Chest Pain: Risk Stratification and CAD

Chest pain

• Chest pain can be caused by conditions that are benign and self-limited, like chest wall pain.
• Chest pain can also be caused by serious conditions such as panic/anxiety disorder.
• Some causes of life-threatening chest pain include myocardial infarction (MI), pulmonary embolism (PE), and aortic dissection.

Initial Risk Stratification

• Group 1 includes those with evidence of ST-segment elevation on initial ECG.
• Group 2 includes those without ST-segment elevation but who are at high risk based on ECG findings, hemodynamic instability, or history.
• Group 3 includes those who have no objective evidence of ACS, but have symptoms that warrant evaluation.
• Group 4 includes those who have an obvious noncardiac cause for their symptoms.

Clinical Decision Rule for Identifying Patients with Chest Pain Caused by CAD

• Scoring one point:
• Men aged 55 years or older, women aged 65 years or older.
• Known vascular disease like CAD, occlusive vascular disease, cerebrovascular disease.
• Pain that worsens with exercise.
• Pain not elicited with palpation.
• Patient assumes pain is of cardiac origin

Assessment of patients with chest pain

• Determine risk of coronary artery disease.
• Low risk is 0 or 1 point.
• Moderate risk is 2 or 3 points.
• High risk is 4 or 5 points.
• Evaluate for noncardiac causes of chest pain unless the patient has other reasons for concern (e.g., heart murmur, dyspnea, arrhythmia).
• Order an ECG for moderate risk patients.
• For patients with findings consistent with ischemic heart disease (e.g., new ST segment elevation > 1 mm), order an ECG, give oxygen and aspirin, and arrange urgent transport to emergency department for further evaluation.
• If the ECG is normal or shows nonspecific ST-T wave changes only, determine if there is a nonischemic ECG abnormality.
• Evaluate for noncardiac causes of chest pain unless the patient has other reasons for concern (e.g., heart murmur, dyspnea, arrhythmia).
• If troponin testing is available and normal six hours after onset of chest pain, the risk of a cardiac event in the next 30 days is less than 1%.
• Consider evaluation by a cardiologist and stress if the patient has at least two of the following risk factors: male sex, age older than 60 years; pressure-type pain; or pain radiating to the arm, shoulder, neck, or jaw

Cardiac causes of Chest pain in primary care

• Cardiac causes account for 16% of chest pain cases.
• Cardiac causes include stable angina (10.5%), non-ischemic (3.8), acute MI (1.5%), and aortic dissection
• For stable angina, a prompt referral to cardiology is required.
• The clinical triad for pericarditis includes pleuritic chest pain, pericardial rub, and diffused ST - T wave changes.

Aortic dissection

• Aortic dissection presents as sudden severe chest or back pain.
• Hypertension is the most common predisposing factor.
• Aortic dissection is a life-threatening emergency with a 50% mortality rate within the first 48 hours if left untreated.

Non-cardiac causes of chest pain in primary care

• Non-cardiac causes account for 68% of chest pain cases.
• Respiratory causes include pneumonia and pulmonary embolism.
• GI or reflux accounts for 19%.
• Psychogenic causes account for 8%.
• Musculoskeletal causes account for 36%.

Pneumonia

• Pneumonia symptoms include fever/chills, cough, and pleuritic chest pain.
• Rales/rhonchi with egophony on auscultation may be present.
• Additional symptoms include dullness on percussion and clinical impression.
• The test of choice is CXR

Pulmonary embolism

• Wells score is used for diagnosis.
• Clinical signs/symptoms of DVT (3 points).
• PE as the most likely diagnosis (3 points).
• Tachycardia >100 bpm (1.5 points).
• Immobilization/surgery in the previous 4 weeks (1.5 points).
• Prior DVT/PE (1.5 points).
• Hemoptysis (1 point).
• Active malignancy treated within 6 months (1 point).
• A score of 0-4 points indicates PE is unlikely.
• A score of >4 points indicates PE is likely.

GERD (Gastroesophageal Reflux Disease)

• Symptoms include retrosternal burning and acid regurgitation.
• Increased symptoms occur at night especially lying down after heavy meal
• A one-week trial of PPIs is a common intervention.

Panic/Anxiety Disorder

• One in four individuals experiencing panic attacks report chest pain and shortness of breath.
• Screening questions include asking if, in the past 6 months, the patient has ever experienced a spell or attack when all of a sudden they felt frightened, anxious, or very uneasy.
• The second questions asks if in the past 6 months, if they have ever had a spell or attack when for no reason their heart suddenly began to race, they felt faint, or you couldn't catch your breath?
• A positive response to either or both questions is a positive screening.

Chest Wall Pain

• The pain is not squeezing or oppressive, but stinging.
• Pain is well-localized on the chest wall.
• Non-exercise-induced chest pain is influenced by movement or posture.
• Reproducible by palpation.
• Absence of cough

Costochondritis

• Warm compress for treatment.
• Reduce aggravation.
• Medical pain management includes Naproxen 550 mg twice daily and Ibuprofen 800 mg three times daily.

Mr. Gold Case Study

• Mr. Gold is complaining of SOB.
• Next steps include pulse oximetry, peak flow, ABGs, CXR and lab work.
• Treatment includes O2, MDI or nebulizer.
• For acute treatment, Albuterol 4 - 8 puffs every 20 minutes up to 4 hours.
• Albuterol 2.5 – 5 mg every 20 minutes x 3, may include Ipratropium bromide 0.5 mg.
• For stabilized patients, Albuterol 2.5 to 10mg every 1 to 4 hours as needed
• Prescribe Oral prednisone, when stable, 60 mg/d taper dose with improvement.
• Refer patients to the ER if they present with hypotension, altered mental status, hypoxia, or unstable arrhythmia.
• Refer if they have stridor and breathing effort without air movement (suspect upper airway obstruction).
• Refer if they exhibit unilateral tracheal deviation and unilateral breath sounds suspect tension pneumothorax.
• Refer if they present with respiratory rate above 40 breaths per minute with retractions, cyanosis, and low oxygen saturation.
• In emergency, assess ABC, administer O2, activate EMS, prepare for ACLS if necessary, prepare IV acess and administer nebulizer, epinephrine if needed.
• Transport to ER.
• Referrral to a pulmonologist, allergist or cardiologist may be necessary.
• Send patients who fail to respond to treatment or who do not improve with initial therapy should be transported to an emergency treatment facility.

Causes of Syncope

• Neurally Mediated Syncope:
• Most common type and is seen primarily in younger adults.
• A reflex response causes vasodilation, bradycardia and systemic hypotension leading to decreased blood flow.
• Includes vasovagal syncope (mediated by stress, fear, noxious stimuli, or heat exposure).
• Situational syncope (micturition, post-exercise, postprandial, GI stimulation, cough, phobia of needle or blood).
• Carotid sinus syndrome hypersensitivity (head rotation or pressure on the carotid - shaving, tight collar.
• Cardiac Syncope:
• Second most common type.
• Generally seen in older adults.
• Results from arrhythmias, mechanical or structural abnormalities.
• Often unprovoked and more likely to present in the ED.
• Sudden death in young adults with syncope is often the result of arrhythmias.
• Arrhythmia: bradyarrhythmias, ventricular tachyarrhythmias, supraventricular tachyarrhythmias, long QT syndrome, pacemaker dysfunction.
• Obstructive cardiomyopathy: hypertrophic cardiomyopathy.
• Structural disease (cardiac): Aortic stenosis, pulmonary stenosis, acute MI, ischemia
• Structural disease (other): pulmonary hypertension, pulmonary embolus, acute aortic dissection.
• Treatments:
• Single or rare episodes of reflex syncope do not require treatment.
• Midodrine (alpha agonist) may be considered in patients with frequent hypotensive symptoms at 5-10 mg three times a day.
• Best to take it before arising in the morning, before lunch, and in the midafternoon.
• Autonomic insufficiency requires Fludrocortisone midodrine, physical therapy, support stockings
• Neurocardiogenic syncope requires Beta blocker, fludrocortisone and salt.
• Hypovolemia requires Fludrocortisone and salt.