Chest PainDustin BergeronChris KordicBrett Stephens

(KEY POINTS)•* Immediate life Threats must be rules out

first•* Some serious disorders, particularly

coronary ischemia and PE, often do not have a classic presentation.

•* Most patients should have Pulse oximetry, ECG, Cardiac Markers, and Chest X-rays

•* Evaluation must be prompt so that patients with ST-elevation MI can be in the Heart Catheterixation Laboratory within the 90 min Standard.

Chest Pain is a very common complaint. Many patients are well aware that it is a warning of potential life threatening disorders and seek evaluation for minimal symptoms. Other patients, including many with serious diseases, minimize or ignore its warnings. Pain Perception varies greatly between individuals as well as between men and women. However described, chest pain should never be dismissed without an explanation of its cause.

•The heart, lungs, esophagus, and great vessels provide afferent visceral input through the same thoracic autonomic ganglia. A painful stimulus in these organ is typically perceived as originating in the chest, but because afferent nerve fibers overlap in the dorsal ganglia, thoracic pain may be felt (AS REFERRED PAIN) anywhere between the umbillcus and the ear, including the upper extremities.

•Many disorders produce chest pain or discomfort. There disorders may involve the cardiovascular, Gi, Pulmonary, neurologic, or musculoskeletal systems.

Immediately Life Threatening• -Acute Coronary Syndromes (MI/Unstable

Angina)• -Thoracic Aortic Dissection• -Tension Pneumothorax• -Esophageal Rupture• -Pulmonary Embolism (PE)•  

Other causes range from serious, potential threats to life to causes that are simply uncomfortable.

•-Chest Wall Disorders (muscle, rib, cartilage)

•-Pleural Disorders•-GI disorders (esophageal reflux or spasm,

ulcer disease, cholelithisasis)• -Idiopathic•-Acute coronary Syndromes

Important Factors

•Nature of Pain•Radiation•Precipitants•Relieving Factors•Associations •Clinical evaluation

Nature of Pain•Constricting suggests angina, esophageal

spasm, or anxiety• A sharp pain may be from the pleura or

pericardium, especially if exacerbated by inspiration.

•A prolonged (>1/2 hr) dull, central crushing pain or pressure suggests MI.

•Stabbing, short lasting (<30s) or pain in continually varying location is less likely to be cardiac

Radiation

To the shoulder, either or both arms or neck/Jaw suggests cardiac ischemia.

The pain of aortic dissection is classically instantaneous, tearing, and interscapular, but may be retrosternal.

Epigastric pain may be cardiac.

Precipitants

•Pain associated with cold, exercise, palpitations, or emotion suggest cardiac pain or anxiety.

• if brought on by food, laying flat, hot drinks, or alcohol, consider esophageal spasm( but meals can cause angina)

Relieving Factors

•If pain is relieved within minutes by rest or nitroglycerin, suspect angina.

•Nitroglycerin can relieve esophageal spasm, but usually more slowly.

• If antacids help, suspect Gi causes.

•Pericarditis pain improves on leaning forward

Associations• Dyspnea occurs with cardiac pain, pulmonary

embolism, pleurisy, or anxiety. • MI may cause nausea, vomiting, or sweating.• In addition to coronary artery disease, angina

may be caused by aortic stenosis (AS), hypertrophic obstructive cardiomyopathy (HOCM) paroxysmal supraventricular tachycardia (SVT) and be exacerbated by anemia.

• Chest pain with tenderness suggests self-limiting costochondritis (Tietze’s syndrome)

Clinical Evaluation History• History of present illness should note LOCATION,

DURATION, CHARACTER, and Quality of pain.

Review of systems• Seek symptoms of possible cause• -leg pain, swelling or both (deep venous thrombosis (DVT)

and therefore possible PE) and chronic weakness, malaise, and weight loss (CANCER)

Past medical history• Document known causes, particularly cardiovascular and

GI disorders. • Risk factors for coronary artery disease- Hypertension,

hyperlipidemia, diabetes, cerebrovascular disease, tobacco use.

Clinical Evaluation Cont..Physical ExaminationVital signs and weight. Pulses palpated in both arms and both

legs. Bp is measured in both arms and pulsus paradoxus is measured.

General Appearance noted (pallor, diaphoresis, cyanosis)

Neck inspected for venous distention and hepatojugular reflux.

Neck palped for carotid pulses, and auscultated for bruit.

Lungs are percussed and auscultated for presence and symmetry of breath sounds, signs of congestion, consolidation, pleural friction rubs, and effusion.

Clinical Evaluation Cont..Cardaic evaluation notes the intensity and timing of the 1st

heart sound (S1) and 2nd heart sounds (S2), clicks and snaps of mitral apparatus, pericardial friction rubs, murmurs, and gallops.

Chest is inspected for skin lesions of trauma or herpes zoster infection and palpated for crepitance and tenderness

Abdomen is palpated for tenderness, organomegaly, and masses or tenderness, particularly in the epigastric and right upper quadrant region.

Legs are examined for arterial pulses, adequacy of perfusion, edema, varicose veins, and signs of DVT (swelling, erythema, and tenderness)

RED FLAGS• Abnormal Vital signs (tachycardia, bradycardia,

tachypnea, Hypotension)

• Signs of Hypoperfusion (confusion, ashen color, diaphoresis)

• Shortness of Breath

• Asymmetric breath sounds or pulses

• New heart murmurs, or Pulsus paradoxus >10mmHg

Case Study 1

•A 51-year-old traveling salesman began to experience chest pain and weakness while driving out of state in a remote area. He presented to a nearby Chiropractor with complaints of a dull ache in his left arm and chest for about seven hours, numbness in the left arm, as well as some weakness when closing his car door. He did not complain of shortness of breath, diaphoresis, or nausea.

Past Medical History

•His medical history included GERD (the date of onset was unclear – but he was taking Zantac), and in the prior 18 months: hernia repair, appendectomy, and a dislocated shoulder.

•He was a non-smoker and had no known history of coronary artery disease (CAD).

• At 11:30 a.m., the patient’s vital signs were: BP 135/96, HR 130, and RR 20. • EKG revealed sinus tachycardia at 114 with

anterior hemi block. • General labs ordered to rule out myocardial

infarction.• . His pain level at that time was 4/10. You give

him Oral Nitroglycerin • Twenty-five minutes later, his pain level was

2/10, and a second nitroglycerin tablet was given.

• Vital signs at that time were BP 100/75, HR 128, and RR 20.

•At 1:10 p.m., the patient’s pain level was zero and vitals were 133/89, HR 114, and RR 20.

•An hour later, all of the laboratory findings were back and included:

• CBC WNL• BS 113 (↑)• BUN 119 (↑),• Troponin .33 (↑ - lab slip stated:

recommend clinical correlation and repeat in 3-6 hours). Enzymes were done once and reported as normal.

Labs

•BS 113 Normal Ranges 70-125 mg/dL

•BUN 119 (↑) 6 – 23 mg/dL

•Troponin .33 Pt. w/ low levels (<0.20) should be reevaluated.

Differental Diagnosis• Myocardial infarction - character of pain; associated

nausea, diaphoresis, flushing, and dyspnea; episode related to activity; relief with rest; obesity; family history; tachycardia; and increased blood pressure.

• Angina pectoris - character of pain; episode associated with activity; repeated episodes; relief with rest; family history; obesity; tachycardia; and increased blood pressure.

• Cholecystitis - character of pain; RUQ tenderness with + Murphy’s sign; age; gender; obesity; relationship to eating fatty foods.

• Gastroesophageal reflux (hiatal hernia) - character of pain; associated with eating on at least two occasions; may be triggered by exercise. 2

• Musculoskeletal strain or spasms - episode associated with activity and is persistent 2; however, pain does not increase with inspiration or changing position; no point tenderness. 3 .

Differential Diagnosis cont..• Pulmonary embolism - obesity; medication history of

oral contraceptive use; dyspnea; sudden onset of pain; however, pain has been occurring intermittently over 1 week and no pleural friction rubs, gallops, or heaves are present.4

• Pericarditis - character of pain; however, no rubs heard and pain does not increase with inspiration 4; no recent viral illness.

• Pleuritic - character of pain with associated upper quadrant abdominal pain; dyspnea; however, no associated fever, pleural rubs, or cough.5

• Psychogenic - unexplained chest pain and hyperventilation; inability to recall past episodes.6

• Aortic dissection - hypertension; family history; however, pain is not “tearing” in nature and does not radiate to the back; pulses are of quality.

WHAT do you do?

•Send to the hospital..Nearest hospital is 100 miles?

•Send him on his way, he’ll live?•Adjust thoracics, subluxation causing

chest pain?

True STORY• The patient was discharged at 3:30 with a

diagnosis of recurrent GERD. His discharge instructions included: maintain diet (avoid caffeine and continue low fat diet)

• Ten days later, while watching TV at home with his family, the patient died. Autopsy results revealed that the patient died of a fatal cardiac arrhythmia, that he had CAD with 80-90 percent stenosis, and that he had had an MI—probably 7-10 days prior to his death.

• Family sued and won 1 Million dollar settlement.

Case Study 2• A 42-year-old female presented to the

emergency department with chest pain and shortness of breath. The week prior to presentation, she had been diagnosed with a Salmonella infection which she had acquired while on vacation in Mexico. She had been treated with antibiotics, and the diarrhea which she was experiencing had resolved. One day later, she developed a pressure-like sensation in the center of her chest and she also seemed to have difficulty catching her breath. When she called her primary care physician, she was instructed to go to the emergency department of the nearest hospital.

• Her medical history was unremarkable and she had no risk factors for cardiovascular disease.

• Physical examination revealed her to be a thin female in no obvious distress.

• Blood pressure was 130/80 and pulse was 80. • Lungs were clear and cardiovascular

examination revealed a friction rub heard best at the left lower sternal border.

• The patient complained that her pain became much worse when she was asked to lie flat on the examination table.

History

WHAT is your diagnosis? •Laboratory studies were normal except

for a sedimentation rate of 40 mm/hr and a CRP of 8.6 mg/L.

CRP is C-reactive protein –its on of the most sensitive acute-phase reactants. CRP will rise from severe trauma, bacterial infection, inflammation.

CRP Acute Inflammation Range (>10.0)

Acute Pericarditis Pt. had a characteristic pericardial friction rub and

her pain was exacerbated with lying down

Pericarditis is an inflammation of the pericardium and may be caused by a number of entities. It is most commonly associated with neoplastic processes or viral infections, but can be associated with tuberculosis, bacterial infections, or be idiopathic. Additionally, it can be autoimmune in nature. In this patient, given her history of recent Salmonella infection, it was likely that her pericarditis was related to this. In most cases, including in this patient’s case, while determining the etiology is usually desired, it is not necessary for proper treatment.

Case Study 3

•A 47 year old male presents to the office with chest pain. He states that the chest pain began about 12 hours ago and feels like a dull throbbing in the center of his chest. He denies dyspnea, dizziness, nausea, diaphoresis, or palpitations. When the pain began, he immediately took an aspirin and then went to bed. When he woke up this morning, the pain was still there, although it is not as intense.

• The patient's medical history includes nephrolithiasis, GERD, and low back pain.

• He takes as-needed antacids and has no drug allergies.

• He does not smoke, and drinks 2-3 beers per night, with more on the weekends.

• Family history includes a father who died at age 59 of a heart attack, and a brother with type 2 diabetes.

Past Medical History

•Initial examination reveals a well-developed, well-nourished Caucasian male in no apparent distress.

•Blood pressure is 115/74, pulse 80, respiratory rate 14, and temperature 98.6 degrees.

• General physical examination is within normal limits.

•Cardiopulmonary examination reveals no abnormalities. There is point tenderness over the costochondral junctions.

•ECG performed in the office reveals sinus rhythm with non-specific T-wave changes.

How should this patient be approached?

•Because of the patient's family history, send the patient to the hospital, and initiate a "rule-out" MI protocol.

•The patient underwent serial cardiac markers, which were all negative. He then underwent a stress test, which was also negative.

•Subsequently, the patient was discharged to outpatient follow-up.

Case Study 4

•A 17-year old boy presented with left-sided chest pain. He was well until 8 days before presentation, when he developed left axillary and shoulder pain. The pain was worse with inspiration. He denied fever, nausea, vomiting, and diarrhea. He reported that he had had rhinorrhea and a dry cough 2 weeks earlier. He had mild shortness of breath with exercise. He had no history of trauma.

Past Medical History

•He had a history of depression with no history of suicide attempts. He denied a history of asthma or other chronic illnesses. His family and social histories were noncontributory. He denied any drug use but did admit to having smoked cigarettes in the past

Physical Examination

• T, 36.6°C; RR, 18 to 20/min; HR, 108 bpm; BP, 120/60 mm Hg; SpO2, 95% in room air

• Weight, 50th to 75th percentile; height, 75th to 90th percentile

• In general, he was in no acute respiratory distress. His chest examination revealed no chest wall deformity, and the chest was nontender to palpation. Breath sounds were decreased at the bases, left greater than right. No wheezes or rales were appreciated. His cardiac examination revealed normal S1 and S2, with no murmurs, rubs, or gallops heard. The remainder of his physical examination was normal.

Differential Diagnosis

• the most common causes for chest pain in the adolescent age group are- psychogenic pain, cough, asthma, musculoskeletal pain, and pneumonia.

• Pneumothorax or pneumomediastinum commonly manifest with the acute onset of chest pain.

• Some abdominal processes, such as pancreatitis or cholecystitis, may manifest with acute chest pain.

• Cardiovascular causes are less common but are life-threatening. With acute chest pain, one should consider coronary artery disease, arrhythmias, structural cardiac defects, and infections.

Diagnosis

• The diagnosis is left spontaneous pneumothorax.

Incidence• Pneumothoraces are divided into three groups:

spontaneous, traumatic, and iatrogenic. Spontaneous pneumothoraces can be either primary, in which there is no underlying lung disease, or secondary, in which underlying lung pathology is present.

• Secondary spontaneous pneumothoraces occur in patients with underlying lung disease. The major causes include airways disease (e.g., cystic fibrosis), infection (e.g., Pneumocystis carinii pneumonia), interstitial lung disease, connective tissue disease, malignancy, and thoracic endometriosis.

• Subpleural bullae are seen in 76% to 100% of children who are taken to video-assisted thoracoscopic surgery.

Clinical Presentation

• Primary spontaneous pneumothorax usually develops while the patient is at rest. Patients describe pleuritic ipsilateral chest pain and dyspnea. With a small pneumothorax, the physical examination may be completely normal. Tachycardia may be noted. In patients with a large pneumothorax, there may be poor chest wall movement, a hyperresonant chest, and decreased breath sounds on the side with the pneumothorax. Tachycardia and hypotension indicate that the patient has developed tension physiology and requires emergency intervention.

THE END

Differential Diagnosis of Chest PainCardiovascular• Typical angina pectoris • Prinzmetal’s or variant angina • Unstable or accelerating angina • Acute myocardial infarction • Aortic dissection • Mitral valve prolapse • Pericarditis • Dressler’s syndrome • Postpericardiotomy syndrome

Pulmonary

•Pneumonia •Pleuritic chest pain •Pulmonary embolism •Pulmonary hypertension •Spontaneous pneumothorax

Gastrointestinal

•Reflux esophagitis •Esophageal spasm/angina •Peptic ulcer •Pancreatitis •Cholecystitis

Musculoskeletal Disorders• Costochondritis • Tietze’s syndrome • Rib fracture or trauma • Cancer metastsis • Sternoclavicular arthritis • Painful xiphoid syndrome • Fibromyalgia • Traumatic muscle pain • Shoulder arthritis/bursitis • Cervicothoracic nerve root compression • Thoracic spine arthritis • Throracic outlet syndrome

Miscellaneous

•Herpes zoster •Anxiety/depressive disorder •Panic disorder •Cocaine use •Post coronary artery bypass pain

Case Study 2•12 year-old boy without significant past

medical history presented with substernal chest pain. He was diagnosed to have left lower lobe pneumonia and was receiving oral antibiotics for 2 days prior to this referral. His chest pain subsided after albuterol nebulizer treatment in a local hospital, but he was found to have elevations of cardiac troponin I (cTnI) and creatine kinase (CK)-MB with ST changes on electrocardiogram (ECG), and was referred for further evaluation.

Family History•Strong history of hypertension •Paternal great grandfather died suddenly

of heart attack at 26 years of age. His maternal great grandmother has a history of heart problems and died at 40 years of age.

•Lab Results•cTnI 20.5 ng/mL (<0.1), total CK 229 U/L

(0-200), CK-MB 30 U/L (CK-MB relative index 13.1) in initial presentation

•cTnI 6.99 ng/mL (<0.1), total CK 86 U/L with CK-MB 4.7 U/L (CK-MB relative index 5.5) 12 hs after the initial laboratory results

•Na 142 mEq/L, K 4.3 mEq/L, Cl 109 mEq/L, CO2 23 mmol/L, BUN 13 mg/dL, Creatine 0.6 mg/dL, Glu 82 mg/dL

•Total Cholesterol 158 mg/dL (144-173), HDL-Cholesterol 18 mg/dL (46-61), LDL-Cholesterol 110 mg/dL (82-109), VLDL-Cholesterol 30 mg/dL (7-12), Triglycerides 185 mg/dL (46-74)

• LDL-C was only marginally elevated, and TG and VLDL-C were elevated in this case. Elevated LDL-C or TC and low levels of HDL-C are well known risk factors of cardiovascular disease. Recently, the Third Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III, or ATP III) by the National Cholesterol Education Program (NCEP) released the updated recommendations for cholesterol testing and management, in that TG and lipoprotein remnants or VLDL-C are listed as "Emerging Cardiovascular Risk Factors" (1). This patient has elevated TG and VLDL-C and these are considered as cardiac risk factors under the new guideline.

There is increased air space opacity present within the left lung base. It is consistent with left basilar pneumonia.

•Electrocardiogram:•ST segment elevations in leads I, II, III

and V6 It is consistent with myocardial ischemia/infarction involving the right coronary artery.

•Echocardiogram•Low normal LV systolic function with

ejection fraction of 59% •No pericardial fluid •The origins of the coronary arteries in the

proximal branches were normal. •No wall motion abnormality and These

echocardiogram findings are not consistent with myocardial infarction or Kawasaki disease.

DIAGNOSIS

•Probable myocarditis - (elevated troponin and ECG changes).

•Left lower lobe pneumonia. •Questionable myocardial

ischemia/infarction involving the right coronary artery (since the ECG changes were primarily in the inferior leads).

•First, it is extremely unusual for 12 year-old boy developing myocardial ischemia/infarction, unless the child has other morbidities such as Kawasaki disease, or mucocutaneous lymph node syndrome. Patients with Kawasaki disease can develop arrhythmia, myocarditis and coronary aneurysm as long term cardiac sequelae .