Chest Pain Lecture Flashcards
Where does visceral pain come from?
Heart, blood vessels, esophagus, and visceral pleura
What does visceral pain feel like?
Difficult to describe and localize
* Discomfort
* Heaviness
* Pressure
* Tightness
* Aching
Pain may radiate
Where does somatic pain come from?
Chest wall, from dermis to the parietal pleura
How would someone describe somatic pain?
- Easily described and precisely located
- Sharp
- Stabbing
- Scratchy
- Without radiation
What are red flags that require immediate evaluation for chest pain?
- Abnormal vital signs
- Concerning EKG findings
- Hx prior CAD
- Multiple ASCVD risk factors: advanced age, HTN, tobacco use, HLD, DM, obesity, family history, ASCVD, sedentary lifestyle
- Abrupt onset, new, or severe chest pain or dyspnea
What is initial management of chest pain?
- Place in treatment bed quickly
- Cardiac monitoring and IV access (2 large bore)
- EKG (within 10 minutes)
- Measure vital signs, then resuscitate as needed, following the ABCs
- Administer supplemental oxygen if O2 saturation at rest is <95%
What are life-threatening conditions that should be ruled out with a chief complaint of chest pain?
- ACS
- Aortic dissection
- PE
- Severe PNA
- Tension pneumothorax
- Esophageal rupture
What physical exam components should be included in the exam for chest pain?
- Chest
- CV
- Lungs
- Pulses
If a patient has visceral pain, what conditions should be considered?
- Typical angina
*** Unstable angina - Acute myocardial infarction
- Aortic dissection
- Esophageal rupture**
- Esophageal reflux or spasm
- Mitral valve prolapse
If a patient has pleuritic chest pain, what conditions should be considered?
- **Pulmonary embolism
- Pneumonia
- Spontaneous pneumothorax**
- Pericarditis
- Pleurisy
If a patient has chest wall pain, what conditions should be considered
often reproducible pain
- Costochondritis
- Precordial catch syndrome
- Xiphodynia
- Radicular syndromes
- Intercostal nerve syndromes
- Fibromyalgia
How would a patient having ACS present?
- Retrosternal, L chest, or epigastric
- Crushing, tightness, squeezing, pressure
- Radiates to R or L shoulder, R or L arm/hand, jaw
- Associated with dyspnea, diaphoresis, nausea
How would a patient with a PE present?
- Focal chest
- Pleuritic pain
- No radiation
- Tachycardia, tachypnea, hypoxia, may have hemoptysis
How would a patient with aortic dissection present?
- Midline, substernal pain location
- Ripping, tearing
- Intrascapular area of back
- Associated secondary arterial branch occlusion
How would a patient with pneumonia describe their pain?
- Focal chest
- Sharp pleuritic
- No radiation
- Associated with fever, hypoxia, may see signs of sepsis
How would a patient with esophageal rupture present?
- Substernal pain
- Sudden, sharp, after forceful vomiting
- Radiates to back
- Associated symptoms of dyspnea, diaphoresis, may see sepsis
How would a patient with pneumothorax present?
- One side of chest
- Sudden, sharp, lancinating, pleuritic
- Shoulder, back radiation
- Associated signs and symptoms: dyspnea
What is the presentation of a patient with pericarditis
- Substernal
- Sharp, constant, or pleuritic character
- Radiation to back, neck, shoulder
- Associated with fever, pericardial friction rub
What is the presentation of a patient with a perforated peptic ulcer?
- Epigastric
- Severe, sharp pain
- Radiation back, up into chest
- Acute distress, diaphoresis
How should a EKG be used to characterize chest pain?
- Cannot exclude ACS or other life-threatening causes
- Compare to previous EKGs if available
- Repeat in 15-30 mins if initially normal
- Repeat any time reoccurs or worsens
In which patients should cardiac enzymes be obtained?
- All patients with suspected ACS
Which cardiac enzyme would you order for suspected ACS?
- Generally troponin, but elevates in 4 hours and peaks in 24-48 hours and remains elevated
- CK-MB only if troponin unavailable or patient had MI in last few days, normalizes in 48-72 hours
If you are suspecting pneumonia, pneumothorax, which diagnostic studies would be ordered?
- Chest X-ray –> non-contrast CT
If you suspect a aortic aneurysm/dissection or PE, what is the best imaging study?
- Chest CTA
What conditions can an emergent echo be helpful in?
- Aortic dissection
- Cardiac tamponade
- New regurgitant murmur
What tests may be helpful other than cxr, ecg, cta, and echo?
- CBC
- BMP or CMP (electrolytes could cause issues and may need to check liver/kidney function for med)
- PT/PTT
- ABG
- Type and crossmatch
- Hcg in women of childbearing age
When would you admit a patient with chest pain?
- Positive cardiac enzymes
- New concerning EKG changes
- Persistent pain
- Concerning physical exam findings
If a patient has a negative EKG, cardiac enzymes, and CXR, what should you do?
- Consider other life-threatening causes
- If everything else rules out and is pain free, okay to discharge
If a patient has a score of 0-3 on the HEART score, what should their disposition be?
2.5% MACE over next 6 weeks, discharge home
If a patient has a HEART score of 4-6, what should their disposition be?
20.3% MACE over next 6 weeks –> admit for clinical observation
If a patient has a HEART score of 7-10, what should their disposition be?
- 72.7% MACE over next 6 weeks –> early invasive strategies
What is a hypertensive crisis?
- SBP >180 mmHg and/or DBP >120 mmHg in both arms multiple times
What are the 2 types of hypertensive crisis?
- Hypertensive urgency- no evidence of end-organ damage
- Hypertensive emergency- evidence of end-organ damage (brain, heart, aorta, kidneys, eyes)
What are conditions caused by hypertensive emergency?
- Brain: hypertensive encephalopathy, SAH, ICH, ischemic CVA
- Heart: acute pulmonary edema, MI, ACS
- Aorta: aortic dissection
- Kidney: acute renal failure
- Eyes: hypertensive retinopathy
- Multiorgan: preeclampsia, eclampsia, acute perioperative HTN, sympathetic crisis
What are signs of end-organ damage?
- Mental status changes, neurologic dysfunction, seizure, acute severe HA
- Visual changes, retinopathy, papilledema
- Sudden onset chest pain
- Dyspnea
- Peripheral edema
- Oliguria
What are labs for hypertensive crisis?
looking for end-organ damage
- BMP: acute elevation of serum creatinine
- UA: proteinuria, red blood cells, or red cell casts
What are imaging/diagnostics for hypertensive crisis?
- Chest X-ray (pulmonary edema or thoracic aortic dissection)
- ECG (cardiac ischemia)
- CT head without contrast (neurologic changes/CVA_
*CTA chest (chest pain/aortic dissection)
How is hypertensive urgency managed?
- BP control within 24-48 hours
- If no hx of HTN: HCTZ
- If hx of HTN: reinstitution or intensification of oral antihypertensive therapy
- Discharged home with rapid follow-up with PCP (within 48 hours)
hypertensiveurgenz (HCTZ)
How is hypertensive emergency managed?
- Rapid, controlled reduction in BP using IV antihypertensives. Reduce SBP by no more than 25% in first hour (aortic dissections, acute ischemic strokes, intracerebral hemorrhage are exceptions)
- If stable, reduce to 160/100 mmHg over next 2-6 hours
- If stability remains, reduce to normal over following 24-48 hour
- Drug of choice tailored to system showing end-organ damage
- Admit to CCU or ICU
What can rapid reduction of BP in hypertensive crisis cause?
Watershed cerebral infarction
A patient has hypertensive emergency leading to a stroke. What drugs would you consider?
- Ischemic stroke: nicardipine
- Stroke: labetolol or enalaprilat
ischemia no flow nicardipine
la la stroke (labetolol, enalaprilat)
A patient has a SAH related to hypertensive emergency. What antihypertensive would you give?
- Nicardipine
subno
A patient has a aortic dissection due to hypertensive emergency. What antihypertensive would be given?
Labetolol or esmolol
the aorta cheated on beta with esmo
A patient has renal insufficiency or failure due to hypertensive emergency. What antihypertensive should be used?
- Fenoldopam
old kidneys
A patient is experiencing CHF due to hypertensive emergency. What medication should be used?
- Enalaprilat
end HF (enalaprilat)
A patient is pregnant with hypertensive emergency. What antihypertensive should be given?
- Hydralazine
amnioticfluid - hydra
What should you be aware of when prescribing nicardipine for hypertensive emergency?
May precipitate myocardial ischemia
Tear or rupture in distal 1/3 of esophagus resulting in pneumomediastinum
Esophageal rupture
What is the etiology of esophageal rupture?
- Forceful vomiting/coughing (MC)
- Blunt and penetrating chest trauma
- Iatrogenic (endoscopy)
- Foreign body ingestion
- Caustic substance ingestion
- Complications of esophageal cancer
Where do almost all esophageal ruptures occur?
- Left posterolateral wall of distal esophagus
What is the clinical presentation of esophageal rupture?
- Sudden onset substernal chest pain following episode of forceful vomiting
- Pain may radiate into neck or abdomen
- Worsened by neck flexion, breathing, and swallowing
What are associated signs and symptoms of esophageal rupture?
- Fever, diaphoresis
- Dyspnea
- Tachycardia
- Subcutaneous emphysema (palpable and audible Hamman’s crunch)
- rapid development of sepsis
What imaging can be used to show esophageal rupture?
- CXR: may be normal initially, may show pneumomediastinum, pneumoperitoneum, pneumothorax; pleural effusion
- Contrast esophagram: water-soluble contrast, extravasation of contrast into mediastinum and pleural space
- CT with IV contrast chest
How is esophageal rupture managed?
- Stabilize air way
- NPO, IV fluids
- Broad spectrum IV antibiotics
- NG or OG tube placement
- Consult surgery
NG or OG tube prevents saliva and gastric content contamination
What broad spectrum antibiotics are used for esophageal rupture?
- First line: ampicillin/sulbactam (Unasyn) or pip/taz (Zosyn)
- Beta-lactam allergy: clindamycin + ciprofloxacin
one esophagus (unasyn or zosyn)
Accumulation of fluid within the pericardial space that affects the normal filling pressures of the right heart chambers
Cardiac tamponade
What causes death with cardiac tamponade?
- Diastolic dysfunction –> reduced cardiac output –> shock –> death
What impacts the rate of development of diastolic dysfunction with cardiac tamponade?
- Rate of fluid accumulation
- Pericardial compliance
- Intravascular volume (hypovolemia lowers ventricular filling pressure)
What is the clinical presentation of cardiac tamponade?
- Dyspnea at rest and with exertion
- Tachycardia
- Hypotension with a narrow pulse pressure, usually due to a drop in SBP
- Pulsus paradoxus
- Jugular venous distention
- Distant heart sounds on auscultation
What is pulsus paradoxus?
- Drop of SBP by >10-20 mHg during inspiration
- Often palpable in radial, brachial, or femoral pulses as weakening or disappearance of pulse during inspiration
How is cardiac tamponade diagnosed?
- Transthoracic echo (most sensitive and specific)
- ECG: low voltage, electrical alternans, signs of underlying disease (ie ST segment elevation in pericarditis
- CXR: may be normal or show enlarged cardiac silhouette
How is cardiac tamponade managed?
- Resuscitation with oxygen, large bore IV fluids to maintain pressure, continuous EKG monitoring, BP monitoring q 5-15 minutes
- Emergency pericardiocentesis if signs of decompensation
- Urgent consult to cardiology and cardiothoracic surgery for pericardiocentesis
Characteristics of ACS
- Chest pain or discomfort with radiation to arm, neck, or jaw
Precipitating factors of ACS
- Exercise
- Stress
- a Cold
Timing of ACS
- Duration <10 minutes, occasionally up to 10-20 mins
- Usually improves within 2-5 mins after rest or with nitro
Associated symptoms with ACS
- Nausea
- Vomiting
- Abdominal bloating
- Diaphoresis
- Dyspnea
- Lightheadedness
- Dizziness
- Syncope
- Anxiety
- Restlessness
- Palpitations
Pops with atypical presentation of ACS
- Female
- Elderly
- Diabetic
PE for ACS
- Well appearing to uncomfortable, pale, cyanotic, in respiratory distress
Complications –> abnormal PE
* Cardiac muscle ischemia can lead to heart failure or shock
* Ventricular aneurysm or rupture
* Arrhythmias if conducting tissues affected
* Infarcted endocardium attracts clots –> PE or CVA
* Left wall non-compliance –> S3 (overly dilated LV) or S4 (non-compliant LV)
Diagnostics for STEMI
- STEMI: new or presumed new ST elevation of >1 mm in 2 anatomically contiguous leads
- Exception in V2 and V3 where >2 mm must be seen in men and >.15-1.5 mm in women
- New LBBB
- Troponin rise in 2-6 hours with peak at 12-24
- CBC, BMP, PT/PTT
Diagnostics for NSTEMI
- New or presumed new horizontal or down sloping ST depression >.5 mm in two anatomically contiguous leads AND/or T wave inversion >.11 mm in two anatomically contiguous leads with prominent R wave or R/S ratio >1
- Troponin elevation
- CBC, BMP, PT/PTT
Initial management for all ACS
- Cardiac monitoring
- IV line (2 large bore)
- Oxygen if <94%
- ASA 160-325 chewed, alt clopidogrel for true ASA allergy
- NTG .4 mg SL or one spray if active chest pain repeat if no effect in 5 mins
- Morphine if pain not relieved with NTG
- B-blocker and statin therapy started within 24 hours
- IV NTG, IV clevidipine, nicardipine, metoprolol, or esmolol if BP elevated despite SL NTG
MOA of NTG
Reduces left ventricular after load through arterial dilation as well as preload through venous dilation
What should you do if chest pain returns or continues and SBP >100 after nitro SL
IV NTG at 10 ug/min and increase by 5 ug/min every 3-5 mins until SBP falls by 10% or chest pain is relieved keep SBP above 90
CIs to NTG
- Severe aortic stenosis
- HCM
- Suspected right ventricular infarct (inferior STEMI with elevation in V1)
- Hypotension (SBP <90 or >30 mmHg below baseline)
- Bradycardia or tachycardia
- PDE5 inhibitor in last 24 hrs
Why would you consider B-blocker and statin in ED?
Refractory hypertension or ongoing ischemia
Cardioselective preferred: metoprolol or atenolol
CI to B blcoker and statin therapy for ACS
- CHF
- Bradycardia
- Conduction blocks
- Hypotension
Characteristics of unstable angina
One of the following:
* Began in last 2 months
* Increasing frequency, intensity, or duration
* Existing angina occurring at rest
Management of unstable angina and NSTEMI
- Initial as above
- Deterine management strategy (consult cardiology):
- Early invasive: coronary angiography with PCI vss CABG
- COnservative: medical therapy only
Dual antiplatelet therapy for all patients: ASA for all, P2Y12 inhibitor (discuss preference with cardiologist): either clopidogrel, ticagrelor, or prasugrel
- Anticoagulant therapy UFH if invasive approach chosen
- LMWH if conservative approach
STEMI management
- Reperfusion with PCI or fibrinolytic
- Antiplatelet therapy
- Anticoagulant therapy
Goal of PCI reperfusion
- 90 minutes if at PCI facility
- 120 mins if non-PCI facility
- Door to departure time <30 mins if non-PCI facility
Indications for fibrinolytics vs PCI for STEMI
- Unable to get to PCI within 120 mins of first medical contact with symptoms that have been present <12 hours
- Goal door to needle time <30 mins
Fibrinolytic agents for STEMI
tPA, rPA, and TNK
Disposition of STEMI management
PCI-go to cath lab from ER
All receiving fibrinolytic therapy must be admitted to ICU ASAP
Chest pain Pattern of discomfort, frequency of occurence, and precipitating factors have remained the same for 3 + months
Stable angina
How long does pain in stable angina usually last?
1-15 mins relieved by NTG
Tx of stable angina
NTG .4 mg SL at onset of pain
Usually improvement within 1-2 mins
If no improvement after 5 mins call 911 repeat dose every 5 mins with max of 3 doses
Chest discomfort in absence of precipitating event occurring at rest or waking patient up at night. Often associated with transient ST segment elevation or depression that is reversed after NTG
Vasospastic or Prinzmetal angina
Treatment of Vasospastic or Prinzmetal angina
Nitroglycerin .4 mg SL
Intima of aorta tears and blood goes between intima and adventitia
aortic dissection
90% of all aortic dissections occur where?
- Right lateral wall of proximal ascending aorta
Risk factors for aortic dissection
- Male sex
- Age over 50
- Poorly controlled hypertension
- Cocaine or amphetamine use
- Bicuspid aortic valve or prior aortic valve replacement
- Certain connective tissue disorders (marfan’s syndrome and ehlers-danlos syndrome)
- Pregnancy
Clinical presentation of aortic dissection
- Lack of classical presentation, typical symptoms less likely in patients >70 (1/3 of all cases)
- Sudden severe pain in chest MC with stanford type A and back pain with stanford type B often a combo of both
- Radiation into abdomen in <50% patients
- Sharp, ripping or tearing, rarely migrating
- Secondary symptoms d/t arterial branch occlusions: neurologic symptoms, syncope, SOB, limb ischemic pain
PE for aortic dissection
- BP hypotensive to normotensive to hypertensive
- May have unilateral pulse deficit carotid, radial, or femoral arteries; most frequently in young patients and males, less frequently in >70 and females
- If aortic regurgitation: diastolic murmur
- Cardiac tamponade
Aortic regurgitation presentation with dissection
MC in patients <70 yo
Soft, high pitched, early diastolic decrescendo murmur heard best at 3rd intercostal space on left (Erb’s point) on end expiration with patient sitting up and leaning forward
How is ADDRS used?
- Review each high risk category and assign score 0-3
- Score of 0-1 order d-dimer, if d-dimer >500 ng/mL, order CTA
- Score 2-3 skip d-dimer and order CTA
Diagnostics for aortic dissection
- CXR: widening of mediastinum
- EKG: may be normal, non-specific ST degment or T-wave changes, ischemic changes
- D-Dimer <500 ng/mL 97% sensitivity that dissection not present, but many conditions can increase dimer levels
- CT angiogram/aortogram preferred: requires IV contrast
- TEE: highly sensitive and specific but limited by sedation, experience echocardiographer and cardiology to interpret
Management of aortic dissection
- Resuscitate as needed
- Reduce BP and HR with B blocker: esmolol or labetolol with goal HR 60 bpm and SBP 120-130
- Pain control: fentanyl
- Emergent consult with vascular surgery
- Disposition: if not taken directly to OR per surgeon decision admit to ICU
What should you monitor for with beta blocker use in aortic dissection
end organ hypoperfusion
b blocker prevents extension of dissection
What would be used if BP not controlled with B-blocker
- IV nicardipine, clevidipine, nitroglycerin, or nitroprusside
Etiology of pericarditis
- Viral
- Post-cardiac injury
- Radiation
- Drugs/toxin
- Malignant
- Idiopathic
Clinical presentation of pericarditis
- Sharp, sever, constant pain with substernal location
- Sudden or gradual onset
- Radiation to back, neck, or shoulders
- Worsened by lying flat and by inspiration and relieved by sitting up and leaning forward
- Associated symptoms: fever, dyspnea due to accentuated pain with inspiration, dysphagia from irritation of esophagus by posterior pericardium
- Pericardial friction rub
Diagnostics for pericarditis
- EKG: diffuse ST segment elevation with PR depression and ST segment depression in aVR, ST elevation d/t inflammation of epimyocardium
- CXR: differentiate left heart failure from pericardial effusion
- TTE: normal unless pericardial effusion
- Labs: make diagnosis and look for complications –> CBC, BMP, ESR, CRP, troponin, BNP
Management of pericarditis
- Stable patients with idiopathic or viral pericarditis may be discharged home
- Physical ativity restriction until all symptoms resolve
- First line- NSAID: ibuprofen for 7-10 days
- Colchicine added to NSAID if hx recurrent pericarditis
- Follow up with PCP or cardiology in 3-5 days
Indications for admission of pericarditis (still treat with NSAID)
- Temperature >38 C (100.4)
- Subacute onset over weeks
- Immunosuppression
- History of oral anticoagulant use
- Associated myocarditis (elevated cardiac biomarkers, symptoms of heart failure)
- Failure to respond to therapy with NSAIDs after 1 week of therapy
- Large pericardial effusion (echo-free space >20 mm)
- Cardiac tamponade
- Uremic pericarditis (renal failure)
- Hemodynamic compromise
