Chest pain

Levines sign

Background
Chest pain is one of the most common chief
complaints of patients presenting to EDs
annually.
About 20% of the annual ED visits are for
chest pain and related symptoms.
Cardiac etiology found in less than one third

Goals
1. Rapid recognition of management of true ACS.
2. Recognition of other life-threatening causes of
chest pain.

PAIN IN THE CHEST

BUT
ORIGIN??

HEART AND VESSELS

LUNGS AND AIRWAYS
OESOPHAGUS
MUSCULOSKELETAL STRUCTURES OF THORAX
NECK,OR SHOULDER??NERVES
ABDOMEN
ANXIETY MANIFESTATION

CHEST PAIN ASSESSMENT

HISTORY
EXAMINATION
ECG
CARDIAC ENZYMES
CXR

TIME IS VITAL

LIFE THREATENING CHEST PAIN IN

THE EMERGENCY DEPARTMENT
HEART ATTACK

ANSWER IS

NO

RELAX
IS IT ENOUGH TO RULE OUT HEART ATTACK?

Life Threatening Chest Pain in

the Emergency Department
Myocardial Infarction
USA
Aortic Dissection
Tension Pneumothorax
Pulmonary Embolus
Ruptured Esophagus/Perforated
Ulcer

CHEST PAIN ASSESSMENT

History

VITALLY IMPORTANT

PAIN
NATURE
SITE
SEVERITY
RADIATION
ONSET
EXAC/RELIEVING FACTORS
ASSOCIATED FEATURES
DURATION
PREVIOUS SIMILAR PAINS

Chest Pain: Physical Exam

Vital signs and general appearance
Carotids and JVP
Lungs
Cardiac exam

Thoracic cage
Abdominal exam
Periphery (pulses)
Skin

CHEST PAIN ASSESSMENT

Examination
General Examination
(sweaty clammy pale cyanosed, anaemic etc pulse BP)
Cardiovascular /Respiratory examination
? Failure ( crackles ,oedema, raised JVP)

Heart Sounds
- rate , nature ,?quiet ? added heart sounds, ?murmurs

Acute Coronary Syndromes

Unstable Angina
Similar pathophysiology

Non-ST-Segment
Elevation MI
(NSTEMI)

ST-Segment
Elevation MI
(STEMI)

Similar presentation and

early management rules
STEMI requires evaluation
for acute reperfusion
intervention

Unstable
Angina
Non occlusive
thrombus

Non specific
ECG
Normal cardiac
enzymes

NSTEMI
Occluding thrombus
sufficient to cause
tissue damage & mild
myocardial necrosis
ST depression +/T wave inversion on
ECG
Elevated cardiac
enzymes

STEMI
Complete thrombus
occlusion
ST elevations on
ECG or new LBBB
Elevated cardiac
enzymes
More severe
symptoms

Clinical Spectrum of Acute Coronary Syndromes

Stable angina Unstable
angina

Evidence of necrosis
ECG early

ECG late

None
ST-segment
depression
and/or
T-wave inversion
No Q

Non-STE MI

STE MI

Positive

Positive

ST-segment
ST-segment
depression
elevation
and/or
T-wave inversion
No Q

Q develops

Antman EM. In: Braunwald E, ed. Heart Disease: A Textbook in Cardiovascular Medicine, 5th ed. Philadelphia, Pa: WB Saunders; 1997.

Diagnosis of Acute MI
STEMI / NSTEMI
At least 2 of the following
Ischemic symptoms
Diagnostic ECG
changes
Serum cardiac marker
elevations

Diagnosis of Unstable Angina

Patients with typical angina - An episode of angina
Increased in severity or duration
Has onset at rest or at a low level of exertion
Unrelieved by the amount of nitroglycerin or rest that
had previously relieved the pain

Patients not known to have typical angina

First episode with usual activity or at rest within the
previous two weeks
Prolonged pain at rest

ACS Clinical Presentation

Substernal chest pain or pressure (>20-30
min)
Localization or radiation to arms, back,
throat, jaw
Accompanying features
Dyspnea
Nausea/vomiting
Diaphoresis
Weakness

ACS: Management

Initial therapy: Oxygen, nitro, ASA, ECG

Antiplatelets: Clopidogrel, Prasugrel
Anticoagulation:
Pain control:
Conservative vs. Invasive management

Differential diagnosis:
Causes of chest pain

PE: Presentation
Presentation variable
Suspect in any patient c/o new or worsening
dyspnea, chest pain or prolonged hypotension
without obvious etiology
Symptoms: dyspnea (sec. to min) > pleuritic chest
pain > cough
Signs: tachypnea > tachycardia > rales > loud P2

Pneumothorax: Presentation
Primary Spontaneous PTX:
Seen in patinets without underlying lung disease
Smoking, FH and Marfans predispose
Usually 20s-40s, present with sudden onset dyspnea and
pleuritic CP at rest
Physical findings include decreased chest excursion,
decreased breath sounds, hyperresonance
Hypoxeima common

Pneumothorax: Presentation
Secondary Spontaneous PTX
Seen in patients with underlying lung disease
Any lung disease predisposes however COPD most
common
Similar physical presentation to PSP
ABG typically abnormal due underlying lung
disease
Traumatic PTX

Pneumothorax: Diagnosis
CXR: Look for
pleural line
Can be difficult in
patients with COPD
CT scan can
overestimate size of
PTX

Pneumothorax

Pneumothorax

Esophageal rupture: Diagnosis

CXR: early shows
mediastinal or free
peritoneal air
Hours to days
later: widening of
mediastinum,
pleural effusion

Aortic dissection: Presentation

Sharp, tearing anterior or posterior chest
and back pain.
Unequal pulses not always present
Typically sudden onset and severe
Complicated by syncope, MI (RCA) or HF
Bed side echo.

Aortic Dissection:
Predisposing factors:
Aortic aneurysm
HTN
Vasculitis
Marfans or other collagen diseases
CABG/cardiac catheterizaion
Drugs (crack cocaine)
Trauma

Aortic dissection

Pericarditis
Chest pain (anterior chest, sharp, pleuritic,
exacerbated by inspiration, can decrease with
leaning forward, radiation to trapezius)
Often first sign of other systemic disease
Multiple possible etiologies, viral and
autoimmune

Myocarditis
Presentation variable
Viral most common etiology in developed
countries
Presents with HF, chest pain, sudden cardiac
death or arrhythmias
Workup with biomarkers, ECG, CXR, TTE,
cardiac MR and endomyocardial biopsy
Consider in young male with new onset HF

Take home message

Never discharge a patient from the ED with
typical chest pain even if his ECG & cardiac
enzymes are unremarkable.
Make sure not to miss alarming ECG changes.
In a patient with MI every minute before
revascularization means increase in the extent
of the infarct area ,so TIME = HEART=LIFE