Evaluation of chest pain…

1. Chief complaint… “Severe chest pain for 2 hours”—first thought? Is this an acute coronary syndrome? • FIRST THINGS FIRST: Any patient with a suspected acute coronary syndrome should chew 160-325 mg of ASA; one simple therapy is associated with a 35-day mortality reduction exceeding 20%) • Now, think…what structures are located in the chest and how should I go about considering this specific patient with chest pain?

2. Evaluation of chest pain… • Cardiac—Acute coronary syndromes, aortic dissection, pericarditis, myocarditis • Pulmonary—pulmonary embolism, pleuritis, pneumothorax • GI—esophageal spasms, GERD, gall bladder

3. Evaluation of chest pain… • Musculoskeletal—costochondritis, muscle strain, rib fracture • Neurologic—herpes zoster (“band-like” burning pain may precede vesicular eruption) • Psychological—panic disorder, depression

4. So, use the PQRST + AAA • Start with the P’s…Pinpoint the pain, what is the precise location? “show me…” • LEVINE (pronounced “La Vine” sign…fist held over sternum is pretty classic for angina or an MI • Swooping the hand from the back, under the axillary region and to the front may indicate “shingles” • Moving the fingers up and down from the bottom of the sternum to the top may indicate heartburn/GERD • Severe tearing chest pain radiating to the back – think aortic dissection (and think it FAST) • Positional and pleuritic pain with pericarditis

5. What precipitated the pain? • Exertion? • What were you doing when the chest pain started? • How long did it take before the chest pain started? Raking leaves? Shoveling snow? Cardiac pain usually has a “lag time” to start • Did the pain start as soon as you picked up the shovel or the rake?

6. FYI: Snow-shovel-related medical mishaps1990-2006 • 195,000+ snow shovel-related injuries treated in emergency rooms in U.S. between 1990-2006 • 53.9% from acute musculoskeletal exertion • 20% slip and fall • 15% hit by a shovel • 6.7% cardiovascular related • 4.4% other • 63% sustained by 18-54 year-olds • Watson O.S, et al. Amer. J. Emer. Med, 2011

7. Back to the P’s • What palliates the pain? • Stopping the activity? How long did it take before the chest pain stopped when you ceased the activity? (cardiac pain—lag time to stop) • Did you put a little white pill under your tongue? If so, how many and how long did it take for the pain to stop? • Did you take an antacid? • Does it hurt when you palpate the area? Consider musculoskeletal pain (Cardiac pain is not reproduced with palpation)

8. Quality or Quantity • What is the Quality of the pain? • Burning? Zoster? GERD? AMI • Squeezing? Angina • Crushing? Vice-like? Acute MI • Tearing? Aortic dissection • Pleuritic w/ dyspnea? pneumothorax

9. R is for Radiate/Referred • Where does it Radiate? Is it Referred pain? • Front, back, side, down arm, up to the jaw, between the scapula, elbow, jaw only?

10. The dermatome chart

11. Dermatomes • Areas of skin that send their sensory information into specific spinal cord segments • Visceral structures share these sensory afferents with skin areas • T1-T4—dermatomes shared with the myocardium, pericardium, aorta, pulmonary artery, esophagus, and mediastinum • Maximal intensity of the visceral pain is in the retrosternal area/precordial area, up the neck, down the inner arm

12. Dermatomes • C3,4, (the phrenic nerves) the center of the diaphragm and shoulder pain • The patient with substernal chest pain, left shoulder pain and intractable nausea—right coronary artery, “inferior MI”? • What’s below the center of the diaphragm? The first part of the duodenum (the “organ of nausea”… • The older patient with fever, tachypnea, shoulder pain and confusion—lobar pneumonia • A fair, fat, fertile, forty-ish female with flatulence and right shoulder pain? Gall bladder? AMI

13. Severity • What is the severity of the pain… • On a scale from 1-10, with 1 being the least and 10 being “outta control”—where do you rank pain on this scale? • The classic MI—9 or 10 or greater

14. Does severity tell you anything special about outcomes after an acute MI? • No…in fact, severe chest pain does not herald worse outcomes. • Long believed by clinicians that a 9 or 10 on the scale resulted in worse outcomes • Severity of chest pain was not significantly associated with AMI (acute myocardial infarction) or the composite outcome of death (Edwards)

15. Atypical chest pain • Forty percent of AMI patients older than 85 present with chest pain vs. 77% of AMI patients younger than 65; Elderly patients more likely to present with dyspnea, diaphoresis, N & V, syncope • Women—54% are at risk for misdiagnosis vs. 33% of men; less likely to present w/ typical chest pain, but more likely to present with tachycardia and hypotension; more likely to report pain in the arm, neck, back and jaw; HA; N & V; dyspnea, cough; chest pain at rest, with mental stress, or during sleep

16. Timing or Temporal sequence • Temporal sequence; Timing • When did it start? • How long did it last? • How often do you experience this type of pain? • What’s unique about the time of day and an acute coronary syndrome?

17. 6 a.m. • Blood pressure and heart rate begin to rise due to adrenalin and cortisol—increasing the workload of the heart • BP is lowest at 4 a.m. • Sharpest rise of BP at 6:45 a.m. • Increasing heart rate and BP help you to become upright in the a.m. • Increasing blood pressure also means that the vessels are constricting—risk?? • If on a beta blocker…QD beta blockers (long-acting) should be taken at night • Example: Toprol XL (metoprolol)

18. How about that first morning cigarette when you first get up? • vasoconstriction

19. 8 a.m.-10 a.m. • Risk for AMI • The liver produces coagulation factors at night and releases early in a.m. • The adrenal gland releases cortisol and adrenalin in the a.m. which increases blood sugar and contributes to platelet aggregation; BP also rises as does heart rate in response to adrenalin in a.m. • Inflammatory mediators are the highest • Take daily aspirin as soon as you get up to inhibit platelet “stickiness”; • ASA stays in the body longer when taken at 7 a.m.

20. Not only are you at highest risk for an acute coronary syndrome in the a.m. • Increased risk of heart irregularities (arrhythmias) • Increased risk of sudden cardiac death (usually due to a ventricular dysrhythmia) • Increased risk of deaths associated with congestive heart failure (August 2005 Journal of Biological Rhythms)

21. The sure-fired way to avoid cardiovascular complications in the morning? • Don’t get up.

22. PQRST • Any additional symptoms? • Sweating? Nausea? Fatigue? Impending doom? • Dizziness? Light-headedness • Dyspnea (cardiac or respiratory)?? BNP test (B-type or brain- natriuretic peptide is released in response to an elevated left ventricular end diastolic pressure which attempts to decrease SVR and increase natriuresis—under 100 pg/mL rules out left ventricular failure; greater than 500 pg/mL rules in CHF)—gray zone between 100 and 500 pg/mL; under 50 pg/mL has a 97% sensivity

23. How about a 38 yo. woman with chest pain? • Quick questions to rule OUT a myocardial infarction in a young woman…what is her risk of having an MI at age 32? • Diabetes • Birth control pills? Obesity? • Autoimmune disease? SLE, RA, vasculitis • Methamphetamine, cocaine • Cardiotoxic chemotherapy • Surgical menopause? • Family history

24. The 7 common primary heart diseases are: • congenital heart disease • ischemic heart disease (coronary artery disease) • hypertensive heart disease • valvular heart disease – acquired or congenital • pulmonary heart disease (cor pulmonale) • primary disorders of the myocardium (cardiomyopathies, myocarditis) • pericardial diseases (pericarditis, tamponade)

25. Find your lines and your spaces… • Suprasternal notch • Clavicle (1st rib is under the clavicle) • 2nd rib is the first palpable rib • 2nd ICS R and L—base of heart • 4th ICS parasternal border • 5th ICS on L (apical area) • Epigastric area • BASE vs. APEX—heart is upside down

26. WTF? • Apex is at the bottom • Base is at the top • No rational explanation • Get over it, but remember it!!

27. Cardiovascular exam --inspection • Skin color, nailbeds, capillary refill (4-6 seconds is normal), ankle edema • 5th L ICS @ MCL for apical impulse • Left 4thparasternal border for the R ventricular area—R 4th for tricuspid • 2nd R ICS—aortic area—heave, pulsation • 2nd L ICS—pulmonic area—heave pulsation • Suprasternal notch—pulsation? • Epigastric area—pulsation?

28. Palpation… • The base of the heart…any thrills? Cat purring… • A thrill with a murmur means that the murmur is at least a grade 4 (4/6) • Think valvular disease—aortic and pulmonic stenosis in 2nd ICS • The 5th L ICS at the MCL The apical area—mitral stenosis

29. Palpation –palpating hearts and pulses since 1550 B.C. (Egyptians) • Identify the apical impulse—should be no bigger than 1-2 cm in size; gentle, brief contraction (only present in 50% of the population—turn patient on L side to feel)—if >4 cm (LR 4.7 for a dilated heart) • Where is it? Outside the MCL (>10 cm from the MSL)—LR for cardiomegaly is 3.4, depressed ejection fraction is 10.1, ↑LVEDV is 8.0, and increased PCWP 5.8) • Is there a pulsation in the epigastric area? Beating up against the pads of your fingers? Beating against fingertips?

30. Peripheral arterial disease—a risk equivalent of CAD • Have PAD? Most likely have CAD • Diffuse disease—males, diabetics, smokers, hypertensive patients • Check all pulses--Dorsal pedalis? Posterior tibial? If absent, try femoral and popliteal • In studies of large numbers of healthy individuals, the dorsal pedalis pulse is not palpable 3-14% of the time and the posterior tibial is absent 0-10% of the time. • Only 0-2% of healthy individuals are missing both pedal pulses). • Listen for bruits over femoral arteries; bruits near umbilicus

31. Characteristics arguingfor the presence of peripheral arterial disease • Absence of both pedal pulses (LR 14.9)* • Presence of any limb bruit (LR 7.3) • Presence of wounds or sores on the feet (LR 7.0) • Absence of the femoral pulse (LR 6.1) • Presence of asymmetric coolness of the foot (LR 6.1) • Unhelpful findings—atrophic skin (LR 1.7), hairless lower limbs (LR 1.7), prolonged capillary refill time (LR 1.9) • McGee S. Evidence-Based Physical Diagnosis. WB Saunders, Co. 2001 • *LR is the Likelihood Ratio

32. Peripheral arterial disease • Intermittantclaudication—muscular pain, aching, numbness w/ exercise; relieved by rest • Ankle/brachial systolic BP—normal is 1-1.2; less than 0.9 = PAD; claudication 0.5-0.9; rest pain less than 0.4 • Risk of amputation is 15-40 x higher in the diabetic • Tx with cilostazol (Pletal)—reduces time to claudication and improves exercise capacity (vasodilators don’t work) • ACE inhibitors have recently shown to be helpful

33. Guys, if you’re not getting blood flow to the feet or the private parts… you are not getting enough blood to the kidney

34. Acute mesenteric arterial occlusion • Severe diffuse abdominal pain—frequently out of proportion to clinical findings • Chronic occlusive disease involving the mesenteric circulation can manifest as abdominal angina—especially after “exercise”—a meal • Weight loss, N & V, early satiety • DON’T forget this as a cause of acute abdominal pain—especially in patients with CAD, PAD

35. Acute arterial peripheral occlusion—medical emergency—6 P’s • Pulselessness • Pallor • Poikilothermia (temperature of the affected extremity varies with ambient temperature • Pain • Paralysis • Paresthesia

36. Abdominal aortic aneurysm (AAA)—usually infrarenal • Abdominal bruits for abdominal aortic aneurysm-- • Usually silent until complication develops; abdominal pulsation • Ultrasound dx—screening for all men age 56-75 who have ever smoked • risk of rupture increases exponentially with size; 3.0-4.4 cm diameter has a 2%/year risk; 4.5-5.9 cm diameter has a 10%/year risk; > 6 cm = 80% rupture within 2 years

37. Triple A--prognosis • Rupture outside the hospital? 80-90% mortality; 50% die at scene; 50% who make it to the hospital die in the OR; 50% of those who survive the operation die of other co-morbid conditions prior to hospital discharge • When to repair? Aneurysm expansion > 0,5 cm/year; thoracic aortic aneurysm > 6 cm (Marfan syndrome—other signs?); abdominal aortic aneurysms > 5.5 cm

38. Jugular vein distention… • The absolute best way to check the amount of volume and pressure on the right side of the heart • Always check the R jugular vein in everyone but especially elderly pts (direct route to heart; L veins cross the mediastinum where the aorta may compress and falsely elevate). • If top of neck veins are elevated> 3 cm above sternal angle check for other signs of heart failure • Hepatomegaly, peripheral edema, S3 gallop, pulmonary crackles

39. Abdominal jugular reflex • The pressure applied over the abdomen shifts blood into the thorax and right atrium • If the right ventricle is unable to handle this increased load, the result is a sustained increase in JVP. • Compression of the liver is unnecessary • Compression of the periumbilical area will suffice • Positive with a sustained increase in the JVP greater than or equal to 4 cm. • LR ratio of 8 for detecting elevated left diastolic pressures

40. Pitting edema… • Subjective grading 1+-4+ • 1+ slight pitting • 2+ deeper but no detectable distortion of tissue • 3+ noticeably deep, extremity full and edematous • 4+ very deep pit (your finger disappears) dependent extremity is grossly distorted

41. Peripheral edema…what does it mean? • Fluid retention—heart failure • Unilateral pitting—consider occlusion of major vein • Edema without pitting—arterial disease and occlusion • Edema as a side effect of drugs that retain water or that are potent vasodilators—NSAIDS and Ca+ channel blockers

42. Now it’s time to listen--Notes on the stethoscope • Ear plugs that fit—block out extraneous noise • Length of tubing no longer than 12”, but 8” is ideal • Any stethoscope of a pastel color is worthless • Do not listen over clothes • The bell—LOW-pitched sounds; the diaphragm—HIGH-pitched sounds • Quiet room—no TV; no visitors; no wives, husbands, lovers, children; no construction

43. Heart valves

44. Position the patient… • Sitting up and leaning forward—brings base of heart closer to chest wall Murmurs of the aortic and pulmonic valves heard best in this position—high-pitched systolic sounds (aortic stenosis)—use the diaphragm of the stethoscope • Left lateral recumbent—best position to hear low-pitched filling sounds during diastole (mitral stenosis)(use the bell of the stethoscope—don’t MUSH it on the skin, hold it lightly!!)

45. But if you only have a minute… • …and the patient is NOT a cardiac patient—you can just listen to the apical or mitral area

46. If you had two minutes and you know the following… • #1 diseased valve of the heart? MITRAL • #2 diseased valve of the heart? AORTIC • SO WHERE WOULD YOU LISTEN FOR EACH OF THE ABOVE? • L 5th ICS for mitral (apical) • 2nd R ICS for aortic (base)

47. Heart sounds—S1, S2 • S1 is the closure of the mitral and tricuspid valves—the END of diastole or filling of the heart (aortic and pulmonic valves open signaling the beginning of systole) • S2 is the closure of the aortic and pulmonic valves—the END of systole or ejecting the blood (mitral and tricuspid valves open signaling the beginning of diastole) • Opening and closing valves are silent unless diseased

48. Listening to heart sounds…

49. So…when you hear an extra heart sound… • First decide if it’s in systole or diastole? • Extra heart sounds can be murmurs… • 50% of all murmurs are systolic…therefore, 50% of all murmurs are diastolic. DUH… Is the murmur after the LUB? Systolic? Is the murmur after the DUB? Diastolic

50. The third heard sound • S3—a diastolic sound • Gallop…lub dub dub, lub dub dub • This can be a normal sound under the age of 35 • however, consider the patient’s history before using this age as a arbitrary number to dismiss a third heart sound