Evaluation of Chest Pain

1. Evaluation of Chest Pain William Norcross, M.D.

2. Evaluation of Chest Pain • Dictum: • With any chief complaint or symptom complex, first rule-out (R/O) life threats. • The stopping point in the R/O should be at the point of your conviction and personal satisfaction that the life threat does not exist. • The R.O process may be very short and simple, e.g. a directed histroy, but if you're not convinced that the life threat is absent, pursue the R/O as far as necessary.

3. Chest Pain is very common. • > 40 recognized entities in differential diagnosis • Life threat (practical) • Acute coronary syndromes (ACS) • Aortic dissection • Pulmonary embolus (PE) • Pneumothorax • Pneumonia • Obscure • Boerhave’s Syndrome • Usually are discovered in W/U of above.

4. Life-Threat Ruled Out • Other entities • Musculoskeletal/serosal problems • e.g. costochondritis, intercostal muscle spasms/strain, pericarditis, pleurisy • Treat with NSAID, opiates, acetaminophen, local measures • GI pathology • Dyspepsia, GE reflux esophageal spasm • Some bad abdominal pathology presents as chest pain • e.g. perfodrated viscous, pancreatitis, cholecystitis • Usually apparent by H&P • Treat with antacids, antispsmodics, etc.

5. Approach to Non-Life Threats • Less urgent • Trial & error approach • Evaluation • H&P, ancillary tests (CRX, EKG, perhaps dimers and cardiac markers)

6. Approach to Non-Life Threats • Pneumonia, pneumothorax easy to diagnose • Note: the diagnostic modality for tension pneumothorax is an intracostal needle, not a CXR. • ACS, PE, aortic dissection: all easy to diagnose if you do the work-up • Triggered by suspicions raised by initial evaluation and R/O life threat

7. Bad things to miss • High mortality out-of-hospital (if undiagnosed)

8. Pulmonary Embolism • Physical exam: tachycardia, tachypnea, sats, R heart findings, leg findings • Ancillary - EKG, CXR, nonspecific d-dimer is usually  (sensitivity > 85%) • Assign likelihood of PE (low, high, intermediate) based on clinical gestalt or grading scales (e.g. Well’s Criteria) • If low probability and d-dimer is , quit (probably) • If intermediate or high, or if low with  d-dimer, further study (V/Q, CT angio, perhaps dopplers)

9. Aortic dissection • History triggers; sudden,radiation, ripping/tearing • Risk factors: HTN, Marfan’s, coarctation, aortic valve replacement, bicuspid aorta • PE: • Severe pain, distress (usually), pulses, BP differential, AI murmur, neuro deficits • All are insensitive markers, varied specificity • Ancillary data • CXR: usually abn (90%) wide mediastinum, abn aorta; non-specific, 10% “normal” • EKG: may show ST segment elevation

10. Acute Coronary Syndrome • Most important due to commonality as well as lethality • Top of differential, first inquiry • ‘ACS’ against the field of everything else

11. ACS • History: Full history Only 4 things are truly predictive of ACS • Presence of chest pain • Chest pain as chief complaint • Radiation to shoulder(s) • History of previous MI • Risk factors (traditional) are not predictive in ED setting

12. ACS • PE: full physical • Only 4 things predictive: • Hypotension • Diaphoresis • Rales • S3 • Markers • CKMB | troponin : sensitivity < 50% at 6 hrs • Neg markers with unstable angina and often initially neg with MI • Neg first set mandates at lest on additional set

13. ACS: EKG • Diagnostic of MI (1 mm elevation ST segments in anatomically contiguous leads) about 50% of the time. • Non-diagnostic (usually non-specific ST/T waves) in around 50% MI. • Normal 5 - 10% MI • If ST  as above there is 80% likelihood of AMI • If new ST 1 mm with inverted T in anatomically contiguouse leads, 20% chance of AMI, 20 -- 50% change unstable angina (UA). • If old ST changes as above and acute chest pain, 5% chance AMI and 20 - 50% UA.

14. Acute Coronary Syndrome • If ACS is Ruled In (with EKG or markers) treat and admit. • If not, then: • If strong suspicion, teat, admit, further R/O • If convinced not ACS (or other potentially serious problem) - • treat symptoms, outpatient manage • If unsure - • treat, admit, further R/O

15. ACS • Approached with clinical gestalt. • More objective decision aids available (ACI - TIPI). • Clinical sensitivity of either approach, > 95%. • Not good enough: the 5% (approximate) do badly. • If in doubt, assume the worst, treat and admit for further evaluation.

16. References • Evaluation of the Patient with Acute Chest Pain. Lee. N Engl J Med 2000; 342: 1187-1195. • Missed Diagnosis of Acute Cardiac Ischemia in the Emergency Department. Pope and others. N Engl J Med 2000; 342: 1163-70. Editorial N Engl J Med 2000; 342: 1207-1209. • Is this Patient Having a Myocardial Infarction? Panju and others. JAMA 1998;280:1256-63. • Prediction of the need for intensive care inpatients who came to Emergency Departments with acute chest pain Goldman and others. N Engl J Med 1996; 334:1498-1504. • ST-segment Elevation in Conditions other than Acute Myocardial Infarction. Wang and others. N Engl J Med 2003; 349:2128-2135. • Triage of patients with Acute Chest Pain and Possible Cardiac Ischemia: The Elusive Search for Diagnostic Perfection. Goldman and others. Ann Int Med 2003; 139: 987-995. • Comprehensive strategy for the evaluation and triage of the chest pain patient. Tatum. Ann Emerg Med 1997;29:116-125. • A computer protocol to predict myocardial infarction in emergency department patients with chest pain. N Engl J Med 1988; 318:797-803. • Prognostic Importance of the Physical Examination for heart failure in non ST elevation Acute Coronary Syndromes: The Enduring value of Killilp Classification. JAMA 2003; 290: 2174. • Use of the Acute Cardian Ischemia Time Insensitive Predictive Instrument (ACI-TIPT) to assist with Triage of Patients with Chest Pain. Selker. Ann Int Med 1998; 129:845-855. • Impact of a Clinical Decision Role on Hospital Triage of Patients with suspected Cardiac Ischemia in the Emergency Department. Reilly and others. JAMA 2002; 288:342-350.