Chest pain

Chest pain - CTSP

...clutch your chest and think.

When called for a patient with CP, angina or MI may be of course your first thoughts. However, the most important tool in identifying the cause of CP is a good history. The patient should be assessed immediately. Never manage CP over the phone. Before you hang the phone, ask the nurse for vital signs.

Initial verbal orders should include:

• Stat ECG

• O2 by NC at 2 L/min

• NTG, 0.4 mg SL q5 min x 3 (Hold if SBP <90 mm Hg)

• ASA, 325 mg PO stat

• Confirm IV access.

Major causes: Think about acute, potentially life-threatening conditions:

• Heart: Angina, MI, acute pericarditis, AS, aortic dissection

  • MI and injury: CAD. Ischemia can also result from psychological stress, fever, large meals, compromised O2 delivery due to anemia, hypoxia, HOCM, HTN.

• Lungs: Pulmonary embolus, spontaneous pneumothorax, pneumonia, pleuritis, pulmonary HTN.

• GI: Esophageal spasm, Boerhaave syndrome, PUD, GERD, pancreatitis, gall bladder disease,

• Others: Herpes zoster, costochondritis, cervical disc disease, arthritis of should and spine, panic attack, anxiety state.

In order of frequency:

• Gastroesophageal disease: 42%; includes: GERD, PUD, esophageal motility d/o, gallstones.

• Ischemic heart disease: 31%

• Chest wall syndromes: 28%

• Pericarditis: 4%

• Pleuritis/pneumonia: 2%

• Pulmonary embolism: 2%

• Lung cancer: 1.5%

• Aortic aneurysm: 1%

• Aortic stenosis: 1%

• Herpes zoster: 1%

HISTORY:

• Check hemodynamic stability before anything else.

• Description of pain: ChLoRIDE PP. Know the time of onset

• Retrosternal chest discomfort, pressure, fullness, squeezing, pain lasting >15 min. Myocardial ischemia is usually associated with gradual intensification of the pain over a periods of minutes.

  • Chest pain that does not change with body position or respiration. Chest pain not associated with chest wall tenderness. When any of these three features is present, it is less likely to be from CAD.

• Pain that fleeting or has lasted for hours without any ECG changes is not likely to be ischemic in origin.

• Radiation to jaw, shoulders, neck, back or inbetween shoulder blades.

• Light headedness, fainting, sweating, N/V, SOB (shortness of breath), anxiety, distress, leg pain or swelling, fever, dysphagia/odynophagia, impending doom.

• Sometime epigastric distress may be the only symptom of ischemia.

• Older females or diabetic patients may present as SOB or nausea as their main symptom.

• Risk factors for CAD: HTN, DM, obesity, BMI: 30 or above, dyslipidemia, HDL <40 (HDL >60 is protective), elevated LDL, physical inactivity, cigarette smoking, microalbuminuria (urine albumin/cr ratio of 30 - 300 mg/g), GFR: 60 ml/min or less, renal insufficiency (Sr. Cr 1.5 or more), age: >45 in males, and >55 in females. If FH/o of CVD is positive in males relatives: <55 yrs and female relatives: <65 years, including SCD (sudden cardiac death), carotid artery disease, PAD, AAA, hyperhomocystinemia, high CRP and circulating fibrinogen.

Focused Exam:

• General Survey: How distressed does the Pt appears? Check ABCs

• Vitals: Hypotension is an ominous sign. Tachycardia may be from PE or from pain. Bradycardia may be from AV block with inferior MI. Take BP in both arms and legs, to check for possible Aortic dissection. Check pulse oximetry.

• Skin: pallor, cool, clammy extremities, capillary refill, (shock states)

• Neck: Assess JVD. Check carotids (one at a time), and listen for any bruit.

• Thorax/Lungs: Check for ACW tenderness and any skin lesions. Anterior posterior compression of patient's thorax. Is the pain completely reproducible. Assess for crackles, absent breath sounds on one side, friction rub. Crepitus of subcutaneous emphysema - PTx or esophageal rupture. Tenderness on the ribs and sternum without crepitance suggests a fracture.

• Heart: Inspect the apical impulse - if localized or presence of heaves (Rt and Lt). Feel for thrills over the respective valvular areas. Listen for murmur, rubs, or gallops. Assess JVD. Muffled heart sounds. S3 (dilated LV), S4 (LVH) in chest pain may reflect changes in the compliance of the ventricles resulting from myocardial dysfunction. Holosystolic murmur of mitral regurgitation (papillary muscle dysfunction).

• Abdomen: Tenderness, bowel sounds.

• Extremities: Edema or evidence of DVT. If dissection is suspected, examine pulses bilaterally in both UE and LE. Check the radial and femoral pulses simultaneously, as these pulses may be an important sign to diagnose aortic or subclavian stenotic disease.

• Labs:

  • ECG for all patients with chest pain.

  • CXR for patients with sign and symptoms of CHF, VHD, pericardial disease, or aortic dissection or aneurysm

  • ABGs, CBC, CCP, CRP

  • Troponin-I q6h x 3, CK-MB

  • BNP, d-Dimer

  • V/Q scan, CT scan Thx with contrast for PE, Ao dissection

  • 2-D echo, TEE if dissection is suspected

  • Duplex dopper US LE

  • ECG: ST elev of >1 mm or more in 2 contiguous leads or new LBBB or sustained VT. Always try to compare with a prior ECG. ST depression of >1 mm or ischemic T waves (symmetrical)

  • Continuous cardiac monitoring

    • Patients who present with ST-segment depression can have either UA or NSTEMI, the distinction being based on the later detection of biomarkers of myocardial necrosis. Inverted T waves, especially if marked (greater than or equal to 2 mm [0.2 mV]), also can indicate UA/NSTEMI.

  • CXR.

  • Amylase, lipase, LFTs if indicated.

  • Provocative tests for CAD (stress test) are not appropriate for patients with ongoing chest pain. Rest myocardial perfusion scans can be considered. A normal scan reduces the likelihood of CAD and can help avoid admission of low-risk patients to the hospital.

  • CT thorax with contrast done promptly if Aortic dissection is considered. if time constrants, do U/S of aorta, or TEE.

    • Stable angina: exercise ECG, stress echocardiography, or stress perfusion imaging

Immediate Tx:

• Cardiac:

  • ABCs

  • Bed rest

    • IV access, O2 by NC at 2 - 4 L/min, cardiac monitor.

    • ASA 325 mg (chew).

  • Sublingual NTG (0.4mg) q5minutes X 3 (hold if SBP <90), if pain persists, also add Morphine 2 - 4mg IV.

    • CXR

  • If evidence of acute MI on Hx, ECG, and +ve Troponin-I. Consider reperfusion Tx: Stat cardiology consult to transfer to Telemetry or Cath. Lab.

  • Fibrinolytic checklist

    • NTG IV 10 - 200 mcg/min

    • If STEMI:

      • Start adjunctive treatments:

        • Metoprolol 5 mg IV, repeat q5 minutes to max: 15 mg.

    • Heparin 60 U/kg (max: 4000 units) IVP, followed by infusion of 12U/Kg/Hr (max: 1000 units/hr) to 14U/Kg/Hr. OR LMWH

      • Clopidogrel (may be deferred until a revascularization decision is made - CABG candidate or not?)

      • Reperfusion strategy. Defined by patient and center criteria

        • PCI

        • Fibrinolysis

    • ACE-I/ARB, within 24 hours of symptom onset.

    • Statin.

    • If high risk UA/NSTEMI:

      • Start adjunctive treatments:

        • Metoprolol 5 mg IV, repeat q5 minutes to max: 15 mg.

      • Heparin 60 U/kg (4000 units) IVP, followed by infusion of 12U/Kg/Hr (1000 units/hr) to 14U/Kg/Hr. OR LMWH

      • Clopidogrel (may be deferred until a revascularization decision is made - CABG candidate or not?)

      • GP IIb/IIIa inhibitor lower mortality, particularly in those undergoing angioplasty.

      • No thrombolytic use

    • High-risk patient:

      • • Refractory ischemic chest pain

        • Recurrent/persistent ST deviation

        • VT

        • Hemodynamic instability

        • Signs of pump failure

        • Early invasive strategy, including catheterization and revascularization for shock within 48 hours of an AMI

      • ACE-I/ARB, within 24 hours of symptom onset.

    • Statin.

Reperfusion goals:

• • Door-to-balloon inflation (PCI) goal of 90 minutes.

  • Door-to-needle (fibrinolysis) goal of 30 minutes.

Aortic dissection:

• Arrange for immediate transfer to CCU/MICU.

• Nitroprusside or labetalol for BP control.

• Stat Vascular surgery/CT surgery consult.

Pulmonary:

• If PE, ensure O2 and IV heparin, pain control.

• PTx: Tension requires immediate needle thoracentesis (decompression) in the 2nd ICS in MCL, followed by chest tube. Other pneumothoraces involving >20% of the lung require chest tube.

GI:

• Antacids such as aluminum hydroxide (Maalox), 30 mL PO PRN q4-6h

• Famotidine (Pepcid), 20 mg PO bid, or omeprazole (Prilosec), 20 mg PO qd.

  • Elevate the head of the bed.

Dipyridamole or adenosine thallium stress test or dobutamine echo

Pt. who cannot exercise to a target HR >85% of MHR

COPD, amputees, deconditioned, weakness/paralysis, lower-extremity ulcer, dementia, obesity

Exercise thallium testing or stress echocardiography

ECG is unreadable for ischemia: LBBB, digoxin use, pacemaker in place, LVH

Indications for CABG

3-vessel with >70 stenosis

Left main disease, >70 stenosis

CAD equivalents: DM, PAD, carotid artery disease, aortic disease.

Therapies in ACS:

Always lower mortality: ASA, metoprolol, statin, clopidogrel, thrombolysis, PCI.

Lower mortality in certain conditions: ACE-I/ARBs if LVEF is low.

Do not lower mortality: O2, morphine, nitrates, CCB, lidocaine, amiodarone.

Complications of MI:

Cardiogenic shock

Valve rupture

Septal rupture

Myocardial wall rupture

Third-degree heart block

Right ventricular infarction