Sumit Bose, MD
PGY-3
Objectives
Overview of chest pain
Differential diagnosis of chest pain
Typical vs. atypical chest pain
Evaluation of chest pain
Review patient cases
Overview
Chest pain accounts for 6 million annual
visits to the EDs in the United States
Chest pain is the second most common
ED complaint
Patients with chest pain present with a
wide spectrum of signs and symptoms
It is up to the clinician to recognize the
life-threatening causes of chest pain
Overview
Cayley 2005
Pearl 1
UpToDate 2012
Typical vs. Atypical Chest Pain
Typical Atypical
Characterized as Pain that can be localized with
discomfort/pressure rather one finger
than pain Constant pain lasting for days
Time duration >2 mins Fleeting pains lasting for a few
Provoked by activity/exercise seconds
Radiation (i.e. arms, jaw) Pain reproduced by
Does not change with movement/palpation
respiration/position
Associated with
diaphoresis/nausea
Relieved by rest/nitroglycerin
Typical vs. Atypical Chest Pain
UpToDate 2012
Typical vs. Atypical Chest Pain
Cayley 2005
Evaluation of Chest Pain
Scenario 1 - Its 2:00 AM and you are the
VA NF intern. The nurse pages you and
tells you that Mr. S, a 67 yro M with
known hx of CAD, who is admitted for ARF
is having chest pain after he walked back
from the bathroom. What would you do
next?
Evaluation of Chest Pain
Scenario 1:
Ask nurse for most current set of vital
signs
Ask nurse to get an EKG
Cayley 2005
Case 1 - Pulmonary Embolism
Diagnostic testing
Pulmonary angiography (Gold standard)
Spiral CT (CT-PE protocol)
V/Q scan (helpful for detecting chronic
VTE)
D-dimer (<500ng/ml helps exclude PE in
patient with low/moderate pre-test
probability)
Case 1 - Pulmonary Embolism
Treatment of PE
Anticoagulant therapy is primary therapy
for PE
Unfractionated heparin
LMWH
For unstable patients, catheter
embolectomy or surgical embolectomy are
options
For patients at risk for bleeding, IVC filter
is an alternative
Case 2
24 yro M is being admitted to you from the
ED for chest pain and EKG abnormalities
PMHx:
SLE
Asthma
You go see the patient and he tells you that
he has had this chest pain for ~2 days, but it
has progressively gotten worse. His chest
pain is worse with breathing. He does report
getting over a recent URI few days ago
Case 2
VS: T 38.1 HR 104 BP 140/76 RR 20 O2 sat 95% on
RA
Physical exam:
Gen in mild distress due to chest pain, leaning forward
while in bed
Lungs CTAB
Chest wall no visible rash, chest wall NT to palpation
Heart tachycardic, nl s1/s2, no rub
Rest of physical exam benign
Labs:
WBC = 14, RFP wnl, AMI panel x 1 = negative
CXR = negative
Case 2
EKG on admission:
Case 2 - Pericarditis
Refers to inflammation of pericardial sac
Goyle 2002
Case 2 - Pericarditis
Goyle 2002
Case 2 - Pericarditis
Diagnostic criteria
UpToDate 2012
Case 2 - Pericarditis
Treatment
UpToDate 2012
Case 3
You are evaluating a patient on the Carpenter
team with chest pain
Oxygen
For O2 sat <90%
Morphine
For refractory chest pain, unrelieved by NTG SL
Pearl 2
ECG Wave-Maven
http://ecg.bidmc.harvard.edu/maven/mavenmain.asp
Summary
Chest pain is a very common complaint but has
a broad differential
Always try to rule out the life-threatening
causes of chest pain
It is important to remember that troponin
elevation DOES NOT always mean ACS
Use the history, physical exam, labs, EKG and
imaging to commit to a diagnosis
Whenever you are stuck, ask for help. Your
seniors are here to help you!
References
Cayley, W.E. Diagnosing the cause of chest pain. (2005). American Family Physician, Vol 72 (10), 2012-
21.
Goyle, K.K. and Walling, A.D. Diagnosing pericarditis. (2002). American Family Physician, Vol 66 (9),
1695-1702.
Diagnostic approach to chest pain in adults. (2012). UpToDate.
http://www.uptodate.com/contents/diagnostic-approach-to-chest-pain-in-
adults?source=search_result&search=chest+pain&selectedTitle=1%7E150
Differential diagnosis of chest pain in adults. (2012). UpToDate.
http://www.uptodate.com/contents/differential-diagnosis-of-chest-pain-in-
adults?source=search_result&search=chest+pain&selectedTitle=3%7E150
Evaluation of chest pain in the emergency department. (2012). UpToDate.
http://www.uptodate.com/contents/evaluation-of-chest-pain-in-the-emergency-
department?source=search_result&search=chest+pain&selectedTitle=5%7E150
Clinical presentation and diagnostic evaluation of acute pericarditis. (2012). UpToDate.
http://www.uptodate.com/contents/clinical-presentation-and-diagnostic-evaluation-of-acute-
pericarditis?source=search_result&search=pericarditis&selectedTitle=1%7E150
Treatment of acute pericarditis. (2012). UpToDate. http://www.uptodate.com/contents/treatment-of-
acute-pericarditis?source=search_result&search=pericarditis&selectedTitle=2%7E150