Chest Discomfort

Introduction
• Chest discomfort is among the most common
reasons for which patients present for medical
attention at either an emergency department
(ED) or an outpatient clinic.
• Acute chest discomfort: (1) myocardial
ischemia; (2) other cardiopulmonary causes
(pericardial disease, aortic emergencies, and
pulmonary conditions); and (3) non-
cardiopulmonary causes
Epidemiology
Causes Chest Discomfort

Gastrointestinal

IHD

chest wall syndrome

pericarditis

pleuritis

pulmonary embolism

lung cancer

a aneurysm

herpes
Differential diagnosis

UpToDate 2012
APPROACH TO THE PATIENT: CHEST DISCOMFORT
 approach
• Priorities assessment of:
– the patient’s clinical stability
– the probability that the patient has an underlying
cause of the discomfort that may be lif
threatening.
Life-threatening causes of chest pain
• Acute coronary syndrome (unstable angina,
NSTEMI, STEMI)
• Aortic dissection
• Pulmonary embolism
• Pneumothorax
• Tension pneumothorax
• Pericardial tamponade
• Mediastinitis (e.g. esophageal rupture)
 History
• Quality of pain
• Location of discomfort
• Pattern
• Provoking and alleviatig factors
• Associated Symptoms
• Past Medical History
 Physical examination
• General
• Vital sign
• Pulmonary
• Cardiac
• Abdominal
• Vascular
• Musculoskeletal
• ECG
• X Ray
• Cardiac biomarkers
• Provocative testing for ischemia
• Echocardiography
• CT angio
• MRI
 Typical vs. Atypical Chest Pain
Typical
• Characterized as
discomfort/pressure rather than
pain
• Time duration >2 mins
• Provoked by activity/exercise
• Radiation (i.e. arms, jaw)
• Does not change with
respiration/position
• Associated with
diaphoresis/nausea
• Relieved by rest/nitroglycerin
Atypical
• Pain that can be localized with
one finger
• Constant pain lasting for days
• Fleeting pains lasting for a few
seconds
• Pain reproduced by
movement/palpation
 Case 1
• You are on the Wearn team and the nurse calls
you and tells you that Ms. Z suddenly started
having chest pain and her O2 sat went from
94% on room air to 88% on 2L via NC
 Case 1
• Ms. Z is a 62 yro F with PMHx of CAD s/p remote PCI to the LAD, COPD and right THA 3 weeks ago who was
admitted for a COPD exacerbation
• EKG on admission:
 Case 1
• You go see the patient. The patient tells you that she was feeling better after
getting duonebs during this admission, but suddenly developed chest pain that is
L-sided, 8/10 and worse with breathing. She has never experienced pain like this
in the past
• Vital signs: Afebrile, HR 120, BP 110/70, RR 28, O2 sat 89% on 2L
• Physical exam
– Gen – in distress, using accessory muscles of respiration
– Lungs – CTAB, no rales/wheezes
– Heart – tachycardic, nl s1, loud s2, no mumurs
– Abd – soft, NT/ND, active BS
– Ext – b/l LEs warm and well perfused
• Labs:
– CBC wnl, RFP wnl, BNP = 520, D-dimer = positive, Troponin = 0.12
Case 1
Case 1
Case 1
Case 1 - Pulmonary Embolism

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

• Preceded by viral prodrome, i.e. flu-like symptoms

• Typically, patients have sharp, pleuritic chest pain

relieved by sitting up or leaning forward
Case 2 - Pericarditis

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

• Patient is a 67 yro M with PMHx of HTN, HLD, DM-2 and

CAD s/p PCI to the LCx in 2007 who is admitted for L leg
cellulitis. He develops new onset chest pain that is
retrosternal, 7/10, associated with nausea and
diaphoresis. Says pain is radiating to his L jaw and is
similar to the chest pain he had during his last MI
 Case 3
• VS: T 37 HR 108 BP 105/60 RR 20 O2 sat 93% on RA
• Physical exam:
– Gen – actively having chest pain, diaphoretic
– Lungs – rales at bilateral bases
– Heart – tachycardic, nl s1/s2, no mumurs or rub
– Rest of the exam benign
• Labs: CBC wnl, RFP wnl, Troponin = 3.2, CKMB = 9, CK =
345
Case 3
 Case 3 - NSTEMI
• Risk stratification?
 Case 3 - NSTEMI
• Management of UA/NSTEMI
– Aspirin
• Inhibits platelet aggregation
– HR control with beta-blocker
• Titrate to goal HR ~ 60 beats/min
– Statin
– Nitroglycerin SL
• Use if patient having active chest pain
• DO NOT USE if patient is hypotensive and concern for RV infarct
 Case 3 - NSTEMI
• Management of UA/NSTEMI
– Plavix
• P2Y12 receptor blocker
• Inhibits platelet aggregation
– Anticoagulation
• Heparin/LMWH
– Inhibits thrombus formation

– Oxygen
• For O2 sat <90%
– Morphine
• For refractory chest pain, unrelieved by NTG SL
QUICK CASES
Case 4
 Case 4
• You find out the patient is having crushing
chest pain radiating to the back. His BP in the
R arm = 193/112 and in the L arm = 160/99

• What diagnosis is on top of your differential?

 Case 4 - Aortic Dissection
• Stanford Classification
– Type A – Involves ascending aorta
– Type B – Involves any other part of aorta
• Diagnostic Imaging
– CXR
– CT chest with contrast
– MRI chest
– TEE
 Case 4 - Aortic Dissection
• Management of Aortic Dissection
– Type A dissection – Surgical
– Type B dissection – Medical
• Mainstay of medical therapy
– Pain control
– HR and BP control
• Goal HR = 60 beats/min, goal SBP = 100-120 mmHg
• Use IV beta-blockers (i.e. Labetalol, Esmolol)
• Can also use Nitroprusside for BP control
• AVOID Hydralazine
 Case 5
• This is a 45 yro M with PMHx of rheumatoid
arthritis who presented with progressive sob.
He was found to have a R-sided pleural
effusion and underwent an US guided
thoracentesis with removal of 1.5 liters of
pleural fluid. Two hours after his procedure,
he develops new onset R-sided chest pain
Case 5
 Case 5 - Pneumothorax
• Management of Pneumothorax
– Supplemental O2 and observation in stable
patients for PTX < 3 cm in size
– Needle aspiration in stable patients for PTX >3 cm
– Chest tube placement if PTX >3 cm and if needle
aspiration fails
– Chest tube placement in unstable patients
 Case 6
• 37 yo woman w 6 months of recurring chest pain-many ER
visits.
• Average of one episode per week. Occurs mainly in
daytime. No trauma
• Burning, Crushing, substernal, radiates to both arms
• No odynophagia, dysphagia, nausea, vomiting or typical
heartburn sx.
• Obesity, HTN, Depression
• Hospitalized for chest pain 2 months ago -> cardiac cath.
• FHx: Father died of heart disease/ mother has HTN
• ROS: pos for SOB, palpitations, depression and anxiety.
Denies cough, wheezing, hemoptysis fever or chills.
 Case Cont
• BP 120/68 WT 236 lbs BMI 38 pulse 72
• HEENT: NCAT
• Lungs: CTAB, No rib tenderness.
• CV: RRR, S1 and S2. No rubs, murmurs or gallops.
• ABD: NABS, soft, Nontender, nondisted, no organomegaly
• Ext: No c/c/e. no joint abnormalities
• Skin: intact except for mild hirsutism.
• Neuro: AAOx3, nonfocal
 Case Cont
• BP 120/68 WT 236 lbs BMI 38 pulse 72
• HEENT: NCAT
• Lungs: CTAB, No rib tenderness.
• CV: RRR, S1 and S2. No rubs, murmurs or gallops.
• ABD: NABS, soft, Nontender, nondisted, no organomegaly
• Ext: No c/c/e. no joint abnormalities
• Skin: intact except for mild hirsutism.
• Neuro: AAOx3, nonfocal
 Next Step
What should be done next?
• Endoscopy
• Ambulatory pH monitoring
• Combined Impedance-pH testing
• Esophageal manometry
• Acid suppression therapy.