Acute Chest Pain in Emergency Room

1. Acute Chest Pain in Emergency Room Dr Chaitanya Vemuri Post Graduate Student

2. Introduction Chest Pain Diseases of heart aorta lungs pleura mediastinum oesophagus stomach abdominal viscera musculoskeletal psychological

3. Approach History Clinical Examination Differential Diagnosis Investigations

4. History Onset of pain ( abrupt / gradual ) Site of pain (substernal, chest wall, diffuse, localized) Quality of Pain ( squeezing, catching, burning, dull ache ) Radiation ( shoulder, jaw, back ) Provocation / Palliation ( activities that provoke pain or alleviate pain ) Timing ( constant / episodic, duration of episodes )

5. Clinical examination ECG Chest X ray 2D Echocardiography Special Investigations

6. Aim in Emergency Room Immediate recognition and exclusion of life-threatening causes of chest pain

7. Acute Coronary Syndrome Aortic Dissection Pulmonary Embolism Pneumothorax Mediastinitis Pericardial Tamponade

8. Case 1 A 58 year old male Smoker k/c/o Systemic Hypertension Dyslipidemia Diabetes mellitus type 2 c/o left sided chest pain since last 30 minutes squeezing pain gradual onset radiating to jaw and left arm associated with dyspnea, sweating and vomiting On ex : Pul : 90 / min BP : 150 / 90 mm Hg RR : 20 /min CVS : S1+,S2+, No murmurs RS : Clear

9. Acute Coronary Syndrome History Left sided or Substernal chest pressure or tightness Onset is gradual Pain radiating to shoulder, jaw Pain increasing on exertion Atypical symptoms � dyspnea, weakness in elderly and diabetics

10. Acute Coronary Syndrome Clinical Examination Nonspecific Signs of Heart failure Acute LVF Bradycardia / Heart block / Hypotension

11. Acute Coronary Syndrome Investigations ECG Cardiac Enzymes 2D Echocardiogram

12. Acute coronary syndrome refers to any constellation of clinical symptoms that are compatible with acute myocardial ischemia and encompasses acute myocardial infarction. - STEMI, - NSTEMI, - Unstable Angina

13. Anterior wall ischemia

14. Evolution of MI

15. Acute anterolateral wall ischemia

16. Acute lateral wall ischemia

17. Acute myocardial infarction

18. Acute anterior wall stemi

19. Acute anteroseptal MI with RBBB

20. Acute inferior wall MI

21. Acute inferior wall MI

22. Posterior wall MI

23. Cardiac Enzymes In patients with negative cardiac enzymes within 6 hrs of onset of pain , another sample should be drawn within 6 � 12 hrs Troponin I & Troponin T : Preferred Biomarker Increase in 3-12 hrs after the onset of MI Peak at 24-48 hrs Return to baseline over 5 -14 days

24. Cardiac Enzymes CK-MB : >95% Sensitivity & Specificity for myocardial injury when measured 24-36 hrs after the onset of chest pain Increase within 3-12 hrs of chest pain Peak at 24 hrs Return to baseline after 48-72 hrs CKMB : CK > 2.5 � Suggests myocardial source but not diagnostic

25. 2D Echocardiogram Look for Regional wall motion abnormality LV function RV function Mitral Regurgitation

26. Management Oxygen Inhalation Morphine � pain relief Antiplatelets Statins Betablockers ACEI /ARB IV/ SC Heparin / Thrombolysis / PCI +/- Diuretics

28. Case 2 70 year old male k/c/o Systemic Hypertension c/o Sudden onset Chest pain tearing in nature along the back

29. Aortic Dissection History Sudden onset of sharp, tearing or ripping pain Maximal severity at onset Often begins in chest / can begin in back

30. Aortic Dissection Clinical Examination Absent upper extremity or carotid pulse Discrepancy in Systolic BP > 20 mm Hg between right and left upper limb Aortic Regurgitation 30 % Neurological findings

31. Aortic Dissection Investigations ECG : 15 % - Ischemic changes 30 % - Non specific ST �T changes CXR : Wide mediastinum / Loss of Normal Aortic Knob Contour � 76 % Normal � 10 %

32. Chest X Ray

33. 2D Echocardiogram

35. Case 3 A 50 Year old female # neck of femur s/p surgery on prolonged bed rest swelling of left lower limb since 1 week sudden onset dyspnea since 4 hrs associated sharp catchy chest pain on right side On ex : Tachypnea Pulse : 110 / min BP : 110/60 mm Hg Chest : Clear ; CVS : S1+S2+ No murmurs

36. Pulmonary Embolism � The Great Masquerader History Risk Factors : Prolonged Immoblization Deep Vein Thrombosis Malignancy Central Venous Instrumentation<3m Pleuritic chest pain Dyspnea ( dominant feature ) Sudden in onset

37. Pulmonary Embolism Clinical Examination Symptoms & Signs � highly non specific & variable and also common in those with and without PE No finding is specific Extremity � may be normal Tachypnea � common Tachycardia Jugular venous distension Non specific focal rales Absent breath sounds Loud P2

38. Pulmonary Embolism Massive Pul Embolism : Acute RV failure Jugular venous distension RV S3 Parasternal Lift Rarely Circulatory Collapse

39. Pulmonary Embolism Blood Tests : D-dimer : A Useful Rule-out Test Sensitivity > 80% for DVT Sensitivity > 95% for PE Not specific for PE Levels increase in MI,Pneumonia,Sepsis Cardiac Biomarkers : Elevated S.Troponin ( RV microinfarct ) Elevated S.BNP / NT-ProBNP ( myocardial strech )

40. Pulmonary Embolism ECG : usually abnormal ; nonspecific Sinus Tachycardia S1Q3T3 T wave inversion in V1-V4 Signs of Right heart strain - Right axis deviation - RBBB - Right atrial enlargement

41. Pulmonary Embolism

42. Chest X Ray

43. Chest X Ray

44. Chest X Ray

45. Echocardiography Not of diagnostic value Useful to rule out mimics of PE : Acute MI Pericardial Tamponade Aortic Dissection Mc Connell�s Sign Specific Appearance of RV Hypokinesia of RV free wall with normal motion of RV apex

46. Diagnostic modalities MDCT Chest with Contrast + Pulmonary angiogram � Principal imaging for the diagnosis of PE Ventilation Perfusion Scan � 2nd line investigation Pulmonary Angiography � Gold standard

47. CT-PA

48. Case 4 A 50 year old male k/c/o COPD � Emphysema Sudden onset Right Chest Pain � Sharp , Catchy With predominant Dyspnea On Ex : Pul 100 /min BP : 110/60mmHg RR: 40/min Deviation of trachea to left side Hyperresonance - Rt side of chest Diminished Breath sounds - Right side of chest

49. Pneumothorax Can occur Following trauma Following pulmonary procedures Primary Spontaneous pneumothorax Secondary pneumothorax � COPD - Asthma - Cystic Fibrosis

50. History Sudden onset pleuritic chest pain Dyspnea as dominant feature Clinical Examination Tachypnea Shift of mediastinum to contralateral side Ipsilateral diminished or absent breath sounds

51. Chest X Ray

52. Case 5 46 year old male c/o Sudden onset diffuse chest discomfort / pain Dyspnea � predominantly On ex : Tachypnea Hyperresonance on percussion bilaterally b/l diminished breath sounds

53. D/D

54. Case 6 A 30 year old male Alcoholic Post alcohol consumption Devoleped severe retching and vomitings Followed by excruciating retrosternal chest pain Also upper abdominal pain On Ex : Tachypnea Cyanosis Fever Hypotension � Shock

55. Mediastinitis � Esophageal Rupture Occurs in Alcoholics Patients with gastric or duodenal ulcer Spontaneous perforation of esophagus after vomiting - Boerhaave�s Syndrome Spontaneous esophageal rupture can also occur in : Caustic ingestion Pill esophagitis Barett�s ulcer following dilatation of esophageal strictures

56. Clinical examination Non specific findings � early in course of illness Subcutaneous emphysema � not specific Hamman�s crunch � mediastinum Pleural effusion

57. Chest X Ray

58. CT Chest

59. Cardiac Tamponade History Sharp anterior chest pain made worse by lying down Pain relieved by sitting forward Pain aggravated by inspiration Dyspnea : common

60. Clinical examination Sinus tachycardia Elevated JVP ( Preserved X descent Absent Y descent ) Pulsus Paradoxsus Hypotension Muffled heart sounds

61. ECG Low voltage complexes Electrical alternans Diffuse PR segment depressions and or ST segment elevations

62. Echocardiography Diastolic collapse of right ventricle and right atrium Diastolic collapse of left ventricle � more specific

63. Echocardiography

64. Common causes of Chest Pain in ER � Not Of Immediate Threat To Life

65. Chest Pain � cardiac CAD � Chronic Stable Angina Variant angina Cocaine precipating ACS Valvular heart disease : AS / MS / PS Pericarditis Myocarditis Stress induced Cardiomyopathy Cardiac Syndrome X Pheochromocytoma

66. Variant angina Vasospastic Angina / Prinzmetal Angina Spontaneous episodes of angina in association with ST segment elevation in ECG Patients : Young females with epicardial disease Chest pain often occurs at rest than in exertion Predominantly in morning Chest pain associated with ST elevation in ECG

67. Variant Angina ECG : ST segment Elevation Stress testing : often normal except when epicardial disease + Coronary Angiogram : often proximal plaque

68. Cardiac Syndrome X Angina pectoris with normal coronary arteries Chest pain episodes often with exertion Chest pain is associated with ST segment depression in ECG

69. Cardiac Syndrome X ECG : Normal / ST Segment Depression Stress Testing : ST Segment depression Coronary Angiography : normal epicardial vessels; no vasospasm

70. Pericarditis Retrosternal and left precordial pain Radiate to left shoulder, neck Aggravated by inspiration , movement, swallowing More in supine position Relieved in sitting and leaning forward position h/o fever + On ex : Pericardial frictional rub

72. Case 7 A 55 year old female No co morbidities Lost her husband 3 days ago � RTA Devoleped sudden onset left sided chest pain On Ex : Pul : 80 / min BP : 100 / 70 mm Hg RR : 20 / min Chest : clear CVS : S1 + S2+ ESM +

73. ECG

74. Investigations Cardiac Enzymes : Trop I : 0.4 CK-MB : 35 2D ECHO : Apical Ballooning of left ventricle in end systole Severe Akinesia of distal portion of LV Reduced EF CAG : Normal Coronaries

75. Tako � Tsubo Cardiomyopathy Apical Ballooning Syndrome Elderly females After severe emotional upset Reversible within 3 � 7 days Normal Coronaries Mech : unknown catecholamines acting on epicardial coronaries

76. 2D Echocardiogram

77. Left Ventriculogram

78. Chest pain � Gastrointestinal Any patient at risk for CAD who presents with anginal quality chest pain - r/o myocardial ischemia before being given gastrointestinal diagnosis

79. GERD Chest pain can mimic angina pectoris Squeezing / Burning pain - Substernal - Radiating - to back Lasting minutes to hours Resolving spontaneously or with antacids Reflux symptoms : dyspepsia / regurgitation / acid taste ECG / Cardiac enzymes / ECHO � R/O ACS Diagnosis : Oesophageal manometry / OGDscopy

80. Mallory Weiss Syndrome h/o non bloody vomiting and retching followed by hemetemesis chest discomfort � epigastric / in back Incidence increases with age Associated with alcoholics and hiatus hernia Mallory-Weiss syndrome is characterized by longitudinal mucosal lacerations � proximal stomach and distal oesophagus Diagnosis : OGDscopy

81. Mallory Weiss Tear

82. Esophageal chest pain Pain provoked by swallowing Pain provoked by postural changes Pain palliated by antacids Inconsistent relationship with exercise Substernal chest pain which doesn�t radiate Frequent episodes Nocturnal pain Pain associated with heartburn, acid taste in mouth

83. Others�. Achalasia cardia Oesophageal spasm Nut cracker esophagus Medication induced esophagitis Radiating visceral pain � Peptic ulcer disease Cholecystitis Biliary Colic Pancreatitis Appendicitis

84. Pulmonary Causes Pneumonia � pleuritic pain Lung Cancer � dull aching pain Sarcoidosis Pleurisy Empyema Empyema necessitans

85. Musculoskeletal Chest pain Insidious onset Recent repetitive unaccustomed activity Pain : localized or diffuse Positional component Persistant � prolonged ( hours � days )

86. COSTOCHONDRITIS : Multiple areas of tenderness in upper costal cartilages at costochondral junctions NO SWELLING TIETZE�S SYNDROME : Painful nonsuppurative localized swelling of costosternal, sternoclavicular, costochondral joints

87. Associated conditions Chronic low back ache, young individual : Ankylosing Spondylitis Ocular Inflammation : Ankylosing Spondylitis Behcets Syndrome Diffuse musculoskeletal pain / sleep disturbance : Fibromyalgia Peripheral joint pain and swelling : RA Skin lesion : Psoriatic Arthritis

88. Neuropathic Pain Herpes zoster Radiculopathy

89. Psychological Causes Panic attack Panic disorder DSM �IV PC

90. Treat Chest Pain with Respect THANK U