Acute Chest Pain “Can I go back to sleep?”
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Transcript Acute Chest Pain “Can I go back to sleep?”
Acute Chest Pain
“Can I go back to sleep?”
Dr. Hussam Al-Faleh
Residents Course
Outline
Clinical presentations
Causes of chest pain
Clinical aids to diagnose Ischemic CP
summery
It’s so painful I can’t
breath!
25yr old male with CP for 3 days
Sharp, central, worse with inspiration, and
lying down, better sitting up, No relation to
exertion
H/o URTI 7 days ago
No RF
BP 110/70, HR 100 bpm, triphasic
pericardial rub
Wide spread ST elevation, PR depression
Diagnosis: Pericarditis
The Sky is falling
40yr old female
CP for 3 months
Can not be described, all over the chest and
both shoulders, radiates to her head,
continuous, not ↑ exertion, but exacerbated
with emotional distress
Divorced and physically abused by daughter
No RF
Normal PE and ECG
Diagnosis: Psychogenic chest pain
Nothing is wrong with me!
63yr male
CP for last month
Central burning, non radiating
occurring only on exertion , relieved
with rest.
HTN
PE & ECG Normal
Diagnosis: Typical anginal pain
I am like no other!
45yr male
Upper back pain for 2 weeks
Never occurs at rest or change in posture,
and provoked by effort relived with rest
H/o Premature atherosclerosis
Normal PE & ECG
Diagnosis: very suspicious for ischemic pain
Causes of Chest pains
Panjue et al JAMA 1998;280,14
Goals of CP assessment
1- Need to r/o serious causes of chest pain “
what is the chance that my patient will die
due his underlying condition”
2- Need to refer for further testing i.e EST,
V/Q scan , Angiogram etc..
3- If cause of CP is not serious how can i
help? eg. NSAIDS for MSL CP, PPI trial/GI
consult for Reflux
Risk stratification
1.
2.
3.
High risk AMI, High risk UA Lyse
or cath
NSTEMI, LBBB, High risk UA
Admit to CCU
Low risk UA, Non ischemic pain
admit to ward or see as outpatient
History
Chest Pain description:
Vital signs/ECG
Location and radiation
Character
Onset and duration
Aggravators and relievers
Severity
Associated symptoms
Panjue et al JAMA 1998;280,14
Panjue et al JAMA 1998;280,14
Typical/Atypical CP
Typical:
1. Substernal
2. Burning/heavy/squeezing
3. ↑ by exertion ↓ rest or NTG
If clinically angina , classify:
Risk factors
Age : males ≥45, females ≥55
Gender
DM
Dyslipidemia
HTN
Smoking
Family history of Premature CAD: males ≤55
females ≤65
Metabolic syndrome
Physical exam
Vitals, Vitals, Vitals
BP (measure both sides)
Pulses paradoxicus
Heart rate (tachy/bradycardia)
Respiratory rate
Fever
O2 Sat
Physical exam
CVS exam:
-
JVP
Carotid bruit
Palpation of chest wall (where is the pain?)
Extra Heart sounds (S3 or 4)
Murmurs (eg, early diastolic, )
Pericardial rub
Physical exam
Chest exam:
-
-
Trachea
Breath sounds
Abdomen:
- Tenderness
Investigations
ECG:
-
-
NORMAL ECG DOES NOT ROLE OUT
ISCHEMIA
Serial ECG’s
Always compare to an old ECG
ST ↑ (localized vs. Wide spread)
ST ↓
T wave inversion (location and symmetry)
or peaking
ECG (cont.)
-
-
Q waves (new)
New conduction defects (LBBB/RBBB)
Voltage/electrical
alternans/Tachycardia
PE patterns (Q1 S3 T3), RBBB,
Other investigations (PRN)
Depending on Hx/PE
CBC
D-dimers
ABG’s
CXR
Troponins I & T
Most sensitive and specific cardiac
markers
Rise 3-12hr after onset of CP
Peak I (24hr), T (12hr-2 days)
Return to normal 5-14 days
Has both diagnostic and prognostic
values
Sample at baseline and after 6-8hr
Conclusion
History and physical are corner stones
in diagnosis of Chest pain
Ensure that patient is stable before
taking a detailed history
Serial ECG’s and cardiac enzymes for
selected patients