Chest Pain




OVERVIEW
Duration:
10-20 min
Quality:
Pressure
Dull
Heaviness
Squeezing
Tight
Location:
Sub-sternal
Worse w/ Exersion

Relieved w/ rest = ANGINA

Pain @ rest =
UNSTABLE ANGINA

EKG
ABNORMAL NORMAL
ST-Depression
(NSTEMI)
ST-Elevation
(STEMI)
  Risk Factors:
Non-Modifiable:

       - (+) FHx
      - Male, > 55 y
      - Female (post menopausal)

Modifiable:

 - HTN (MC Risk factor)
 - DM (worst risk factor)
 - HL                         
 - Smoker (greatest immediate imporvement)
 - Cocaine/Amphetamine Use
Ischemia Infarct

Unstable Angina

MI
β-MONAH: CATH in < 1 hr   YES
NO
CP onset
< 12h
> 12h
β-Blocker
Morphine
O2
NTG
Aspirin
Heparin

-Statin

TNK (prefer <1-3hr)
-or-
Angioplasty within 90 min or ED arrival

[Stents]
Elective CABG ?
Cardiology Consult

STRESS TEST

DC
NORMAL ABNORMAL
(ST-Depression)
  Next Step?
Contraindication:
- Melena
- Recent Surgery
- BP > 180/110
- Brain bleed (anytime in life)
- Aortic Dissection
To Dx? To Manage?
ANGIOGRAM

β-MONAH
β-Blocker
Morphine
O2
NTG
Aspirin/ACEI
Heparin/LMWH
-Statin

1-2 vessel 3 vessel

-OR-

LMA (>50% block)

Angio w/ stent

CABG



Conditions Associated w/ Troponin Levels
in the Absence of Ischemic Heart Disease

Conditions Associated with Elevated Troponin Levels in the Absence of Ischemic Heart Disease
Cardiac contusion
Cardioinvasive procedures (surgery, ablation, pacing, stenting)
Acute or chronic congestive heart failure
Aortic dissection
Aortic valve disease
Hypertrophic cardiomyopathy
Arrhythmias (tachy- or brady-)
Apical ballooning syndrome
Rhabdomyolysis with cardiac injury
Severe pulmonary hypertension, including pulmonary embolism
Acute neurologic disease (e.g., stroke, subarachnoid hemorrhage)
Myocardial infiltrative diseases (amyloid, sarcoid, hemochromatosis, scleroderma)
Inflammatory cardiac diseases (myocarditis, endocarditis, pericarditis)
Chronic Kidney Disease
Drug toxicity (e.g; Cocaine)
Respiratory failure
Sepsis
Burns
Extreme exertion (e.g., endurance athletes)

Conditions Associated with CK-MB Levels

Conditions Associated with Elevated CK-MB Levels
Common Uncommon Unclear
Unstable angina, acute coronary ischemia Congestive heart failure Acromegaly
Hypothermia
Inflammatory heart diseases (pericarditis, myocarditis, endocarditis) Coronary artery disease after stress test Rocky Mountain spotted fever
Angina pectoris Typhoid fever
Cardiomyopathies Valvular defects Chronic bronchitis
Circulatory failure and shock Tachycardia Lumbago
Cardiac surgery Cardiac catheterization Febrile disorder
Cardiac trauma Electrical countershock Isolated rare case in normal person
Skeletal muscle trauma (severe) Noncardiac surgery
Brain and head trauma
Dermatomyositis, polymyositis Peripartum period
Miscellaneous drug overdoses
Muscular dystrophy, especially Duchenne
CO poisoning 
Extreme exercise Prostatic cancer
Malignant hyperthermia
Reye syndrome
Rhabdomyolysis of any cause
Delirium tremens
Ethanol poisoning (chronic)
 

ECG by Anatomy









Work-up

  1. EKG, CXR, CBC, BMP, PT/INR, STAT TROPONIN I or T, CK, CK-MB.
  2. Digoxin level (If pt on digoxin)

Risk factors assessment:

  • Stress Test:
    • Pt with LBBB = Dobutamine Echo OR Adenosine MPI.  NO EXERCISE STRESS TEST.
What stress test to use?

IMAGING

 Exercise EKG
Dipyridamol OR adenosine thallium stress test OR Dobutamine echo Exercise thallium OR Exercise stress echo??
Pts who cannot exercise to target HR or > 85% of maximum:
- COPD/Asthma (Dobutamine stress test)
- Amputation
- Deconditioning
- Weakness/Previous Stroke
- Lower-extremity ulcer
- Dementia
- Obesity (Sestamibi nuclear stress test)
EKG is unreliable for ischemia:
- Digoxin use
- LBBB
- Wolf-Parkinson whitee
- Pacemaker in place
- Left ventricular hypertrophy
- > 1 mm of ST-depression at rest (any baseline anomaly of ST segment on EKG)
- Your pts who can tolerate exercise.
Contraindications to EXERCISE stress test:
Absolute contraindications to exercise testing include:
  • an acute MI within the previous 2 days,
  • unstable angina,
  • cardiac arrhythmias causing symptoms or hemodynamic compromise,
  • severe aortic stenosis (Severe aortic stenosis typically is associated with an aortic valve area (AVA) of < 0.8 cm)
  • symptomatic decompensated heart failure,
  • acute pulmonary embolism or infarct,
  • acute pericarditis or myocarditis,
  • acute aortic dissection, and
  • Lack of ACLS equipment or signed consent.
Contraindications to Dipyridamole & Adenosinee stress test:
  • Asthma
  • COPD
  • HypOtension
  • Bradycardia, or
  • Heart block

 
High-Risk Findings on Stress Test:
The provocation of ischemia at a workload of 6.5 METs or less, or a high-risk exercise treadmill score (> –11), implies severe limitation of the ability to increase coronary blood flow, and indicates a high risk for adverse cardiac outcome (>3% annual mortality). Other high-risk findings include:
  • severe resting left ventricular dysfunction ((<35%)
  • severe left ventricular dysfunction with exercise (≤35%)
  • a stress-induced large perfusion defect, particularly if anterior
  • stress-induced multiple perfusion defects of moderate size
  • a large, fixed perfusion defect with left ventricular dilation or increased lung uptake (thallium-201)
  • a stress-induced moderate perfusion defect with left ventricular dilation or increased lung uptake (thallium-201)
  • echocardiographic wall-motion abnormalities involving two or more segments developing with a low dose of dopamine or at a heart rate <120 beats/min
  • evidence of extensive ischemia on stress echocardiographyy

 

Recommends initial invasive strategy in patients with the following characteristics:
  • Recurrent angina or ischemia at rest or with low-level activities despite intensive medical therapy.
  • Elevated cardiac biomarkers (TnT or TnI)
  • New or presumably new ST-segment depression
  • Signs or symptoms of HF or new or worsening mitral regurgitation
  • High-risk findings from noninvasive testing
  • Hemodynamic instability
  • Sustained ventricular tachycardia
  • PCI within 6 months
  • Prior CABG
  • High-risk score (eg, TIMI, GRACE)
  • Reduced left ventricular function (LVEF < 40%)

Historical Factors that Increase the Likelihood
of Acute Myocardial Infarction

Historical Factors that Increase the Likelihood of Acute Myocardial Infarction
Pain Descriptor
Radiation to right arm or shoulder
Radiation to both arms or shoulders
Associated with exertion
Radiation to left arm
Associated with diaphoresis
Associated with nausea or vomiting
Worse than previous angina or similar to previous myocardial infarction
Described as pressure

Historical and Exam Factors that Decrease the
Likelihood of Acute Myocardial Infarction

Historical and Exam Factors that Decrease the Likelihood of Acute Myocardial Infarction
Pain Descriptor
Described as pleuritic
Described as positional
Described as sharp
Reproducible with palpation
Inframammary location
Not associated with exertion
 

DDx

 
Chest Wall Pain Pleuritic Pain Visceral Pain
Costosternal syndrome Pulmonary embolism Typical exertional angina
Costochondritis (Tietze syndrome) Pneumonia Atypical (nonexertional) angina
Spontaneous pneumothorax
Precordial catch syndrome Unstable angina
Slipping rib syndrome Pericarditis Acute myocardial infarction
Xiphodynia Pleurisy
Radicular syndromes   Aortic dissection
Intercostal nerve syndromes   Pericarditis
  Esophageal reflux or spasm
Fibromyalgia  
    Esophageal rupture
    Mitral valve prolapse
 

Life-Threatening Causes of Chest Pain

Life-Threatening Causes of Chest Pain: Classic Symptoms Compared
Disorder Pain (location) Pain (character) Pain (radiation) Associated Symptoms
Angina pectoris Retrosternal or epigastric Crushing, tightness, squeezing, pressure R or L shoulder, R or L arm/hand, jaw Dyspnea, diaphoresis, nausea
Massive pulmonary embolismm Whole chest Heaviness, tightness None Dyspnea, unstable vital signs, feeling of impending doom
Segmental pulmonary embolism Focal chest Pleuritic None Tachycardia, tachypnea
Aortic dissection Midline, substernal Ripping, tearing Intrascapular area of back Secondary arterial branch occlusion
Pneumothorax One side of chest Sudden, sharp, lancinating, pleuritic Shoulder, back Dyspnea
Esophageal rupture Substernal Sudden, sharp, after forceful vomiting Back Dyspnea, diaphoresis, may see signs of sepsis
Pericarditis Substernal Sharp, constant or pleuritic Back, neck, shoulderr Fever, pericardial friction rub
Pneumonia Focal chest Sharp, pleuritic None Fever, may see signs of sepsis
Perforated peptic ulcer Epigastric Severe, sharp Back, up into chest Acute