Chest Pain: ED Overview & Risk Factors

Overview of Chest Pain in the ED

• Chest pain is the second most common complaint in the ED, with abdominal pain being the first
• Approximately 5% of all ED visits are for chest pain
• Over 50% of chest pain patients require admission to the hospital or observation units
• Only about 10% of these admissions are due to acute coronary syndrome (ACS)
• About 2% of myocardial infarctions (MIs) are initially missed during presentation
• Differential diagnoses for chest pain range from benign conditions to life-threatening ones that can cause death within an hour
• Severity of chest pain is not directly correlated with the severity of the underlying disease, meaning a patient with mild pain can still be experiencing an MI
• Topics covered include atraumatic chest pain and the "BIG 7" diagnoses: ACS/MI, PE, aortic dissection, esophageal rupture, tension pneumothorax, cardiac tamponade, and pneumonia

Initial Approach and Risk Factors

• Initial assessment involves determining if the patient is sick or not sick
• Key considerations: hypoxia/hypoxemia, abnormal vital signs, EKG findings, prior MI history
• High-risk indicators include multiple risk factors and abrupt, severe chest pain

Immediate Actions for Sick Patients

• Resuscitation should occur simultaneously with evaluation, following the ABCs (Airway, Breathing, Circulation)
• Intravenous access, oxygen administration, and cardiac monitoring should be initiated

Potential Interventions

• Fluid administration
• Vasopressors use
• Advanced Cardiac Life Support (ACLS) protocols

History and Risk Factors

DERV

• Diaphoresis (LR 1.5)
• Exertional (LR 2.81)
• Radiation
  • Right arm (LR 2.31, higher than left)
  • Both arms (LR 2.58)
  • Left arm (LR 1.36)
• Vomiting (LR 0.89 for nausea or vomiting)

Somatic vs. Visceral Nerve Fibers

Somatic Nerve Fibers

• Innervate the chest wall from the dermis to the parietal pleura and correlate with dermatomes
• Pain is easily described and well-localized
  • Patients can often point to the specific location with one finger
  • Pain quality is often described as "sharp"
• Examples: costochondritis or dermatomal diseases like shingles

Visceral Nerve Fibers

• Enter the spinal cord at various levels, mapping to parietal cortex levels shared with somatic fibers
• Pain is difficult to describe and hard to pinpoint, often radiating to adjacent areas
• Quality described as discomfort, heaviness, pressure, tightness, or achiness
• More concerning for conditions like ACS/MI, dissection, esophageal rupture, GERD, or esophageal spasm

Pain Descriptors and Associated Conditions

• Anginal/Crushing: Likelihood Ratio (LR) of 1.52, shares etymology with words like strangle, angst, anger, anguish, and anxious
• Ripping or Tearing: highly indicative of dissection.
• Pleuritic: Pain that worsens with deep breaths or chest movement, consider PE, rib fractures, pneumothorax, hemothorax, pericarditis, or pneumonia
• Reproducible: Pain that worsens when touched, suggests musculoskeletal causes like costochondritis, but does not rule out MI
• Burning: Suggests GERD or shingles
• Sharp (somatic): While generally indicative of somatic pain, 22% of MI patients may describe their pain as sharp

Risk Factors and Atypical Presentations

• Reports indicate 22% of MI patients describe their pain as "sharp”, takeaway point is the symptom does not exclude MI
• Maximal pain at onset: Raises suspicion for dissection
• "This feels like my last heart attack" : LR 3.35
• Paucity of risk factors: should not rule out potential diagnoses
• Risk factors for chest pain diagnoses: age >40, CKD, HTN, DM, tobacco use, hyperlipidemia, obesity, cocaine use, and HIV

Historical Risk Factors

• Medications for related conditions
• Exogenous estrogen
• Chemotherapy

Typical vs. Atypical Presentations

• Rejecting "typical" versus "atypical" characterizations, and instead focus on classic and nonclassic ACS presentations
• Classic ACS: exertional, anginal, retrosternal pain lasting longer than 30 minutes coupled with radiation to the arm/neck/jaw, vomiting, nausea, and diaphoresis (DERV)
• Nonclassic ACS: Any other presentation

ACS in Pre- and Perimenopausal Women

• Often presents without exertion, isn't relieved with nitro or rest, but has relief with antacids
• Common chief complaints include fatigue rather than chest pain palpitations with associated symptoms like nausea, emesis, jaw pain, and neck or back pain

Vital Signs and Physical Exam Findings

• Tachycardia: Can result from shock, pain, infection or compensation
• Tachypnea: Can be related to pain, compensation for poor gas exchange, anxiety, or anemia
• Hypotension: May be due to pump or pipe issues
• Hypertension: Can be chronic or caused by pain or compensation
• Fever: Can be indicative of infection, or PE
• Hypoxemia: Suggests PE, pneumothorax, or pneumonia
• Normal Pulse Ox: Carbon monoxide poisoning

General Observations

• Assess if the patient appears sick or not sick
• Evaluate skin color for pallor or jaundice
• Check for diaphoresis

HEENT

• Check blood in mouth (hemoptysis or hematemesis?)

Neck

• Check for jugular venous distension

Chest Wall Examination

• Look for shingles
• Check for tenderness to palpation, up to 15% of MI have chest wall tenderness
• Heart auscultation
  • S3 gallop suggests MI
  • Friction rub suggests pericarditis
  • Distant sounds suggest tamponade
• Lung auscultation -Inspiratory crepitus suggests esophageal rupture -Crackles suggest pneumonia or CHF
• Abdominal assessment
  • Check for distension
• Examination of limbs -Look for unilateral or bilateral edema

Initial Workup and Differential Diagnosis

• Establish IV access, administer oxygen, and monitor vital signs
• Consider MONA (Morphine, Oxygen, Nitro, Aspirin)
  • This is a guideline, not a rigid rule
  • Aspirin can be life-saving

Recurring Discussion of "Big 7" Diagnoses

• ACS/MI: Classic presentation with chest pain
• PE: Consider with tachycardia and hypoxia without other explanation
• Aortic Dissection: Suspect if chest pain is accompanied by other symptoms

Diagnostic Considerations

• Esophageal Rupture: Covered in detail below
• Tension Pneumothorax: Presents with shortness of breath, shock, and asymmetrical breath sounds or chest rise
• Cardiac Tamponade: Covered in detail below
• Pneumonia: Suspect if fever and crackles are present

Other Diagnoses

• "Simple" Pneumothorax: Get a chest X-ray
• Myocarditis: Inflammation of the myocardium results in heart failure; biopsy is required for diagnosis
• Pericarditis: Inflammation of the pericardium without myocardial involvement

Pericarditis Diagnostic Criteria

• Requires 2 of 4: chest pain that improves when bent over, friction rub, EKG abnormalities, new or worsening pericardial effusion
• Endocarditis: Consider if fever and new murmur are present, especially in IV drug users
• Mallory-Weiss tear: Partial mucosal tear, lacking complete perforation like in Boerhaave syndrome
• Unstable Angina: New onset, occurs at rest, with minimal exertion, or is worsening
• Prinzmetal Angina: Classically triggered by stimulants and occurs at rest, commonly during sleep
• Anxiety: Consider as a cause of chest pain only as a last resort
• EKG: Should be performed within 10 minutes of patient arrival, useful for MI, and PE
  • S1Q3T3, can be indicative of PE, though not always sensitive or specific
• Chest X-Ray: To evaluate for esophageal rupture, dissection, pneumonia, pneumothorax, or PE

Troponin and Other Labs

• Troponin: Proteins from cardiac muscle cells that leak into the blood during damage to myocytes and draw multiple times
• Electrolytes, CBC, BNP, D-Dimer
• Imaging: CTPE or ultrasound

Nitroglycerin Administration

• Don't use nitro with hypotension
• Response doesn't exclude MI
• GI cocktail has same consideration

Heart Attack Evaluation

• Assess rate, rhythm and axis
• Inferior leads 2,3,avf, and the anterior v1,v2,v3

Disposition Decisions

• ICU Admission: Hemodynamic instability requiring pressors
• Step-down Unit Admission: High-risk ACS or submassive PE
• Floor or Observation Admission: Pneumonia
• Operating Room: Dissection

Boerhaave Syndrome (Esophageal Rupture)

• Predominantly in males
• Alcohol consumption is a major risk factor
• Sudden onset sharp substernal chest pain following forceful vomiting, or as the result of coughing, straining, seizures, or peripartum
• Pain worsens with swallowing + dyspnea

Physical Exam Findings

• Patient typically appears ill
• Tachycardia
• Possible fever
• Diaphoresis
• Hypotension
• Crepitus in the neck or chest due to subcutaneous emphysema
• Hamman's Crunch: Audible crepitus synchronous with heartbeat heard
• Abdominal rigidity

CXR Findings

• Pleural effusion, usually on the left side
• Pneumothorax
• Pneumomediastinum
• Pneumoperitoneum
• Subcutaneous air

Diagnosis + Management

• Requires CT with oral contrast.
• Consult surgery immediately, broad-spectrum antibiotics, and begin resuscitation
• X-ray Review - ABCDE (Airways, Bones, Cardiac silhouette, Diaphragm everything under, Everything else)

Cardiac Tamponade

• Typically accumulation of fluid in the pericardium, obstructing cardiac filling and circulation, rather than chest pain
• Heart attack
• Causes (nontraumatic): Malignancy, idiopathic pericarditis, uremia, bacterial or tubercular pericarditis, hemorrhage, lupus, or myxedema
• History
  • Exertion causes dyspnea

Physical Exam (Beck's Triad)

• Physical exam including hypotension, Distended jugulars and muffled heart sounds.
• Tachycardia
• Low SBP
• Pulsus paradoxus

Diagnostics

• CXR
• Echocardiogram
• EKG may be low (rare but classic)

Treatment + Disposition

• May improve filling of the right ventricular.
• Pericardiocentesis, labs should be tested

Take-Home Points

• Diagnosing MI requires a holistic approach and can't be ruled out
• Chest pain "plus" dissection
• Esophageal rupture and tamponade are medical emergencies
• Follow patient symptoms derived from DERV

Study Guide Material

• Why are lectures on chest pain focused on MI and ACS
• List 7 diagnoses worth remembering
• What defines "sick" vs "no-sick" .....