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CHEST PAIN
Differential Diagnosis
and Diagnostic Challenge
Raymond P. Kelly DO
FACOEP
WHAT DO YOU
NEED TO THINK ABOUT
WHEN SOMEONE FLIES IN WITH…
CHEST PAIN?
Impact of Chest Pain In the
Emergency Department
– Pressure or – Nausea/Vomiting*
Squeezing pain – Fatigue*
– Radiation to – Diaphoresis*
Arm/Jaw – Signs of CHF*
– Anxiety – Shortness of Breath/
Wheezing*
– Tachycardia/
Bradycardia
∗ Anginal Equivalents
Coronary Artery Disease
SIGNS AND SYMPTOMS
– Immobilization/ – Prior
Immobility Thromboembolism
– Postoperative – Pregnancy/Postpart
(Pelvic and Lower – Estrogen Use
Abdominal – Cancer
Surgery in past 6
months) – Oral Contraceptives
– Family History – Prolonged travel
Pulmonary Embolism
SIGNS AND SYMPTOMS
KTrauma KCollagen
KCancer Vascular
KRecent MI or Diseases
Surgery – Dressler’s KDrugs
syndrome KAnticoagulants
KRecent Viral
Infection
Acute Pericarditis
SIGNS AND SYMPTOMS
KSubsternal Pain KAnxiety
KVaries with KAnorexia
Respiration
KFever
KIncreased with
Recumbency KPericardial
KRelived by Friction Rub
Leaning Forward
Acute Pericarditis
• EKG evolves over 4 stages:
– I – (most common presentation) ST
elevation and PR depression =
“classic diagnostic finding”
– II – normal EKG
– III – Deep symmetric T-wave
inversions throughout
– IV – Normal EKG
Acute Pericarditis
CARDIAC TAMPONADE
• Is the most serious complication of
pericarditis
• Presentation – tachycardia, hypotension,
elevated jugular venous pressure, and
pulsus paradoxus (> 10mm decrease in
systolic BP during inspiration)
• BECK’S TRIAD – Muffled heart sounds,
elevated jugular venous distention (JVD),
and hypotension
Acute Pericarditis
Findings With Tamponade
• CXR – Enlarged cardiac silhouette in absence of
findings of heart failure
• EKG – Low voltage and electrical alternans
• Echocardiography – is the study of choice and
will confirm the presence of pericardial fluid as
well as impaired filling of the atrium and right
ventricle
Acute Pericarditis
• Emergent pericardiocentesis is the treatment of
choice for hemodynamically unstable patients
• Removal of even small amounts of fluid can lead
to dramatic improvement
• Can be done with ultrasound guidance if patient
is stable
• Intubation of these patients with PPV can lead to
precipitous drops in blood pressure due to
increased preload reduction
Cocaine Chest Pain
RISK FACTORS
• Younger patients with classic angina
– Known drug abuse history – always ask
about recent use (< 24 hrs)
– Cocaine use also associated with:
• Aortic Dissection
• Pulmonary Infiltrates (Crack Lung)
Pneumothorax
• Traumatic
– Penetrating Trauma
– Blunt trauma with associated rib
fractures or ruptured bleb
– S/P Chest Instrumentation – CVP Lines,
Nerve Blocks
• Spontaneous
– Primary - Rupture of a small
unrecognized bleb
– Secondary – Changes in barometric
pressure, PPV, COPD, Lung infections
Mitral Valve Prolapse
• MVP is the most frequently diagnosed
valvular abnormality
• More common in women than men
• Discomfort associated is often atypical
and associated with dizziness,
hyperventilation, anxiety, depression,
palpations, and fatigue
• Mid-systolic click and late systolic
murmur
• Beta blockers are often helpful
Pneumonia
KBiliary Colic
KPancreatitis
KEsophageal Spasm
KEsophageal Reflux
KGastritis/ Peptic Ulcer Disease
KEsophageal Rupture (Boerhaave’s
Syndrome)
Gastrointestinal Causes
• Avoid the “GI cocktail” as a diagnostic
challenge
• No data to support chest discomfort relieved
by antacids is more likely to be noncardiac
than pain that is not so relieved
• Conversely, nitroglycerine is a smooth
muscle dilator that may relive esophageal
spasm or biliary colic
• Diagnostic decisions should not be influenced
by response to a therapeutic trial
Musculoskeletal Chest Pain
and Other Considerations
• Palpation of the chest should REPRODUCE,
not produce the pain
• If you don’t completely expose and inspect
the chest you may never find the lesions of
Herpes Zoster that have appeared on the
chest wall
• Costochondritis is inflammation of the costal
cartilages and is often sharp and varies with
respirations
Musculoskeletal Chest Pain
and Other Considerations
• Other funny words
– Tietze Syndrome = erythema, tenderness,
and swelling of the costochondral cartilage
– Xiphodynia
– Texidor Twinge – short, lancinating
discomfort at cardiac apex associated with
breathing and poor posture/ inactivity
– Epidemic Pleuridynia – the “Devil’s Grip”
Chest Pain Diagnosis
• The HISTORY is the single most important tool
to distinguish between the various causes
• The key is to ask questions in such a way that
allows the patient to describe their symptoms in
their own words
Chest Pain Diagnosis
• Duration • Frequency
• Constant
• Location • Intermittent
• Retrosternal • Sudden vs.
• Subxyphoid Delayed Onset
• Diffuse
Chest Pain Diagnosis
• Precipitatin • Quality
g Factors • Burning
• Exertion • Squeezing
• Stress • Dull
• Food • Sharp
• Respiration
• Tearing
• Movement
• Heavy
Chest Pain Diagnosis
ASSOCIATED SYMPTOMS
• Shortness of • Back Pain
Breath • Radiation to
• Diaphoresis neck or arms
• Palpitations
• Nausea
• Weakness
• Vomiting
• Fatigue
• Jaw Pain
Electrocardiogram
Cardiac Ischemia
• Inexpensive and readily available
• Sensitivity of initial tracing is less than
40%
– Serial EKGs may be helpful if ACS is
suspected
• Increased suspicion if have:
– T-wave inversions
– ST abnormalities
• Comparison to old tracings often helpful
Electrocardiogram
Pulmonary Embolism
• PNEUMOTHORAX
– A missed tension pneumothorax is
immediately life threatening
• PNEUMONIA
– Sometimes occurs as a consequence
of ischemic heart disease and
congestive heart failure
Chest Radiograph
• AORTIC DISSECTION
– Widened mediastinum seen in
approximately 80% of patients
– A normal chest x-ray does not rule it out
• ACUTE PERICARDITIS
– Usually normal unless massive pericardial
effusion
• ESOPHAGEAL RUPTURE
– Usually will show mediastinal air or a left
pleural effusion
Laboratory
• Cardiac Enzymes (CK-MB and
Troponin)
– High positive predictive value
– If initially negative, cannot be used to R/O
MI**
– Negative cardiac markers do not exclude
unstable angina**
• D-Dimer
– Sensitive, but poor specificity for
pulmonary embolism (PE)
Laboratory
• CBC/ SMA-7
– Basic metabolic screening in chest pain patients
• Coagulation Studies (PT/PTT)
– Essential if considering use of thrombolytic agents
or heparin
• Liver Function Studies/ Amylase
– To rule out GI causes
• Toxicological Screen – if suspecting cocaine
use
Laboratory
• MYOCARDIAL IMAGING
– Echocardiography
• Wall motion abnormalities due to
ischemia or infarction
• Helpful in diagnosing pericardial and
valvular heart disease
• Useful in detecting aortic dissections,
particularly the transesophageal method
Special Imaging Tests
• MYOCARDIAL IMAGING
– Echocardiography - A Stress
echocardiogram is only for
patients who have ruled out for
infarction
Special Imaging Tests
• MYOCARDIAL IMAGING
– Perfusion Imaging uses an intravenously
injected radioactive tracer that is rapidly
redistributed in the tissues. Areas without
uptake represent either infarcted or
ischemic myocardium
• Thallium studies
• Technetium/ Sestamibi – more useful
Special Imaging Tests
• CT Scanning
– Sensitive for aortic dissection
– Useful in some centers for detecting
pulmonary embolism using spiral CT and
IV contrast
• Accurate for PE in proximal pulmonary vascular
tree
• May be normal with small distal PE
– Always done on STABLE patients
Special Imaging Tests
• V/Q Scan
• For diagnosing Pulmonary Embolism
(PE)
• Reported as high, intermediate, or low
probability of PE
• If result is intermediate, or low, and
clinical suspicion is high, must proceed
to pulmonary angiography
Special Imaging Tests
• Pulmonary Angiography
– “Gold Standard for Diagnosis of PE
– Used when PE is not excluded or
confirmed
• “normal” spiral CT (possible distal PE)
• Intermediate probability V/Q scan
– Associated with higher morbidity and
mortality than other studies described
Initial Stabilization and
Treatment
• ABC’s
• Oxygen
• IV access
• Pulse Oximiter
• Cardiac Monitoring
• Continuous BP Monitoring
• Prompt evaluation of the EKG
Initial Stabilization and Treatment
ACLS Guidelines
• Reduce pain and anxiety
• Reduce work load of the heart
• Control extremes of blood pressure
• Assess and treat cardiogenic shock
• Assess and treat congestive heart failure
• Evaluate conduction disturbances -
anticipate appropriate interventions
Initial Stabilization and
Treatment – More ACLS
• If ACS is suspected, remember that
“MONA” greets the patient at the door
– Morphine – for immediate pain
management
– Oxygen – Is good
– Nitroglycerine dilate coronary arteries
– Aspirin – reduce platelet adherence
Initial Stabilization and
Additional Treatments
– Metoprolol – Adenosine
– Labetalol – Diltiazem
– Nitroprusside – Lidocaine
– Atropine – Procainamide
– Magnesium – Amiodarone
– Epinephrine – Vasopressin
Initial Stabilization and
Additional Treatments
– Heparin
– Low Molecular Weight Heparin
– Glycoprotein IIb/IIIa Inhibitors
– Thrombolytic agent du jour
– Angiontensin Converting Enzyme Inhibitors
– Percutaneous Transluminal Coronary
Angioplasty
– Intraaortic Balloon Pump
Summary Points
• Consider the deep differential in
patients with chest pain
• Do not exclude ACS on the absence of
risk factors
• A single negative cardiac marker does
not exclude AMI
• Negative cardiac markers do not
exclude unstable angina
• A normal ABG does not rule out PE
• All that wheezes is not asthma
?