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Approach To Chest Pain

Approach To Chest Pain. Chest Pain. TABLE 1-2 DIFFERENTIAL DIAGNOSIS OF EPISODIC CHEST PAIN RESEMBLING ANGINA PECTORIS DURATION QUALITY PROVOCATION RELIEF LOCATION COMMENT

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Approach To Chest Pain

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  1. Approach To Chest Pain

  2. Chest Pain • TABLE 1-2 DIFFERENTIAL DIAGNOSIS OF EPISODIC CHEST PAIN RESEMBLING ANGINA PECTORIS DURATION QUALITY PROVOCATION RELIEF LOCATION COMMENT Effort angina 5-15 minutes Visceral (pres- During effort or Rest, nitroglyc- Substernal, radi- First episode • sure) emotion erin ates vivid Rest angina 5-15 minutes Visceral (pres- Spontaneous (? Nitroglycerin Substernal, radi- Often nocturnal • sure) with exercise) ates Mitral prolapse Minutes to Superficial Spontaneous (no Time Left anterior No pattern, vari- • hours (rarely visceral) pattern able character Esophageal re- 10 minutes to 1 Visceral Recumbency, Food, antacid Substernal, epi- Rarely radiates flux hour lack of food gastric Esophageal 5-60 minutes Visceral Spontaneous, Nitroglycerin Substernal, Mimics angina spasm cold liquids, ex- radiates • ercise Peptic ulcer Hours Visceral, burning Lack of food, Foods, antacids Epigastric, substernal ‘‘acid’’ foods Biliary disease Hours Visceral (waxes Spontaneous, Time, analgesia Epigastric, ? Colic • and wanes) food radiates Cervical disc Variable (gradu- Superficial Head and neck Time, analgesia Arm, neck Not relieved by • ally subsides movement, pal- rest • pation Hyperventilation 2-3 minutes Visceral Emotion, tachy- Stimulus removal Substernal Facial paresthe- • pnea sia Musculoskeletal Variable Superficial Movement, Time, analgesia Multiple Tenderness • palpation Pulmonary 30 minutes + Visceral (pres- Often spontane- Rest, time, bron- Substernal Dyspneic sure) ous chodilator • Reproduced with permission from Christie, L.G., Jr., and Conti, C.R.: Systematic approach to the • evaluation of angina-like chest pain. Am. Heart J. 1027, 1981.

  3. Chest Pain TABLE 1-3 SOME FEATURES DIFFERENTIATING CARDIAC FROM NONCARDIAC CHEST PAIN FAVORING ISCHEMIC ORIGIN AGAINST ISCHEMIC ORIGIN Character of Pain Constricting Squeezing ‘‘Knife-like,’’ sharp, stabbing Burning ‘‘Jabs’’ aggravated by respiration ‘‘Heaviness,’’ ‘‘heavy feeling’’ Location of Pain Substernal In the left submammary area Across mid-thorax, anteriorly In the left hemithorax In both arms, shoulders In the neck, cheeks, teeth In the forearms, fingers In the interscapular region Factors Provoking Pain Exercise Pain after completion of exercise Excitement Provoked by a specific body motion Other forms of stress Cold weather After meals From Selzer, A.: Principles and Practice of Clinical Cardiology. 2nd ed. Philadelphia, W.B. Saunders Company, 1983, p. 17.

  4. Patterns of Pain

  5. Differential Dx by Location

  6. Chest PainPhysical Exam • Vital Signs • Febrile- Endocarditis, Dressler’s, Demand Ischemia • BP- Hypertensive, Ischemia, Aortic Dissection, CHF (diastolic dysfxn) • Hypotensive, Cardiogenic Shock, CHF (systolic dysfxn, AS) • HR- arrhythmia, afib, v-tach, heart block • RR/SaO2- CHF, PE

  7. Chest PainPhysical Exam • Mental Status- alertness (shock), anxiety • HEENT: Mucous Membranes, Carotid Upstrokes (AS, AI, Bisferiens, Alternans), Bruits, Thyroid (CHF, Angina), Cx Tenderness, JVP- CHF,valve disease, Cannon a-waves • Lungs: RR, Rales, Wheezing (Bronchoconstriction or CHF), Pleural Effusion • Extrem: Equal BP’s, pulses (dissection, PVD), femoral/abdominal bruits, perfusion (cool, clammy, shock), Edema-CHF

  8. Chest PainCardiac Exam • Rate/Rhythm- arrhythmia (Afib, V-Tach, Bradycardia), heart block • PMI- displaced, sustained (CHF), palpable S3, S4 • Heart Sounds: S1 Loud (MS), Soft (MR, AVB) Variable(Afib), OS(MS), Mid Sys Click (MVP) Split S2 (BBB, PE, PA HTN, AS, LV Ischemia, Severe MR) • Murmurs- (Separate topic) AS, AI(esp acute), Ischemic MR • S3- CHF, S4-LV Non compliance (Ischemia, HTN)

  9. ST Elevation Myocardial Infarction (STEMI) • Admit, O2 • ASA • SL NTG, +/- IV NTG (SBP>100) • MSO4 2-4mg, (MONA) • Heparin (UFH or LMW) • Beta-blocker • Candidate for Thrombolytics

  10. Definite Indications for PTCA/Thrombolytic Therapy • Consistent clinical syndrome • Chest pain, new arrhythmia, unexplained hypotension, pulmonary edema • Diagnostic EKG • >1mm ST elevation in >2 contiguous leads • New LBBB • Less than 12 hours since onset of pain

  11. Relative Indications for PTCA/Thrombolytic Therapy • Consistent Clinical Syndrome • Chest pain, new arrhythmia, unexplained hypotension or pulmonary edema • Nondiagnostic ECG • Left bundle-branch block of unknown duration

  12. Absolute Contraindications for Thrombolytic Therapy • History of hemorrhagic stroke • Stroke or CVA within 1 year • Allergy to the agent • Surgery or trauma in past 2 wks • Known intracranial neoplasm • Suspected aortic dissection • Active internal bleeding (except menstruation)

  13. Relative Contraindications for Thrombolytic Therapy • Severe uncontrolled hypertension (>180/110 mm Hg) • History of chronic severe hypertension • CVA or intracerebral pathology > 1 yr ago • Current anticoagulant use • Recent trauma (within 2-4 weeks) • Allergy or prior exposure to streptokinase

  14. Active peptic ulcer disease Significant hepatic dysfunction Recent (2-4 weeks) internal bleeding Bleeding diathesis Noncompressible arterial or central venous puncture Pregnancy Relative Contraindications for Thrombolytic Therapy

  15. PTCA vs. Thrombolysis • PAMI Trial Demonstrated Superiority of PTCA over Thrombolysis • Hospital Mortality 6.5% with Thrombolysis vs 2.6% with PTCA • ICH 2% with Thrombolysis vs 0.2% with PTCA • 90 min Door to Balloon Time • Experienced Operators

  16. Non-ST Elevation MI (NSTEMI)

  17. NSTEMI, Early Invasive Strategy

  18. Chest Pain Uncertain Etiology • EKG with Symptoms • 4% of MI’s normal EKG • Non Invasive Imaging :Resting Nuclear Imaging/Echo/Contrast During Symptoms, CT Angio, EBCT, MRI Hyperenhancement • Cardiac Enzymes • Stress Testing • Cardiac Catheterization

  19. Bayes Theroem

  20. Predictive Value

  21. Predictive Value ETT

  22. ETT in Women

  23. Cardiac Stress TestingNuclear • TABLE 9-4 SENSITIVITY AND SPECIFICITY FOR DETECTION OF CORONARY ARTERY • DISEASE BY 201Tl SINGLE-PHOTON EMISSION COMPUTERIZED TOMOGRAPHY • NUMBER OF • AUTHOR PATIENTS SENSITIVITY (%) SPECIFICITY • Tamaki et al. 104 91 92 • De Pasquale et al. 210 95 71 • Borges-Neto et al. 100 92 69 • Maddahi et al. 110 96 56 • Fintel et al. 112 91 90 • Iskandrian et al. 164 88 62 • Go et al. 202 76 80 • Mahmarian et al. 360 93 87 • van Train et al. 242 95 56 • Total 1901 91 73

  24. Stress Echo

  25. Contraindications to ETT

  26. ETT High Risk Features • TABLE 5-4 EXERCISE PARAMETERS ASSOCIATED WITH • AN ADVERSE PROGNOSIS AND MULTIVESSEL CORONARY • ARTERY DISEASE • Duration of symptom-limiting exercise (< 6 METs) • Failure to increase systolic blood pressure ³120 mm Hg, or a • sustained decrease ³10 mm Hg, or below rest levels, during • progressive exercise • ST segment depression ³2 mm, downsloping ST segment, • starting at < 6 METs, involving ³5 leads, persisting ³5 min- • utes into recovery • Exercise-induced ST segment elevation (a Vr excluded) • Angina pectoris during exercise • Reproducible sustained (> 30 sec) or symptomatic ventricular • tachycardia

  27. EBCT

  28. Multislice CT Leber et al., JACC July 2005

  29. Diagnostic Accuracy CTA Leshka et.al. Eur Heart Journal 2005

  30. CTA Exclusions • BMI>30 • Afib • Coronary Calcium • Previous Stent • HR>75 • Hemodynamic Instability, inability to take beta-blockers • Renal Insufficiency, Contrast allergy • Coronary Size <3mm

  31. Coronary Angiography

  32. Cardiac Catheterization • Remains the “Gold Standard” • High risk patients • Non diagnostic non-invasive tests • Hemodynamic, Anatomical, Physiological Assessment • FFR, IVUS • Immediate Intervention if Needed

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