Transcript Approach_Chest_Pain

Approach To Chest Pain
Chest Pain

TABLE 1-2
DIFFERENTIAL DIAGNOSIS OF EPISODIC CHEST PAIN RESEMBLING ANGINA PECTORIS
DURATION
Effort angina 5-15 minutes

Rest angina
5-15 minutes
QUALITY
PROVOCATION
RELIEF
LOCATION
Visceral (pressure)
During effort or
emotion
Rest, nitroglycerin
Substernal, radi- First episode
ates
vivid
Nitroglycerin
Substernal, radi- Often nocturnal
ates
Left anterior
No pattern, variable character
Substernal, epi- Rarely radiates
gastric
Substernal,
Mimics angina
radiates
Visceral (pressure)
Mitral prolapse Minutes to
Superficial

hours
(rarely visceral)
Esophageal re- 10 minutes to 1 Visceral
flux
hour
Esophageal
5-60 minutes
Visceral
spasm
Spontaneous (?
with exercise)
Spontaneous (no
pattern
Recumbency,
lack of food
Spontaneous,
cold liquids, ex
ercise
Peptic ulcer
Hours
Visceral, burning Lack of food,
‘‘acid’’ foods
Biliary disease Hours
Visceral (waxes Spontaneous,

and wanes)
food
Cervical disc
Variable (gradu- Superficial
Head and neck
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ally subsides
movement, pal
pation
Hyperventilation 2-3 minutes
Visceral
Emotion, tachy
pnea
Musculoskeletal Variable
Superficial
Movement,

palpation
Pulmonary
30 minutes +
Visceral (pres- Often spontaneDyspneic
sure)
ous
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Time
Food, antacid
Nitroglycerin
Foods, antacids
Epigastric, substernal
Time, analgesia
Epigastric, ?
radiates
Arm, neck
Time, analgesia
Stimulus removal Substernal
Time, analgesia
Multiple
Rest, time, bron- Substernal
chodilator
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COMMENT
Reproduced with permission from Christie, L.G., Jr., and Conti, C.R.: Systematic approach to the
Colic
Not relieved by
rest
Facial paresthesia
Tenderness
Chest 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
Patterns of Pain
Differential Dx by Location
Chest Pain
Physical Exam
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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
Chest Pain
Physical 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
Chest Pain
Cardiac Exam
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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)
ST Elevation Myocardial
Infarction (STEMI)

Admit, O2
 ASA
 SL NTG, +/- IV NTG (SBP>100)
 MSO4 2-4mg, (MONA)
 Heparin (UFH or LMW)
 Beta-blocker
 Candidate for Thrombolytics
Definite Indications for
PTCA/Thrombolytic Therapy
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Consistent clinical syndrome
– Chest pain, new arrhythmia, unexplained
hypotension, pulmonary edema
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Diagnostic EKG
– >1mm ST elevation in >2 contiguous leads
– New LBBB
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Less than 12 hours since onset of pain
Relative Indications for
PTCA/Thrombolytic Therapy
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Consistent Clinical Syndrome
– Chest pain, new arrhythmia, unexplained
hypotension or pulmonary edema
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Nondiagnostic ECG
– Left bundle-branch block of unknown duration
Absolute Contraindications for
Thrombolytic Therapy
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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)
Relative Contraindications for
Thrombolytic Therapy

Severe uncontrolled hypertension
(>180/110 mm Hg)
 History of chronic severe hypertension
 CVA or intracerebral pathology > 1 yr ago
 Current anticoagulant use
 Recent trauma (within 2-4 weeks)
 Allergy or prior exposure to streptokinase
Relative Contraindications for
Thrombolytic Therapy
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Active peptic ulcer disease
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Significant hepatic dysfunction
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Recent (2-4 weeks) internal bleeding
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Bleeding diathesis
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Noncompressible arterial or central
venous puncture
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Pregnancy
PTCA vs. Thrombolysis
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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
Non-ST Elevation MI
(NSTEMI)
NSTEMI, Early Invasive
Strategy
Cardiac Events at 30 Days
CONS (%) INV (%) OR
P value
No. Pts
1106
1114
1o Endpoint
10.5
7.4
0.67
0.009
Death/MI
7.0
4.7
0.65
0.02
Death
1.6
2.2
1.40
0. 29
MI
5.8
3.1
0.51
0.002
Rehosp ACS
5.5
3.4
0.61
0.018
Cardiac Events at 6 Months
CONS (%) INV (%) OR
P value
No. Pts
1106
1114
1o Endpoint
19.4
15.9
0.78
0.025
Death/MI
9.5
7.3
0.74
<0.05
Death
3.5
3.3
0.93
0.74
MI
6.9
4.8
0.67
0.029
Rehosp ACS
13.7
11.0
0.78
0.054
Subgroups: Primary Endpoint
Death, MI, Rehosp ACS at 6 Months
(66%)
(34%)
CONS
(%)
19.4
19.6
INV
(%)
15.3
17.0
Age < 65 yrs
Age > 65 yrs
(57%)
(43%)
17.8
21.7
14.9
17.1
Diabetes
No diabetes
(28%)
(72%)
27.7
16.4
20.1
14.2
ST  *
No ST 
(38%)
(62%)
26.3
15.3
16.4
15.6
19.4
15.9
1O Endpoint
%Pts
Men
Women
Total Population
*Interaction P=0.006
others P=NS
0
0.5
1
1.5
INV Better CONS Better
Troponin T: 1oEP at 6 months
Death, MI, Rehosp ACS at 6 Months
CONS
INV
*
30
(%)
25
p=NS
20
15
14.5
OR=0.52
*p<0.001
24.2
Interaction
P<0.001
16.9
14.3
10
5
N=414
N=396
N=463
N=495
0
TnT TnT cut point = 0.01 ng/ml
TnT +
(54% of Pts TnT +)
Chest Pain Uncertain Etiology
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EKG with Symptoms
– 4% of MI’s normal EKG
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Non Invasive Imaging :Resting Nuclear
Imaging/Echo/Contrast During Symptoms,
CT Angio, EBCT, MRI Hyperenhancement
 Cardiac Enzymes
 Stress Testing
 Cardiac Catheterization
Bayes Theroem
Predictive Value
Predictive Value ETT
ETT in Women
Cardiac Stress Testing
Nuclear
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TABLE 9-4
SENSITIVITY AND SPECIFICITY FOR DETECTION OF CORONARY ARTERY
DISEASE BY 201Tl SINGLE-PHOTON EMISSION COMPUTERIZED TOMOGRAPHY
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NUMBER OF
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AUTHOR
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Tamaki et al.
104
91
92
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De Pasquale et al.
210
95
71
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Borges-Neto et al.
100
92
69
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Maddahi et al.
110
96
56
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Fintel et al.
112
91
90
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Iskandrian et al.
164
88
62
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Go et al.
202
76
80
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Mahmarian et al.
360
93
87
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van Train et al.
242
95
56
1901
91
73
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Total
PATIENTS
SENSITIVITY (%)
SPECIFICITY
Stress Echo
Contraindications to ETT
ETT High Risk Features
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TABLE 5-4 EXERCISE PARAMETERS ASSOCIATED WITH
AN ADVERSE PROGNOSIS AND MULTIVESSEL CORONARY
ARTERY DISEASE
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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 minutes into recovery
Exercise-induced ST segment elevation (a Vr excluded)
Angina pectoris during exercise
Reproducible sustained (> 30 sec) or symptomatic ventricular
tachycardia
EBCT
Multislice CT
Sensitivity
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
Diagnostic Accuracy CTA
Leshka et.al. Eur Heart Journal 2005
CTA Exclusions
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BMI>30
Afib
Coronary Calcium
Previous Stent
HR>75
Hemodynamic Instability, inability to take betablockers
Renal Insufficiency, Contrast allergy
Coronary Size <3mm
Coronary Angiography
Cardiac Catheterization
Remains the “Gold Standard”
 High risk patients
 Non diagnostic non-invasive tests
 Hemodynamic, Anatomical, Physiological
Assessment
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– FFR, IVUS
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Immediate Intervention if Needed