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PART V ATHEROSCLEROTIC CARDIOVASCULAR DISEASE 35 Approach to the Patient with Chest Pain MARC P. BONACA AND MARC S. SABATINE CAUSES OF ACUTE CHEST PAIN, 599 Musculoskeletal and Other Causes, 601...

PART V ATHEROSCLEROTIC CARDIOVASCULAR DISEASE 35 Approach to the Patient with Chest Pain MARC P. BONACA AND MARC S. SABATINE CAUSES OF ACUTE CHEST PAIN, 599 Musculoskeletal and Other Causes, 601 IMMEDIATE MANAGEMENT, 605 Myocardial Ischemia or Infarction, 599 Chest Pain Protocols and Units, 605 DIAGNOSTIC CONSIDERATIONS, 601 Pericardial Disease, 600 Early Noninvasive Testing, 605 Clinical Evaluation, 601 Vascular Disease, 600 Initial Assessment, 601 REFERENCES, 607 Pulmonary Conditions, 600 Decision Aids, 604 Gastrointestinal Conditions, 601 Acute chest pain remains one of the most common reasons for MI usually occurs in the setting of coronary atherosclerosis, but it seeking care in the emergency department (ED), accounting for may also reflect dynamic components of coronary vascular resis- almost 10% of the approximately 100 million nontraumatic visits in tance. Coronary spasm can occur in normal coronary arteries or, in the United States and representing the second most common com- patients with coronary disease surrounding atherosclerotic plaques, plaint.1 Such pain suggests acute coronary syndrome (ACS), but after and in smaller coronary arteries (see Chapter 36). Other less com- diagnostic evaluation, only 10% to 15% of patients with acute chest mon causes of impaired coronary blood flow include syndromes that pain actually have ACS.2–5 It is difficult to differentiate patients with compromise the orifices or lumina of the coronary arteries, such as ACS or other life-­threatening conditions from those with noncar- coronary arteritis, proximal aortitis, spontaneous coronary dissection, diovascular, non-­life-­threatening chest pain. The diagnosis of ACS is proximal aortic dissection, coronary emboli from infectious or non- missed in approximately 2% of patients, which can lead to substantial infectious endocarditis or thrombus in the left atrium or left ventricle, consequences—for example, the short-­term mortality in patients with myocardial bridge, or a congenital abnormality of the coronary arter- acute myocardial infarction (MI) who are mistakenly discharged ies (see Chapter 82). from the ED is twofold higher than that expected for patients who The classic manifestation of ischemia is angina, which is usually are admitted to the hospital. However, for patients with a lower risk described as a heavy chest pressure or squeezing, a burning feel- for complications, these concerns must be balanced against the cost ing, or difficulty breathing. The discomfort often radiates to the left and inconvenience of admission and against the risk for complica- shoulder, neck, or arm. It typically builds in intensity over a period tions from tests and procedures with a low probability of improving of a few minutes. The pain may begin with exercise or psychological patient outcomes. stress, but ACS most commonly occurs without obvious precipitat- There have been several advances in the accurate and efficient ing factors. evaluation of patients with acute chest pain, including more specific Atypical descriptions of chest pain reduce the likelihood of myo- blood markers for myocardial injury6,7; decision aids to stratify patients cardial ischemia or injury. The American College of Cardiology (ACC) according to their risk of complications; early exercise testing2,4,8; radio- and American Heart Association (AHA) guidelines list the following as nuclide scanning for lower-risk patient subsets (see Chapter 18)2,4,8; pain descriptions uncharacteristic of myocardial ischemia2: multi­slice computed tomography for anatomic evaluation of cor- Pleuritic pain (i.e., sharp or knifelike pain brought on by respira- onary artery disease (CAD), pulmonary embolism (PE), and aortic tory movements or coughing) dissection9–11 (see Chapter 20); and the use of chest pain units2,4,8,12,13 Primary or sole location of the discomfort in the middle or lower and critical pathways for efficient and rapid evaluation of lower-­risk abdominal region patients.2,4,8,12,13 Pain that may be localized by the tip of one finger, particularly over the left ventricular apex Pain reproduced with movement or palpation of the chest wall or CAUSES OF ACUTE CHEST PAIN arms Constant pain that persists for many hours In a typical population of patients being evaluated for acute chest Very brief episodes of pain that last a few seconds or less pain in EDs, about 10% to 15% have ACS.1,14,15 A small percentage has Pain that radiates into the lower extremities other life-­threatening problems, such as PE or acute aortic dissec- Nevertheless, data from large populations of patients with acute tion, but most leave the ED without a diagnosis or with a diagnosis chest pain indicate that ACS occurs in those with atypical symp- of a non–cardiac-­related condition.16 Such noncardiac conditions toms at sufficient frequency that no single factor suffices to exclude include musculoskeletal syndromes, disorders of the abdominal vis- the diagnosis of acute ischemic heart disease. Clinicians should be cera (including gastroesophageal reflux disease), and psychological mindful of “angina equivalents” such as jaw or shoulder pain in the conditions (Table 35.1). absence of chest pain or dyspnea, nausea or vomiting, and diapho- resis. In particular, women, older persons, and individuals with dia- betes may experience atypical symptoms of myocardial ischemia or Myocardial Ischemia or Infarction infarction (see Chapter 91). Data from the National Registry of Myo- The most common serious cause of acute chest discomfort is myo- cardial Infarction demonstrate that among patients hospitalized with cardial ischemia or infarction (see Chapters 37–39), which occurs MI, women—particularly young women—less likely manifest chest when the supply of myocardial oxygen is inadequate for the demand. pain than men.17 Additional content is available online at Elsevier eBooks for Practicing Clinicians 599 extern.ir  600 TABLE 35.1 Common Causes of Acute Chest Pain V SYSTEM SYNDROME CLINICAL DESCRIPTION KEY DISTINGUISHING FEATURES ATHEROSCLEROTIC CARDIOVASCULAR DISEASE Cardiac Angina Retrosternal chest pressure, burning, or heaviness; Precipitated by exercise, cold weather, or emotional radiating occasionally to the neck, jaw, stress; duration of 2–10 min epigastrium, shoulders, left arm Rest or unstable angina Same as angina, but may be more severe Typically 3× normal limit 1–3× normal limit ≤normal limit Adapted from the HEART Score. Poldervaart JM, Reitsma JB, Six J, et al. Using the HEART score in patients with chest pain in the emergency department. Ann Intern Med. 2017;167(9):688; and Backus BE, Tolsma RT, Boogers MJ. The new era of chest pain evaluation in the Netherlands. Eur J Emerg Med. 2020;27(4):243–244. extern.ir  606 Symptoms suggestive V of ACS ATHEROSCLEROTIC CARDIOVASCULAR DISEASE Noncardiac Chronic stable diagnosis angina Definite ACS Treatment as See ACC/AHA Possible ACS, See ACC/AHA indicated by guidelines for but nondiagnostic ECG guidelines for alternative stable ischemic and normal initial troponin NSTEACS or STEMI diagnosis heart disease Observe Follow-up at 1-3 hr: ECG and troponin No recurrent pain Negative troponin Elevated troponin and ECG or ischemic ECG changes Very low Not very low clinical risk clinical risk Noninvasive testing Positive Discharge to home; arrange for outpatient follow-up Negative FIGURE 35.2 Algorithm for the evaluation and management of patients suspected of having ACS. (Adapted from Amsterdam EA, Wenger NK, Brindis RG, et al. 2014 AHA/ ACC guideline for the management of patients with non-­ST-­elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014 Dec;64:e139–e228.) Most studies have used the Bruce or modified Bruce treadmill pro- TABLE 35.6 Indications and Contraindications for Exercise tocol. Multiple studies have demonstrated that in low-­risk patients, Electrocardiographic Testing in the Emergency Department (ED) exercise testing is safe and has a negative predictive value of typi- cally greater than 99%, although the positive predictive value is fre- Requirements before exercise electrocardiographic testing that quently less than 50% (depending on the prevalence of ACS in the should be considered in the ED setting: tested population).2,24 N  o evidence of myocardial injury by serial troponin (see section on Patients with low clinical risk for complications can safely undergo biomarkers) exercise testing after their second negative troponin test (several hours E CG at the time of arrival and preexercise 12-­lead ECG show no later depending on testing strategy) and no other evidence of myocar- significant abnormality dial ischemia.2,24 In general, protocols for early or immediate exercise A  bsence of rest electrocardiographic abnormalities that would preclude testing exclude patients with electrocardiographic findings consistent accurate assessment of the exercise ECG with ischemia not recorded on previous tracings, ongoing chest pain, F rom admission to the time that results are available from the second or evidence of congestive heart failure. The AHA/ACC guidelines note set of cardiac enzymes: patient asymptomatic, lessening chest pain indications for and contraindications to exercise on electrocardio- symptoms, or persistent atypical symptoms graphic stress testing in the ED (Table 35.6).2 For low-­risk patients with no evidence of myocardial ischemia after serial ECGs and biomarkers, Absence of ischemic chest pain at the time of exercise testing outpatient stress testing ideally within 24 hours, and no later than 72 Contraindications to exercise electrocardiographic testing in the ED hours, is safe. setting: New or evolving electrocardiographic abnormalities on the rest tracing Noninvasive Imaging Tests Abnormal cardiac enzyme levels Stress echocardiography or radionuclide scans are the preferred non- invasive functional testing modalities for patients who cannot undergo Inability to perform exercise treadmill electrocardiographic testing because of physical disability or W  orsening or persistent ischemic chest pain symptoms from admission who have resting ECGs that confound interpretation. Imaging studies to the time of exercise testing are less readily available and more expensive than exercise electro- Clinical risk profiling indicating that imminent coronary angiography is likely cardiography but are more sensitive in detecting coronary disease, extern.ir  607 quantifying the extent of, and localizing the jeopardized myocardium. with a reduction in ED costs and length of stay and no difference in High-­risk rest perfusion scans are associated with an increased risk death or rehospitalizations.65 Most of these studies were performed 35 for major cardiac complications, whereas patients with low-­risk scans using conventional (less sensitive) cTn assays and CTA and are associ- Approach to the Patient with Chest Pain have low 30-­day cardiac event rates (