Untitled Quiz

Approach to Chest Pain

• Chest pain ranges from life-threatening to non-life-threatening conditions.
• Symptoms and their severity may not always correlate with the underlying pathology.
• Acute coronary syndrome (ACS), aortic dissection, pulmonary embolism (PE), pneumothorax, pericarditis with tamponade, and esophageal rupture are severe potential causes of chest pain.
• Atypical or unclear chest pain is a common presentation in emergency departments (EDs).

Introduction

• Chest pain can range from life-threatening to non-life-threatening diseases.
• Disassociation exists between the intensity of symptoms and the seriousness of the underlying pathology.
• Acute coronary syndrome (ACS), aortic dissection, pulmonary embolism (PE), pneumothorax, pericarditis, and esophageal rupture are potential catastrophic causes of chest pain.
• Atypical or unclear causes of chest pain are common presentations in the ED.

Differential Diagnoses of Chest Pain

• Table 22.1 provides a comprehensive list of critical and non-emergent diagnoses of chest pain categorized by organ system.
• Cardiovascular: Acute myocardial infarction (AMI), acute coronary ischemia, aortic dissection, cardiac tamponade, unstable angina, coronary spasm.
• Pulmonary: Tension pneumothorax, pulmonary embolism (PE), pneumothorax, mediastinitis, pleuritis.
• Gastrointestinal: Esophageal rupture (Boerhaave syndrome), esophageal tear (Mallory-Weiss), esophageal spasm, cholecystitis, pancreatitis.
• Musculoskeletal: Muscle strain, rib fracture, arthritis, costochondritis, nonspecific chest wall pain.
• Neurologic: Spinal root compression, thoracic outlet syndrome, herpes zoster, postherpetic neuralgia
• Other: Psychological, hyperventilation.

Pathophysiology

• Afferent fibers from the heart, lungs, large vessels, and esophagus connect to the same thoracic dorsal ganglia.
• Visceral fibers of these organs produce indistinct pain quality and location.
• Pain originating in the thorax can be felt anywhere from the jaw to the epigastrium.

Initial Assessment and Rapid Stabilization

• All patients, excluding those with obvious benign causes, undergo electrocardiography (ECG) as soon as possible after reporting chest pain.
• The clinician assesses the patient's appearance, ECG findings, and vital signs to determine if intervention is needed immediately.
• Patients with abnormal vital signs, or ECG findings of ischemia, injury, prior coronary artery disease, multiple atherosclerotic risk factors, new onset severe chest pain, or dyspnea should be placed in a treatment bed quickly
• The ECG should be interpreted for acute myocardial infarction (AMI) promptly by the emergency clinician after it is completed.
• Initiate cardiac monitoring and intravenous access.
• Treat immediate life needs (airway, breathing, circulation).
• Monitor vital signs frequently.
• Administer oxygen if the patient's oxygen saturation is <94%.
• Stable patients may have a focused history and physical exam, as well as a chest X-ray.
• Unstable patients should be stabilized first, then a diagnosis can be sought.

Significant Symptoms of Chest Pain

• Table 22.2 categorizes significant symptoms of chest pain based on their associated diagnoses.
• Pain Characteristics
• Associated Symptoms

Pivotal Findings in Physical Examination

• Table 22.3 details pivotal findings from the physical examination, associated with various diagnoses.
• Appearance, vital signs: such as tachycardia or bradycardia, hypotension or hypertension, fever, or hypoxemia are associated with particular diagnoses.

Ancillary Testing of Patients with Chest Pain

• Table 22.4 lists ancillary testing for various possible diagnoses of chest pain.
• ECG, chest X-ray, ABG, CT scan, bedside ultrasound as supporting tests.

Selected Common or Critical Causes of Chest Pain

• Summarizes common or critical reasons behind chest pain.

Acute Coronary Syndrome

• Classic presentation: Retrosternal, left anterior crushing, squeezing, tightness, or pressure, worsened by exertion, relieved by rest.
• Non-classic presentations differ in duration and location.
• Women and various other patient populations can present with atypical symptoms.

Major Risk Factors for Coronary Artery Disease

• Age, gender, hypertension, tobacco use, high cholesterol, diabetes, truncal obesity, family history, sedentary lifestyle.
• Cocaine use can accelerate atherosclerosis and contribute to severe coronary artery disease.

Examination of Patients with ACS

• Examination may be normal, with no findings specifically attributable to AMI
• Vital sign abnormalities may include hypertension, hypotension, tachycardia or bradycardia.

ECG Guidelines

• Guidelines recommend ECG within 10 minutes of ED arrival for chest pain patients.
• Quickly screening helps to rapidly identify STEMI.
• ST-segment elevation in at least two contiguous leads >1mm suggests AMI, requiring immediate reperfusion therapy.

ST-Segment Elevation

• ST-segment elevation can also occur in patients with pericarditis, myocarditis, early repolarization, left ventricular hypertrophy, ventricular aneurysms, or left bundle branch block.
• A normal ECG does not rule out conditions like acute coronary syndrome (ACS).
• Repeated ECGs at 15-30 minute intervals should be compared to prior ECGs for dynamic considerations.
• Specific ECG findings correlate with different locations of myocardial infarction (MI): such as anteroseptal, anterior, anterolateral, lateral, inferior, inferolateral, posterior, and right ventricular.

Cardiac Troponins

• cTn are proteins essential to cardiac muscle contraction.
• Myocardial injury releases cTn into the blood, quantifying damage

Recent Developments in cTn Testing

• High-sensitivity troponin assays are extremely sensitive for detecting AMI.
• Serial cTn measurements are essential to exclude AMI in patients presenting with chest pain.
• Patients with prolonged symptoms and low risk factors may have a single cTn measurement sufficient to exclude AMI.

ACS Management

• Immediate reperfusion therapy is crucial for ST-elevation myocardial infarction (STEMI).
• Percutaneous coronary intervention (PCI) or thrombolysis within 90 minutes is recommended.
• Antiplatelets, anticoagulants, and nitrates may be administered.

Pulmonary Embolism (PE)

• Symptoms may include sharp chest pain (worsened by breathing), dyspnea, hypoxia, syncope, or shock.
• PE risk factors associated with surgery, immobility, pregnancy, estrogen use, active cancer.
• Physical exam findings are not specific to PE and may be unreliable.
• Clinical decision aids, like the Wells and Revised Geneva Scores, stratify risk for PE.
• Pulmonary Embolism Rule-Out Criteria (PERC rule) can exclude PE in low-risk patients.

Aortic Dissection

• Aortic dissection is characterized by tearing pain radiating between scapulae.
• Symptoms may include secondary symptoms like stroke, AMI, or limb ischemia due to branch occlusions.
• Focal neurologic deficits are rare but increase likelihood of dissection.
• A chest radiograph may show a wide mediastinum but is not definitive.

Pneumonia

• Pneumonia can be life-threatening in high-risk patients (elderly, immunocompromised).
• Symptoms include sharp, pleuritic chest pain, fever, cough, sputum, dyspnea, and hypoxia.
• Auscultation may reveal reduced breath sounds, rales, or bronchial breath sounds over affected areas.
• Chest X-ray confirms diagnosis.

Esophageal Rupture (Boerhaave's Syndrome)

• Usually associated with forceful vomiting.
• Symptoms include sudden onset, sharp substernal pain that may radiate, dyspnea, and tachycardia.
• Physical exam may reveal crepitus (subcutaneous emphysema).
• Chest X-ray may show pleural effusion or pneumomediastinum but not always conclusive.
• CT scan with water-soluble contrast is often necessary.

Spontaneous Pneumothorax

• Characterized by sudden onset, sharp pleuritic chest pain, and dyspnea.
• Typically occurs in tall, slender males, with risk factors including smoking, and lung diseases.
• Auscultation may show reduced breath sounds and hyperresonance.

Tension Pneumothorax

• Clinical diagnosis characterized by vital signs instability and decreased air entry on the affected side.
• Chest radiography is contraindicated in this case; bedside ultrasound may be used instead
• Rapid decompression is crucial, and definitive treatment depends on the cause of the pneumothorax.
• Treatment may include oxygen, analgesia, and a tube thoracostomy.

Acute Pericarditis

• Characterized by sharp, severe, constant chest pain, radiating to the back, neck or shoulders, worsened by laying flat.
• Pericardial friction rub is a key finding
• Classic ECG changes may include diffuse ST elevation with PR depression.
• Treatment varies and may include NSAIDs, corticosteroids, and colchicine, also consideration of pericardial effusion.

Cardiac Tamponade

• Occurs due to pericardial fluid accumulation, compressing the heart.
• Causes include malignancy, uremia, pericarditis, autoimmune diseases, aortic dissection, or post-cardiac surgery.
• Clinically, patients often present with Beck's triad (hypotension, JVD, muffled heart sounds) and/or tachycardia, pulsus paradoxus, dyspnea, and/or pain.
• Key diagnostic tool is echocardiography; rapid pericardiocentesis may be required;
• Underlying cause must be addressed.

Chest Wall Pain

• Pain is sharp, focal, reproducible by palpation, often positional, worsened by breathing, or coughing.
• Causes include musculoskeletal conditions such as costochondritis, and xiphodynia.
• Pleurisy can also manifest with sharp, pleuritic chest pain.

Gastrointestinal (GI) Pain

• Often cannot be definitively differentiated from other causes by history and physical alone.
• Includes various conditions like gastritis, esophageal reflux, peptic ulcer disease, and pancreatitis.
• Symptoms may include burning, gnawing discomfort, metallic taste, or epigastric tenderness.
• Directed history and a gastrointestinal specialist consultation may be needed.

Panic Disorder

• Characterized by recurrent, intense fear or discomfort (panic attacks), often accompanying other physical symptoms (chest pain, dyspnea).