Chest Pain

Saif Al-Nahhas

Introduction

• Common presentation to ED

• ACS and PE

• Deconstruct two “classic” cases

ACS

• Umbrella term – covers a spectrum

• Unstable angina, NSTEMI, STEMI

• Pathophysiology is the same

Atherosclerotic Plaque

ACS – The Classic Case

• 55 year old male

• Sudden onset central chest tightness radiating into jaw and left shoulder

• Pain on exertion but now at rest

Classical Presentation

• Over the age of 85, 60-70% of patients with acute MI present without chest pain

• 7% of patients with acute MI had pain reproduced on chest wall palpation

• Right shoulder pain more indicative of MILusiani L, Peronne A, Pesaventol R. Prevalence, clinical features and scute course of atypical myocardial infarction. Angiology 1994; 45:49-55.

The ECG

The ACS Challenge

• 6.4% of all patients with AMI have an initially normal ECG

• Serial ECGs should be carried out in patients with ongoing symptoms

• Cardiac enzymes only detect cell death but not ischaemia

Smith SW, Zvosek DL, Sharkey SW.. The ECG in Acute MI: An Evidence-based Manual of Reperfusion Therapy.. Philadelphia: Lippincott WiIliams & Wilkins; 2012 pp. 19-27.

Making the Diagnosis

• History and Risk Factors

• ECG

• Biochemical markers (Troponin)

Risk Stratification

• GRACE criteria – Mortality at 6 months

• TIMI Score – Death, MI or PCI at 2 weeks

• Discharge low or moderate risk (troponin negative) with OP follow up clinic

• Admit those high risk for IP investigation

ACS Treatment - Stable

• Morphine, Oxygen, Nitrates, Aspirin

• Antiplatelet agents (Clopidogrel)

• LMWH – Fondaparinux/clexane

• Others – beta blockers, ACE inh, Statins

ACS Treatment -Unstable

Chest Pain Radiating to the Back

Pulmonary Embolus

• Rarely diagnosed in ED

• Potentially lethal

• Subtle

PE Deaths

Ryu JH, Olsen EJ, Pellikka PA. Clinical recognition of pulmonary embolism: problem of unrecognised and asymptomatic cases. Mayo Clinc Proc 1998; 73:873-9

The Classic Case

• 32 year old female

• SOB and Pleuritic CP for a few days

• Presents with haemoptysis

The Presentation

• In study 387 patient with confirmed PE…

• 34% asymptomatic

• Classic triad of pleuritic chest pain, haemoptysis and dyspnoea only found in 20% of patients

• Atypical presentations include fever, wheeze, back pain, syncope

Laack TA, Goyal DG. Pulmonary embolism: an unsuspected killer. Emerg Med Clin N Am 2004; 22:961–83.

Pleuritic Chest Pain

• 44% patients with PE

• 30% without PE

• 16% of PE patients described pain as chest tightness or ischaemic sounding pain

Miniati M Perdiletto R et al. Accuracy of clinical assessment in the diagnosis of pulmonary embolism. Am J Resp Crit Care Med 1999;159:864–271.

Dyspnoea

• A good sign

• Upwards of 80% PE patients report dyspnoea

• Not related to severity

Riedal M. Pulmonary embolism: 1. pathophysiology, clinical presentation and diagnosis. Heart 2001; 85:229–40.

The ECG

S1 Q3 T3

• Can be as high as 50% in patients with confirmed PE

• 12% of patients with suspected PE in equivalent frequency

Roger M, Markropoulos D et al. Diagnostic value of the electrocardiogram in supected pulmonary embolism. Am J Cardiol 2000; 86:807–09.

Other ECG Findings

• Sinus tachycardia range from 8 – 69%

• RBBB range from 6 – 67%

• Right atrial strain 2 – 31%Chan TC, Vilke GM, Pollack M et al. Electrocardiographic manifestations: pulmonary embolism. J Emerg Med 2001; 21:263–70.

Precordial T Wave Inversion

• Study of 80 patients with confirmed PE

• T wave inversion precordial leads (68%)

• Exceeded those of sinus tachycardia (26%) and S1Q3T3 (50%) in their series

Ferrari E, Imbert A et al. The ECG in pulmonary embolism: predictive value of negative T waves in precordial leads – 80 case reports. Chest 1997; 111:537–43.

Chest X-Ray

Risk Stratification

• All suspected patients must undergo this

• D-Dimer excludes PE in low risk groups

British Thoracic Society Guidelines for the management of suspected acute pulmonary embolism. Thorax 2003; 58:470-84.

Wells Criteria for PE

• Suspected DVT +3

• PE likely diagnosis +3

• HR >100 bpm +1.5

• Immobilisation (>3/7) or surgery (<4/52) +1.5

• Previous DVT/PE +1.5

• Haemoptysis +1

• Malignancy +1

<2 Low 2-6 Moderate >6 High

Risk Stratification

• Major risk factor present

• PE is the most likely diagnosis

• PERC Rule (8 criteria <1.6%)Wells PS, Anderson DR, Rodger M, et al. Derivation of a simple clinical model to categorize patients probability of pulmonary embolism: increasing the models utility with the SimpliRED D-dimer. Thromb Haemost 2000; 83:416–20.

Bayesian Principles

Imaging- V/Q

Imaging - CTPA

Imaging Pregnant Women

• CTPA – higher radiation to breasts and contrast

• V/Q higher radiation to foetus

• Consider Bilateral Lower limb US doppler

Treatment – Massive PE

• Initially ABC

• Consider thrombolysis (alteplase) for peri-arrest

• Unfractionated heparin for others pre emergency Echocardiogram or CTPA

Treatment – Sub Massive PE

• LMWH – clexane 1.5mg/kg

• Safe for outpatients or in pregnancy

• Ambulatory care

• Confirmed cases warfarinised INR 2-3

Emergency Medicine – Avoiding the Pitfalls and Improving the OutcomesA Mattu & D Goyal

Summary

• Chest pain is a common ED presentation

• Most patients have a benign diagnosis

• Don’t rely on “classical” presentations

• Don’t ignore dyspnoea