Approach to Chest Pain in the ED

LTC Marco Coppola, DO, FACEP

Medical Director, Department of Emergency Medicine Las Colinas Medical Center, Questcare Medical Services Professor, Department of Emergency Medicine Texas A&M University System Health Science Center College of Medicine

--Updated May, 2005 by--

MAJ Robert B Blankenship, MD, FACEP

Assistant Program Director, MAMC / UW Emergency Medicine Residency Program Madigan Army Medical Center

Government Services Chapter

American College of Emergency Physicians
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Overview/Objectives
After this lecture you should be able to: List five life-threatening causes of chest pain. Recite the risk factors for AMI, PE, and aortic dissection Given a clinical scenario, be able to describe how to approach and order appropriate studies for your stimulated patient in the ED.
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Introduction
Approximately 5 % of all ED visits are for chest pain1
5 million visits / yr

Acute myocardial infarction (AMI) is a leading cause of death in the US2

Errors in diagnosis account for 20% of medical malpractice

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Diagnostic Challenge
Always possible to be cardiac in origin Referred pain Interpretation of pts subjective perception of pain Most tests are not helpful in the ED History is your best tool to sorting out the etiology of chest pain
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Differential Diagnosis
Life-threatening causes of CP in the ED Unstable angina Acute MI Aortic dissection Pulmonary embolus Spontaneous pneumothorax Boerhaaves Syndrome
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Initial Evaluation History

History is, by far, your best diagnostic tool

May be divided into three areas:

Proximate history Remote history Risk factors

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Initial Evaluation Proximate History

Pain location? Quality? Radiation? Severity? Timing? Relief/exacerbation? Associated symptoms? Trauma?
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Initial Evaluation Remote History

Previous episodes
Related to exertion

Previous admissions or workups

EKGs, CXRs, treadmills, cardiac cath, etc.

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Initial Evaluation
Risk Factors - MI
Absolute:
family history, HTN, DM, smoking, elevated cholesterol

Contributory:
age over 30, male, obesity, sedentary, cocaine

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Initial Evaluation
Risk Factors - PE
Immobilization
Paralysis Paresis Plaster Plane (travel)

Burns History of DVT or PE Hypercoagulable states

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Recent surgery Trauma Obesity Cardiac disease

Pregnancy Protein C/S Deficiency AT III deficiency Malignancy Estrogen therapy

Initial Evaluation
Risk Factors - Dissection
Hypertension Predisposing conditions:
Marfans, Ehlers-Danlos syndrome, Turners syndrome, coarctation of the aorta, pregnancy, trauma

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Initial Evaluation
Risk Factors - Esophageal Pain
sensitivity to gastric acid disorders of motility reflux, spasm, achalasia

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Physical Examination General Appearance and Vitals

Look for tachypnea, diaphoresis, cyanosis, pallor

Obtain vital signs and blood pressure in both arms appearance of pt is more important than actual physical exam
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Specific Findings
Myocardial Infarct
New murmur - papillary muscle dysfunction Extrasystolic sound - useless in ED setting

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Specific Findings
Pulmonary Embolism
DVT
2550 % OF DVTs have PEs (most are asymptomatic)3

Dyspnea 84%, cough 53% Tachypnea 92%, tachycardia 44%

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Specific Findings
Aortic Dissection
Hypertension and tachycardia
Hypotension can occur in dissection of ascending aorta

Abnormal aortic contour on CXR (90%) Decreased / unequal pulses in radial, femoral, or carotid arteries (50%) Paraplegia / neurologic presentation (40%)
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Specific Findings
Spontaneous Pneumothorax
Acute onset of pleuritic chest pain Dyspnea and tachypnea Decreased breath sounds on side of pneumothorax If tension pneumothorax, may see:
JVD Hypotension
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How to Approach ED Patients

ABCs, establish safety net: oxygen, monitor, IV lines, vital signs

Diagnosis specific:
CXR, EKG, cardiac enzymes CXR, arteriogram CXR, EKG, D-Dimer CXR with inspiratory/expiratory views CXR, gastrograffin swallow
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Clinical Characteristics
Angina
Episodic, lasting 5-15 min, induced by exertion Relieved in 3-5 min by rest or SL NTG

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Clinical Characteristics
Unstable Angina
Pain at rest or minimal activity Pain prolonged or more severe Pain occurring with increased frequency

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Clinical Characteristics
Acute MI
Pain longer than 15-30 min, building up to maximum dull or presure-like pain in the midsternal or peristernal associated symptoms
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Clinical Characteristics
Acute MI
Be weary of the five causes of silent / atypical MI presentations:
D E A T H Diabetes Elderly Alcohol Trauma to the thoracic spinal cord Hypertension
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Clinical Characteristics Aortic Dissection

1000-fold less common than AMI

Most are hypertensive males 50 70 yo

Intrascapular severe pain with abrupt onset, and worst at onset

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Clinical Characteristics
Pulmonary Embolism
Evidence of right-heart strain on EKG
S1Q3T3, RAD

Hamptons Hump and Westermarks Sign

Specific but rare

Wells criteria
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Clinical Scoring Tools Wells Criteria Pulmonary Embolism

Criterion
Suspected DVT

Points
3

An alternate diagnosis is less likely than PE

Heart rate > 100 beats/min Immobilization or surgery in the previous four weeks

3
1.5 1.5

Previous PE / DVT
Hemoptysis Malignancy (on treatment, treated in past six months)
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1.5
1 1

Clinical Scoring Tools Wells Criteria Pulmonary Embolism

Score Range Mean Probability of PE 0 2 points 3.6 %
3 6 points 20.5 %

% with this Interpretation score of risk 40 %

53 %

Low
Moderate

> 6 points

66.7 %
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7%

High

Proximate History
Esophageal Pain
Heartburn, odynophagia, spasm-like pain 15-60 min after eating GI Cocktail challenge may alleviate pain, but it is often impossible to distinguish esophageal pain from cardiac pain
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Clinical Characteristics
Musculoskeletal Pain
Pain lasts few seconds to hours Positional and tender Pain may be reproducible on palpation
8% of AMIs have reproducible chest pain

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Chest Pain Pearls

A normal EKG and initial cardiac enzymes does not rule out an MI

Examine every CXR closely for evidence of pneumothorax or aortic dissection. Remember bilateral BPs - especially in elderly and predisposing conditions
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References
1. Lee TH, Goldman L: Evaluation of the patient with acute chest pain. New Engl J Med 342:1187, 2000. 2. Tintinalli JE, et al. Emergency Medicine A Comprehensive Study Guide. Chapter 49, 2004.

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References
3. American College of Emergency Physicians

Clinical Policies Committee; Clinical Policies Committee Subcommittee on Suspected Pulmonary Embolism. Clinical policy: critical issues in the evaluation and management of adult patients presenting with suspected pulmonary embolism. Ann Emerg Med 2003 Feb;41(2):257-270
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