Chest Pain

Jean J. Chatham, MD

What to do when the nurses call to tell you that so and so is complaining of chest pain.

Go see the patient and write a note in the chart

Why is the patient admitted to the hospital?

This is why sign outs are so very important to effective cross cover. Helps to focus on helping that individual patient.

Differential Diagnosis of Chest Pain

Non Cardiac
Cardiac

Non Cardiac Chest Pain

Pulmonary
Pneumonia Pleuritis Pneumothorax Pulmonary Embolism Tumor

Musculoskeletal
Costochondritis Cervical Disk Disease Rib Fracture Intercostal Muscle Cramp

Gastrointestinal
GERD Esophageal spasm Mallory-Weiss Tear Peptic Ulcer disease Biliary/Gallbladder Disease Pancreatitis

Other
Herpes Zoster Disorders of the Breast Splenic Infarct Panic Attacks/Anxiety Disorder Fibromyalgia DKA

Cardiac Chest Pain

Aortic Dissection Pulmonary Embolism Pulmonary Hypertension Pericardial Diseases Aortic Stenosis Heart Failure Cocaine Abuse Acute Coronary Syndromes
Stable Angina Unstable Angina Myocardial Infarction Cardiogenic Shock

How do you distinguish cardiac chest pain from non-cardiac chest pain?

 Talk to the patient Examination of the patient

ANGINA
Pain Pressure Vice like squeezing elephant sitting on my chest Indigestion/heart burn

Canadian Cardiovascular Society Classification of Angina

Class I
II

Activity Provoking Prolonged Exertion

Walking >2 Blocks

Limitation none
slight

III
IV

Walking <2 Blocks

Minimal/Rest

marked
severe

Character/Quality of the pain Location and Radiation of the pain Associated symptoms What exacerbates and what relieves the pain Duration of the pain Have they had it in the past and what was it attributed to?

 General Appearance Vital Signs

At the time of your exam and the trend BP in both arms Pulses in all extremities

Focused Cardiovascular Exam

Assessing for Heart Failure
Neck Veins S3/S4 Murmurs (new MR murmur) Lung exam for pulmonary edema (rales) Friction Rub

Braunwald p 6

Braunwald p 6

CAD Risk Factors

Important CAD Risk Factors

Smoking High Cholesterol High Blood Pressure Diabetes Family History of CAD

Goldman and Braunwald p 92

Acute Coronary Syndrome

Cannon p5

Acute Coronary Syndrome

Acute Coronary Syndrome

Goldman and Braunwald p 93

Role of EKG

GET AN EKG IN ALL CASES OF CHEST PAIN

Role of EKG
Compare EKG with pain to older one, preferably one where patient was pain free Rate Rhythm Axis Intervals ST/T waves

Role of EKG
Prevalence of MI
80% with new ST elevation 20% with new ST depression

EKG not consistent with ischemia

2-4% had MI

GET AN EKG IN ALL CASES OF CHEST PAIN

Unstable Angina
Chest Pain consistent with angina Non-ST segment elevation Not new LBBB Considered the differential diagnosis of chest pain

What Should You Do?

Bedrest Oxygen unless contraindicated (severe COPD) Chew ASPIRIN 325mg, regardless of if they took one earlier. Assess for active GI bleed. Anticoagulation
Heparin LMWH Hirudin

What Should You Do?

Nitrate Therapy
sublingual NTG Patch/Paste IV NTG

Beta blockers
consider HR/BP, rhythm, possible location of ischemia and if the patient is in heart failure metoprolol 5mg IV q5min x 3 metoprolol 25 mg po q6h (hold SBP less 90)

What Should You Do?

Pain Free Maximize NTG therapy Minimize Oxygen Demand Morphine Sulfate 2 mg IV q5-10 min

What Should You Do?

Antiplatelet therapy
clopidigral (Plavix) is an ADP antagonist Glycoprotein IIB/IIIA
tirofiban (Agrastat) eptifibatide (Integrilin) abciximab (ReoPro)

Lipid Lowering
Recent evidence would point to the early use of statin therapy regardless of cholesterol status as a way to decrease oxidative stress

What Should You Do?

Labs to be ordered
CK with MB Troponin CBC PT/PTT within that admission BMP and LFT if not known in last 24 hours Fasting Lipid panel with AM labs Chest X-Ray

Braunwald 1202

Braunwald 1202

CAD affects 60 million Americans and is the leading cause of death of both men and women in the U.S