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Questions and Answers

What criteria indicate an AMI that would benefit from rapid reperfusion interventions?

T wave inversions in multiple leads

Normal ST-segment morphology

New ST-segment elevation of ≥1 mm in at least two contiguous leads (correct)

Hyperacute T waves in one lead

Which of the following conditions represents occlusive myocardial infarction (OMI)?

ST depression

New onset bundle branch block (correct)

Early repolarization

Myocarditis

What can lead to a misinterpretation of ECG results in the context of acute myocardial infarction (AMI)?

Normal ECG findings

Presence of ST elevation in all patients

Repeated ECGs showing identical results

Failure to detect existing ischemic changes (correct)

What is a common characteristic of non-occlusive myocardial infarction (NOMI)?

ST depression and T wave inversions Signup and view all the answers

Why is the initial ECG insufficient to exclude acute coronary syndrome (ACS)?

It represents only a single time point in a dynamic process Signup and view all the answers

What physiological response may myocardial ischemia enhance in patients presenting with new palpitations?

Automaticity and irritability Signup and view all the answers

Which of the following is NOT a major risk factor for coronary artery disease?

Frequent exercise Signup and view all the answers

How does chronic cocaine use affect coronary artery disease?

It accelerates atherosclerosis Signup and view all the answers

Why are cardiac risk factors less useful for diagnosing ACS in an individual patient?

They are not specific enough Signup and view all the answers

What examination finding may suggest the presence of acute myocardial ischemia?

Abnormal heart sounds Signup and view all the answers

What does the presence of crackles on lung auscultation indicate in a patient with ischemia?

Ischemia-induced congestive heart failure Signup and view all the answers

What is the recommended timeframe for performing an ECG upon ED arrival in patients with symptoms concerning for ACS?

Within 10 minutes Signup and view all the answers

Which symptom might reproducible chest wall tenderness suggest?

Musculoskeletal etiology Signup and view all the answers

What is the significance of electrocardiography (ECG) in the assessment of chest pain?

It should be performed as soon as possible for almost all patients. Signup and view all the answers

Which of the following conditions is NOT mentioned as a potentially catastrophic cause of chest pain?

Fractured ribs Signup and view all the answers

What factors determine whether immediate intervention is necessary for a patient with chest pain?

Assessment of the patient's appearance, ECG, and vital signs. Signup and view all the answers

What immediate measures should be taken in the assessment of a patient with chest pain?

Initiate cardiac monitoring and establish IV access. Signup and view all the answers

Which of the following best describes the pathophysiology behind chest pain originating from thoracic organs?

Afferent fibers from thoracic organs converge in the same dorsal ganglia, causing overlapping pain signals. Signup and view all the answers

What is the recommended action for patients with abnormal vital signs and suspected acute coronary events?

Quickly transfer them to a treatment bed. Signup and view all the answers

In which cases should oxygen be administered to patients presenting with chest pain?

If ambient saturation is low or if they have known coronary artery disease. Signup and view all the answers

Which symptom is crucial for quickly identifying acute coronary syndrome in chest pain patients?

Any abrupt, new, or severe chest pain or dyspnea. Signup and view all the answers

What is the sensitivity of high-sensitivity cTn assays for acute myocardial infarction (AMI) when used within 3 hours of chest pain onset?

92% to 94% Signup and view all the answers

In what circumstance may AMI be safely excluded with a single cTn measurement?

In select, low-risk patients with constant symptoms for more than 6 to 12 hours Signup and view all the answers

What is the initial requirement for patients diagnosed with ST-Elevation Myocardial Infarction (STEMI)?

Immediate reperfusion therapy Signup and view all the answers

Which treatment is NOT recommended for patients in shock who have ST-Depression or T-wave Inversion (NSTEMI/Unstable Angina)?

Nitrates Signup and view all the answers

Which of the following is a key component of medical therapy for NSTEMI/Unstable Angina?

Antiplatelets Signup and view all the answers

What is the role of serum markers in patients with non-diagnostic ECGs?

They're helpful for NSTEMI diagnosis and risk stratification Signup and view all the answers

What percentage of patients with AMI can be identified using a single fourth-generation cTn assay within 2 to 3 hours of emergency department arrival?

Approximately 80% Signup and view all the answers

What is the recommended action for patients with diagnostic ST-segment elevation on their initial ECG?

Treatment and disposition decisions can be made without serum markers Signup and view all the answers

Which symptom is commonly associated with pulmonary embolism (PE)?

Sharp chest pain Signup and view all the answers

What is the preferred hospital unit for patients requiring close monitoring for pulmonary embolism?

Cardiac care unit (CCU) or intensive care unit (ICU) Signup and view all the answers

Which test is considered the most sensitive for detecting large to medium-sized pulmonary embolisms?

CT pulmonary angiography Signup and view all the answers

What does a normal d-dimer test indicate in a hemodynamically stable patient?

Exclusion of pulmonary embolism Signup and view all the answers

Which common physical examination finding may be observed in patients with pulmonary embolism?

Hypoxemia Signup and view all the answers

Which risk factor is associated with an increased likelihood of developing pulmonary embolism?

Recent surgery Signup and view all the answers

What electrocardiogram (ECG) finding is commonly seen in pulmonary embolism?

Sinus tachycardia Signup and view all the answers

Which statement is true regarding the use of clinical decision aids for pulmonary embolism?

They can risk-stratify patients with possible pulmonary embolism. Signup and view all the answers

What symptom is commonly associated with gastritis and esophageal reflux?

Burning sensation in the lower chest Signup and view all the answers

What type of ulcer pain is often exacerbated by eating?

Gastric ulcer pain Signup and view all the answers

Which of the following symptoms is NOT associated with panic disorder?

Tight substernal chest pain Signup and view all the answers

What is a characteristic feature of duodenal ulcer pain?

It can be relieved after eating. Signup and view all the answers

What percentage of patients with chest pain in the ED met the diagnostic criteria for panic disorder in a study?

25% Signup and view all the answers

What factor can precipitate esophageal spasm?

Drinking cold liquids Signup and view all the answers

In patients identified with panic disorder, what percentage were ultimately diagnosed with acute coronary syndrome (ACS)?

9% Signup and view all the answers

What is the recommended approach for treating a patient with suspected panic disorder?

Diagnosis of exclusion considering other causes Signup and view all the answers

Study Notes

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).

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