Parenteral nutrition

Esophageal Rupture-Principles of surgical treatment

• Debridement

• Treat the underlying problem– Cancer– Stenosis– Reflux

• Repair of perforation

• Drainage

Gastroesophageal Reflux Disease

• 50% of asthma patients have objective evidence of esophageal reflux

• Pathophysiology: Reflux vs Reflex

• Anti-reflux surgery improves asthma symptoms– 90% of children

– 70% of adults

GERD – Diagnostic evaluation

• History and Physical Exam• Tests

– 24 hour ambulatory pH Monitoring

– Manometry

– Barium swallow

– Upper endoscopy

GERD- Complications

• Stricture 4-20%

• Barrett’s esophagus 10-15%

• Esophageal ulcer 2-7%

• Hemorrhage 2%

GERD- Pathophysiology

• More frequent and prolonged relaxations of the lower esophageal sphincter

• Increased exposure of esophageal mucosa to acid, pepsin and bile salts

• Hiatal hernia ???

GERD- Goals of treatment

• Heal the injured mucosa

• Eliminate symptoms

• Prevent or treat complications of GERD

GERD – Treatment Options

• Lifestyle modifications

• H2 Blockers

• Proton Pump Inhibitors

• Surveillance for persistent symptoms

• Endoscopy

• Anti-reflux surgery

Empyema

• Infection of the pleural space

• Usually a complication of a bacterial pneumonia or lung abscess

Empyema- Common organisms

• Staphylococcus aureus (most common)

• Streptococcus

• Pseudomonas

• Klebsiella pneumoniae

• E. Coli

• Proteus

• Bacteroides

Empyema - Diagnosis

• History and Physical Exam

• Chest radiograph

• Chest CT scan

• Needle aspiration

Empyema- Treatment Goals

• Resolve sepsis• Complete expansion of lung

• Antibiotics• Drain the space (abscess) – Chest tube

– Child vs Adult

• Decortication– VATS– Thoracotomy