Chest Pain

Sumit Bose, MD
PGY-3
Objectives
Overview of chest pain
Differential diagnosis of chest pain
Typical vs. atypical chest pain
Evaluation of chest pain
Review patient cases
Overview
Chest pain accounts for 6 million annual
visits to the EDs in the United States
Chest pain is the second most common
ED complaint
Patients with chest pain present with a
wide spectrum of signs and symptoms
It is up to the clinician to recognize the
life-threatening causes of chest pain
Overview

Cayley 2005
Pearl 1

CHEST PAIN ACS

POSITIVE TROPONIN ACS
Life-threatening causes of
chest pain
Acute coronary syndrome (unstable
angina, NSTEMI, STEMI)
Aortic dissection
Pulmonary embolism
Pneumothorax
Tension pneumothorax
Pericardial tamponade
Mediastinitis (e.g. esophageal rupture)
Differential diagnosis

UpToDate 2012
 Typical vs. Atypical Chest Pain
Typical
Characterized as
discomfort/pressure rather
than pain
Time duration >2 mins
Provoked by activity/exercise
Radiation (i.e. arms, jaw)
Does not change with
respiration/position
Associated with
diaphoresis/nausea
Relieved by rest/nitroglycerin
Atypical
Pain that can be localized with
one finger
Constant pain lasting for days
Fleeting pains lasting for a few
seconds
Pain reproduced by
movement/palpation
Typical vs. Atypical Chest Pain

UpToDate 2012
Typical vs. Atypical Chest Pain

Cayley 2005
Evaluation of Chest Pain
Scenario 1 - Its 2:00 AM and you are the
VA NF intern. The nurse pages you and
tells you that Mr. S, a 67 yro M with
known hx of CAD, who is admitted for ARF
is having chest pain after he walked back
from the bathroom. What would you do
next?
Evaluation of Chest Pain
Scenario 1:
Ask nurse for most current set of vital
signs
Ask nurse to get an EKG

Ask nurse to have the admission EKG at

bedside if available
Go see the patient!
Evaluation of Chest Pain
Once at bedside, determine if patient is
stable or unstable
Read and interpret the EKG. Compare
EKG to old EKG if available
If patient looks unstable or has
concerning EKG findings, call your
senior resident for help
Evaluation of Chest Pain
If patient is stable:
Perform a focused history
Does patient have known CAD or other cardiac risk factors?
Is the pain typical/atypical?
Is the pain similar to prior MI?

Perform a focused physical exam

Look for tachycardia, hypertension/hypotension or hypoxia on vital signs
General: Sick appearing, actively having chest pain
HEENT: JVD, carotid bruits
Chest: Rales, wheezes or decreased breath sounds
CVS: New murmurs, reproducible chest pain, s3 gallop
Abd: Abdominal tenderness, pulsatile mass
Ext: Edema, peripheral pulses
Skin: Rash on chest wall
Evaluation of Chest Pain
Labs/imaging/disposition
CXR
Cardiac biomarkers
ABG?
Telemetry/ICU

Write a clinical event note!

Evaluation of Chest Pain
Scenario 2 - You are the orphan intern
and you get a page from 67121 and the
DACR informs you that you have a 45
yro female in the ED who is being
admitted to the Hellerstein service for
r/o ACS. How would you approach this
patient?
Evaluation of Chest Pain
Scenario 2:
Get report from ED physician about the
patient
Ask ED physician about patients initial
presentation
Get last set of vital signs

Ask ED physician to order EKG and CXR

Evaluation of Chest Pain
Go to UH Portal and print out an old
EKG for comparison
Review prior discharge summaries
Quickly review prior cardiac work up
echo, stress tests and cath reports
Review any labs/imaging from current
ED visit
CASES
Case 1
You are on the Wearn team and the
nurse calls you and tells you that Ms. Z
suddenly started having chest pain and
her O2 sat went from 94% on room air
to 88% on 2L via NC
Case 1
Ms. Z is a 62 yro F with PMHx of CAD s/p remote PCI to the LAD, COPD and right THA 3
weeks ago who was admitted for a COPD exacerbation
EKG on admission:
Case 1
You go see the patient. The patient tells you that she was feeling
better after getting duonebs during this admission, but suddenly
developed chest pain that is L-sided, 8/10 and worse with breathing.
She has never experienced pain like this in the past
Vital signs: Afebrile, HR 120, BP 110/70, RR 28, O2 sat 89% on 2L
Physical exam
Gen in distress, using accessory muscles of respiration
Lungs CTAB, no rales/wheezes
Heart tachycardic, nl s1, loud s2, no mumurs
Abd soft, NT/ND, active BS
Ext b/l LEs warm and well perfused
Labs:
CBC wnl, RFP wnl, BNP = 520, D-dimer = positive, Troponin = 0.12
Case 1
Case 1
Case 1
Case 1 - Pulmonary Embolism

Cayley 2005
Case 1 - Pulmonary Embolism
Diagnostic testing
Pulmonary angiography (Gold standard)
Spiral CT (CT-PE protocol)
V/Q scan (helpful for detecting chronic
VTE)
D-dimer (<500ng/ml helps exclude PE in
patient with low/moderate pre-test
probability)
Case 1 - Pulmonary Embolism
Treatment of PE
Anticoagulant therapy is primary therapy
for PE
Unfractionated heparin
LMWH
For unstable patients, catheter
embolectomy or surgical embolectomy are
options
For patients at risk for bleeding, IVC filter
is an alternative
Case 2
24 yro M is being admitted to you from the
ED for chest pain and EKG abnormalities
PMHx:
SLE
Asthma
You go see the patient and he tells you that
he has had this chest pain for ~2 days, but it
has progressively gotten worse. His chest
pain is worse with breathing. He does report
getting over a recent URI few days ago
Case 2
VS: T 38.1 HR 104 BP 140/76 RR 20 O2 sat 95% on
RA
Physical exam:
Gen in mild distress due to chest pain, leaning forward
while in bed
Lungs CTAB
Chest wall no visible rash, chest wall NT to palpation
Heart tachycardic, nl s1/s2, no rub
Rest of physical exam benign
Labs:
WBC = 14, RFP wnl, AMI panel x 1 = negative
CXR = negative
Case 2
EKG on admission:
Case 2 - Pericarditis
Refers to inflammation of pericardial sac

Preceded by viral prodrome, i.e. flu-like

symptoms

Typically, patients have sharp, pleuritic chest

pain relieved by sitting up or leaning forward
Case 2 - Pericarditis

Goyle 2002
Case 2 - Pericarditis

Goyle 2002
Case 2 - Pericarditis
Diagnostic criteria

UpToDate 2012
Case 2 - Pericarditis
Treatment

UpToDate 2012
Case 3
You are evaluating a patient on the Carpenter
team with chest pain

Patient is a 67 yro M with PMHx of HTN, HLD,

DM-2 and CAD s/p PCI to the LCx in 2007 who is
admitted for L leg cellulitis. He develops new
onset chest pain that is retrosternal, 7/10,
associated with nausea and diaphoresis. Says
pain is radiating to his L jaw and is similar to the
chest pain he had during his last MI
Case 3
VS: T 37 HR 108 BP 105/60 RR 20 O2 sat 93%
on RA
Physical exam:
Gen actively having chest pain, diaphoretic
Lungs rales at bilateral bases
Heart tachycardic, nl s1/s2, no mumurs or rub
Rest of the exam benign
Labs: CBC wnl, RFP wnl, Troponin = 3.2, CKMB
= 9, CK = 345
Case 3
Case 3 - NSTEMI
Risk stratification?
Case 3 - NSTEMI
Management of UA/NSTEMI
Aspirin
Inhibits platelet aggregation
HR control with beta-blocker
Titrate to goal HR ~ 60 beats/min
Statin
Nitroglycerin SL
Use if patient having active chest pain
DO NOT USE if patient is hypotensive and concern for RV
infarct
Case 3 - NSTEMI
Management of UA/NSTEMI
Plavix
P2Y12 receptor blocker
Inhibits platelet aggregation
Anticoagulation
Heparin/LMWH
Inhibits thrombus formation

Oxygen
For O2 sat <90%
Morphine
For refractory chest pain, unrelieved by NTG SL
Pearl 2

USE THE CHEST PAIN ORDER SET!

Order Set
QUICK CASES
Case 4
Case 4
You find out the patient is having
crushing chest pain radiating to the
back. His BP in the R arm = 193/112
and in the L arm = 160/99

What diagnosis is on top of your

differential?
Case 4 - Aortic Dissection
Stanford Classification
Type A Involves ascending aorta
Type B Involves any other part of aorta
Diagnostic Imaging
CXR
CT chest with contrast
MRI chest
TEE
Case 4 - Aortic Dissection
Management of Aortic Dissection
Type A dissection Surgical
Type B dissection Medical
Mainstay of medical therapy
Pain control
HR and BP control
Goal HR = 60 beats/min, goal SBP = 100-120 mmHg
Use IV beta-blockers (i.e. Labetalol, Esmolol)
Can also use Nitroprusside for BP control
AVOID Hydralazine
Case 5
This is a 45 yro M with PMHx of
rheumatoid arthritis who presented with
progressive sob. He was found to have
a R-sided pleural effusion and
underwent an US guided thoracentesis
with removal of 1.5 liters of pleural
fluid. Two hours after his procedure,
he develops new onset R-sided chest
pain
Case 5
Case 5 - Pneumothorax
Management of Pneumothorax
Supplemental O2 and observation in stable
patients for PTX < 3 cm in size
Needle aspiration in stable patients for PTX
>3 cm
Chest tube placement if PTX >3 cm and if
needle aspiration fails
Chest tube placement in unstable patients
 Pearl 3

ECG Wave-Maven
http://ecg.bidmc.harvard.edu/maven/mavenmain.asp
 Summary
Chest pain is a very common complaint but has
a broad differential
Always try to rule out the life-threatening
causes of chest pain
It is important to remember that troponin
elevation DOES NOT always mean ACS
Use the history, physical exam, labs, EKG and
imaging to commit to a diagnosis
Whenever you are stuck, ask for help. Your
seniors are here to help you!
 References
Cayley, W.E. Diagnosing the cause of chest pain. (2005). American Family Physician, Vol 72 (10), 2012-
21.
Goyle, K.K. and Walling, A.D. Diagnosing pericarditis. (2002). American Family Physician, Vol 66 (9),
1695-1702.
Diagnostic approach to chest pain in adults. (2012). UpToDate.
http://www.uptodate.com/contents/diagnostic-approach-to-chest-pain-in-
adults?source=search_result&search=chest+pain&selectedTitle=1%7E150
Differential diagnosis of chest pain in adults. (2012). UpToDate.
http://www.uptodate.com/contents/differential-diagnosis-of-chest-pain-in-
adults?source=search_result&search=chest+pain&selectedTitle=3%7E150
Evaluation of chest pain in the emergency department. (2012). UpToDate.
http://www.uptodate.com/contents/evaluation-of-chest-pain-in-the-emergency-
department?source=search_result&search=chest+pain&selectedTitle=5%7E150
Clinical presentation and diagnostic evaluation of acute pericarditis. (2012). UpToDate.
http://www.uptodate.com/contents/clinical-presentation-and-diagnostic-evaluation-of-acute-
pericarditis?source=search_result&search=pericarditis&selectedTitle=1%7E150
Treatment of acute pericarditis. (2012). UpToDate. http://www.uptodate.com/contents/treatment-of-
acute-pericarditis?source=search_result&search=pericarditis&selectedTitle=2%7E150