Transcript approach to the patient with chest pain

APPROACH TO THE
PATIENT WITH CHEST PAIN
YEDITEPE UNIVERSITY FACULTY OF MEDICINE
PHASE 4 CARDIOLOGY COURSE 2014-2015
PROF. MUZAFFER DEGERTEKIN, M.D., PhD.
MUSTAFA AYTEK SIMSEK, M.D., Attending
Physician
APPROACH TO THE PATIENT WITH CHEST
PAIN

CAUSES OF ACUTE CHEST PAIN

DIAGNOSTIC CONSIDERATIONS

IMMEDIATE MANAGEMENT
ACUTE CHEST PAIN

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Acute chest pain is one of the most common reasons
for presentation to the emergency department
15% to 25% of patients with acute chest pain
actually have ACS
The diagnosis of ACS is missed in approximately 2%
of patients
Mortality for patients with acute myocardial
infarction (MI) who are mistakenly discharged from
the ED increases twofold
CAUSES OF ACUTE CHEST PAIN

Myocardial Ischemia or Infarction,

Pericardial Disease,

Vascular Disease,

Pulmonary Conditions,

Gastrointestinal Conditions,

Musculoskeletal and Other Causes,
MYOCARDIAL ISCHEMIA OR INFARCTION
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The most common serious cause of acute chest
discomfort
Supply of myocardial oxygen is inadequate
compared with the demand
Usually occurs in the setting of coronary
atherosclerosis
MYOCARDIAL ISCHEMIA OR INFARCTION
OTHER LESS COMMON CAUSES
Coronary spasm
 Coronary arteritis,
 Proximal aortitis,
 Spontaneous coronary dissection,
 Proximal aortic dissection,
 Coronary emboli from infectious or noninfectious
endocarditis,thrombus in the left atrium or left ventricle,
 Myocardial bridge,
 Congenital abnormality of the coronary arteries

MYOCARDIAL ISCHEMIA OR INFARCTION



Classic manifestation of ischemia is angina, which is
usually described as a heavy chest pressure or
squeezing, a burning feeling, or difficulty breathing
The discomfort often radiates to the left shoulder,
neck, or arm. It typically builds in intensity over a
period of a few minutes.
The pain may begin with exercise or psychological
stress, but ACS most commonly occurs without obvious
precipitating factors
NOT CHARACTERISTIC
OF MYOCARDIAL
ISCHEMIA
 Pleuritic pain (i.e., sharp or knifelike pain
brought on by respiratory movements or cough)


Primary or sole location of discomfort in the
middle or lower abdominal region
Pain that may be localized at the tip of one
finger, particularly over the left ventricular
apex
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Pain reproduced with movement or palpation of
the chest wall or arms

Constant pain that persists for many hours
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Very brief episodes of pain that last a few
seconds or less
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Pain that radiates into the lower extremities
PERICARDIAL DISEASE

The visceral surface of the pericardium is
insensitive to pain, as is most of the parietal
surface (Therefore, noninfectious causes of pericarditis usually
cause little or no pain. In contrast, infectious pericarditis almost
always involves surrounding pleura)

Pleuritic pain with breathing, coughing, and
changes in position (Because the central diaphragm receives
its sensory supply from the phrenic nerve, and the phrenic nerve
arises from the third to fifth cervical segments of the spinal cord, pain
from infectious pericarditis is frequently felt in the shoulders and
neck)

Involvement of the more lateral diaphragm can
lead to symptoms in the upper abdomen and
back (confusion with pancreatitis or cholecystitis)
VASCULAR DISEASE
ACUTE AORTIC DISSECTION


The sudden onset of excruciating ripping pain
The location of which reflects the site and
progression of the dissection (Ascending aortic dissections tend to
manifest with pain in the midline of the anterior chest, and posterior descending aortic
dissections tend to manifest with pain in the back of the chest).
PULMONARY CONDITIONS


Dyspnea and pleuritic symptoms
The location of which reflects the site of pulmonary
disease

Pneumothorax. sudden in onset and is usually
accompanied by dyspnea

Tracheobronchitis…burning midline pain

Pneumonia..pain over the involved lung
GASTROINTESTINAL CONDITIONS



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Irritation of the esophagus by acid reflux can
produce a burning discomfort that is exacerbated
by alcohol, aspirin, and some foods
Mallory-Weiss tears of the esophagus prolonged
vomiting episodes
Cholecystitis right upper quadrant abdominal
pain
Pancreatitis aching epigastric pain
MUSCULOSKELETAL AND OTHER CAUSES

Costochondritis

Cervical disc disease,

Herpes zoster

Heavy exercise affecting the nerves of the chest
wall
PANIC SYNDROME

Major cause of chest discomfort in ED

Chest tightness

Shortness of breath
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a sense of anxiety
INITIAL ASSESSMENT

Evaluation of the patient with acute chest pain

Hemodynamic instability

A 12-lead electrocardiogram (ECG)
INITIAL ASSESSMENT

History
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Physical Examination
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Electrocardiography

Chest Radiography

Biomarkers
INITIAL APPROACH: HISTORY
Are you having discomfort?
 How would you describe the discomfort?
 Where is the discomfort?
 Does it radiate anywhere?
 Any aggravating/alleviating factors?
 Any associated discomfort?


Diaphoresis, nausea, vomiting, cough, fevers
20
INITIAL APPROACH: HISTORY
Frequency of the discomfort?
 Time of onset or acute worsening?
 Has there been any progression?
 History of Cardiopulmonary disease?
 Risk factors for cardiopulmonary disease?
 Family history of cardiopulmonary disease?

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PHYSICAL EXAMINATION

Vital signs,

Examination of the peripheral vessels


Identify potential precipitating causes

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Uncontrolled hypertension, anemia, hyperthriodism
Important comorbid conditions


Bruits or absent pulses
Chronic obstructive pulmonary disease
Evidence of hemodynamic complications

Congestive heart failure,
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New mitral regurgitation, hypotension
ELECTROCARDIOGRAPHY
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10 minutes after presentation
New persistent or transient
ST-segment abnormalities
(≥0.1 mV) and T inversion
(≥0.2 mV)
During a symptomatic episode
at rest and resolve
CHEST RADIOGRAPHY


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Usually non-diagnostic
Pulmonary edema (ischemia-induced diastolic or
systolic dysfunction)
Pneumothorax, Pneumonia
BIOMARKERS

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A cardiac troponins (T or I; cTnT or cTnI)
Creatine kinase MB isoenzyme (CK-MB, less
sensitive)
TROPONINS
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Blood should be obtained for testing at hospital
presentation, and at 6 to 9 hours
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A normal reference values 0.01 to 0.07 ng/ml
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Ultrasensitive assays <0.001 ng/ml or <1 pg/ml


Serial sampling up to 12 hours after presentation %90
to %95
3 hours of the onset of chest pain 80% to 85%
CREATINE KINASE MB ISOENZYME
LACK OF SPECIFICITY

Found in





Skeletal muscle,
Tongue,
Diaphragm,
Small intestine, uterus, and prostate
Eleveted
Muscular dystrophy
 High-performance athletics
 Rhabdomyolysis
 Alcohol abuse or trauma vs


Shorter half-life
Useful for gauging the timing of an MI
 Diagnosing reinfarction

OTHER MARKERS
Serum myoglobin
 heart-type fatty acid binding protein
 C-reactive protein
 serum amyloid A,
 myeloperoxidase
 interleukin-6
 D-dimer
 B-type natriuretic peptides
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OTHER MARKERS

hs-C-reactive protein (prognostic)

D-dimer (PE)

B-type natriuretic peptide (HF, prognostic)
ACUTE CORONARY SYNDROME
LIKELIHOOD THAT SIGNS AND
SYMPTOMS
Ischemic Discomfort
Acute Coronary Syndrome
Presentation
Working Dx
ECG
Cardiac
Biomarker
Final Dx
No ST Elevation
ST Elevation
Non-ST ACS
UA
NSTEMI
Unstable
Angina
Myocardial Infarction
NQMI
Qw MI
Libby P. Circulation 2001;104:365, Hamm CW, Bertrand M, Braunwald E, Lancet 2001; 358:1533-1538; Davies MJ. Heart 2000; 83:361366. Anderson JL, et al. J Am Coll Cardiol. 2007;50:e1-e157, Figure 1. Reprinted with permission.