Chest Pain

Bader Alyahya

Objectives

• Overview of chest pain
• Differential diagnosis of chest pain
• Typical vs. atypical chest pain
• Evaluation of chest pain
• Review patient cases

Overview

• Chest pain accounts for 6 million annual visits to EDs in the United States.
• It is the second most common ED complaint.
• Patients present with a wide spectrum of signs and symptoms.
• The clinician’s priority is to recognize life-threatening causes.

Life-Threatening Differential Diagnosis (The “Big 5”)

1. ACS (Acute Coronary Syndrome) - Give “Jive Xhong” [sic] & aspirin to decrease morbidity.
2. PE (Pulmonary Embolism)
3. Aortic Dissection
4. Tension Pneumothorax
5. Pericarditis (Note: listed in intro, also consider Tamponade)
6. Esophageal Rupture (Mediastinitis)

Initial Approach

• ABC’s first: Always look for conditions requiring immediate intervention; assess appearance and vital signs.
• Aspirin: Administer for potential ACS.
• EKG: Obtain within 10 minutes.
• Monitoring: Continuous cardiac and vital sign monitoring.
• Pain Relief: Provide appropriate analgesia.
• History & Physical: Guided by the wide differential diagnosis.
• Logical/Physical Exam Notes: “Hishog” [sic]

ECG Interpretation & MI Localization

Territory	Leads
Inferior	II, III, aVF
Anteroseptal	V₁, V₂, V₃, V₄
Anterolateral	V₁, V₂, V₃, V₄, V₅, V₆
Extensive Anterolateral	V₁-V₆, I, aVL
Lateral	V₅, V₆
High Lateral	I, aVL
Inferolateral	(7) V₂, V₃, V₅, V₆, I, aVL

ECG Notes:

ECG Interpretation Notes

Posterior MI

• Detection: Not shown on a standard 12-lead ECG.
• Clinical Suspicion: Suspect when there is Typical Chest Pain with ST depression in V₁, V₂, V₃ and prominent R-waves (these are reciprocal changes).
• Extended ECG: Place leads posteriorly to confirm:
  • V₇: Posterior axillary line (same level as V₆).
  • V₈: Tip of the scapula (mid-scapular line).
  • V₉: Left paraspinal region (between scapula and spine).

Right Ventricular (RV) Infarct

• Association: Suspect in all Inferior MIs (occurs in ~20% of cases).

• Diagnostic Move: Move lead V₄ to the right side (V₄R).

• Treatment Protocol:

  • Give Fluids: Preload dependent.
  • DO NOT Give Nitroglycerin: This may precipitate cardiac arrest due to a critical decrease in preload.

• Prognosis: If an acute inferior MI is present, checking for RV involvement is crucial as mortality is higher if both are present.

Cardiogenic Shock & Hypotension

• Assessment: If the patient is hypotensive, check lung sounds:
  • Lungs Clear: Likely RV Infarct → Treat with Fluids.
  • Rales/Congestion Present: Likely extensive Anterior MI (Pump failure) → Treat with Inotropes.

Reciprocal Changes

• Definition: Mirror images of ST elevation (finding these increases the sensitivity/specificity for diagnosing an MI).
• Patterns:
  • Posterior $\leftrightarrow$ Anterior (Septal leads V₁-V₃): ST depression in V₁-V₃ is reciprocal to posterior elevation.
  • Anterior $\leftrightarrow$ Inferior: LAD occlusion may show reciprocal changes in II, III, aVF.
  • Inferior $\leftrightarrow$ Lateral (High Lateral): Inferior elevation often shows depression in aVL (and vice versa).
  • Lateral $\leftrightarrow$ Inferior: (Removed “Septal” as it is less standard).

High Lateral MI

• Unique Feature: Often described as the only MI pattern that may not strictly follow the “consecutive leads” rule in early presentation.
• Criteria: Isolated ST elevation in aVL is a subtle but high-risk sign.
  • Key confirmation: Look for reciprocal ST depression in Lead III.
  • If you see elevation in aVL + depression in III, treat as High Lateral MI until proven otherwise.

Clinical Presentation

History (OPQRST)

• O - Onset
• P - Provocation / Palliation
• Q - Quality / Quantity
• R - Region / Radiation
• S - Severity / Scale
• T - Timing / Time of onset

Physical Exam

• General Appearance and Vitals: “Sick vs. Not Sick.”
• Chest Exam:
  • Inspection: Scars, heaves, tachypnea, work of breathing.
  • Auscultation: Murmurs, rubs, gallops, breath sounds.
  • Percussion: Dullness.
  • Palpation: Tenderness, PMI.
• Key Finding: Reproducible chest pain “points toward a musculoskeletal” cause.

Differential Diagnosis

Life-Threatening Causes

• Acute Coronary Syndrome (Unstable Angina, NSTEMI, STEMI)
  • STEMI: ST elevation in 2 continuous leads.
  • NSTEMI: Aspirin; pain management; Cath within 2nd day.
  • Unstable Angina: Emergency Cath if pain is ongoing.
  • Note: NSTEMI with -ve troponin → becomes +ve troponin.
• Aortic Dissection
• Pulmonary Embolism
• Tension Pneumothorax
• Pericardial Tamponade
• Mediastinitis (e.g. esophageal rupture)
• Pericarditis: Previous URI infection; pain changes with position of the patient.

Comprehensive Differential (UpToDate 2012)

Category	Conditions
Non-ischemic Cardiovascular	Aortic dissection, Myocarditis, Pericarditis
Pulmonary	Pleuritis, Pneumonia, Pulmonary embolus, Tension pneumothorax
Psychiatric	Affective disorders (depression), Anxiety, Hyperventilation, Panic disorder, Somatiform, Thought disorders
Gastrointestinal	Biliary (Cholangitis, Cholecystitis, Colic), Esophageal (Spasm, Reflux, Rupture), Pancreatitis, PUD (Perforating vs Nonperforating)
Chest Wall	Cervical disc disease, Costochondritis, Fibrositis, Herpes zoster (pre-rash), Neuropathic pain, Rib fracture, Sternoclavicular arthritis

Typical vs. Atypical Chest Pain

Typical Cardiac Pain

• Described as discomfort/pressure rather than “pain.”
• Duration > 2 minutes.
• Provoked by activity/exercise.
• Radiation (i.e. arms, jaw).
• Does not change with respiration or position.
• Associated with diaphoresis/nausea.
• Relieved by rest or nitroglycerin.

Atypical (Unlikely Cardiac) Pain

• Pain localized with one finger.
• Constant pain lasting for days.
• Fleeting pains (seconds).
• Pain reproduced by movement or palpation.

The Rational Clinical Examination Systematic Review

• Key Effect: Perform ECG every 10-20 min (4 times total). If normal, it will not change after that.
• Source: JAMA. 2015;314(18):1955-1965.

Table 2: Performance of Chest Pain Characteristics (ACS)

Likelihood Ratios (MI) Summary (UpToDate 2012)

Evaluation & Management Workflow

Scenario 1: The Intern’s Call

• Setting: 2:00 AM. Mr. S, 67M with CAD and AKI, has chest pain after walking from the bathroom.
• Immediate Action:
  1. Ask nurse for current vital signs.
  2. Request an EKG and admission EKG for comparison.
  3. Go see the patient!
• Assessment:
  • Determine stability.
  • Interpret EKG vs. baseline.
  • If unstable or concerning EKG, call senior resident.
• Stable Patient Protocol:
  • Focused History (CAD risk, typical/atypical, prior MI similarity).
  • Focused Physical:
    • Vitals (Tachycardia, BP shifts, Hypoxia).
    • HEENT (JVD, carotid bruits).
    • Chest (Rales, wheezes).
    • CVS (Murmurs, reproducible pain, S3 gallop).
    • Abd (Tenderness, pulsatile mass).
    • Ext/Skin (Edema, pulses, rash).
• Diagnostics/Disposition:
  • CXR, Cardiac biomarkers, ABG?
  • Telemetry/ICU.
  • Write a clinical event note!

Supplemental Clinical Findings

Case Note: 60M with CP 2 days ago (No active pain)

• ECG Findings: Axis (P 81, QRS 31, T 113). Anteroseptal STEMI (unconfirmed).

Case Note: 70M with radiation to both shoulders

Clinical Pearl: Inferior or Posterior MI

• Next Step: Check Right Ventricular involvement.

Clinical Pearl: Posterior MI

• Usually not isolated.
• Perform extended ECG (2 leads): one below scapula, one between scapula and vertebra.
• 20% have RV involvement or fracture leading to hypotension → Treat with fluids.

Clinical Cases

Case 1: Pulmonary Embolism (PE)

• Presentation: 62F, 3 weeks post-right THA, admitted for COPD exacerbation. Sudden onset L-sided chest pain (8/10), pleuritic, O2 sat drop (94% → 88% on 2L NC).
• Initial management: Give aspirin. Repeat ECG 4 times if no change (unstable vs non-STEMI).
• Vitals: Afebrile, HR 120, BP 110/70, RR 28.
• Exam: Accessory muscle use, EAE, loud S2.
• Labs: Positive D-dimer, Troponin 0.12 (Normal < 0.04), BNP 520.
• Clinical Notes: “Plastic chest Pain” [sic]. “To send to CT, increase the sum Five five.”

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PE

• S1Q3T3: Present in only 20% of PE.
• CXR Findings:
  • Westermark sign: Clarified area (hyperlucency) secondary to oligemia.
  • Hampton sign: “Dome stuffed” (hump).
• Management Plan: Give heparin (“heforin” [sic]) and send to CT.

Wells Score & PE Management

• PERC Score first; if high, do Wells.
• If negative D-dimer helps exclude in low/mod probability.
• Wells Criteria: Clinical signs of DVT (3), Alt diagnosis less likely (3), Heart rate > 100 (1.5), Immobilization (1.5), Previous VTE (1.5), Hemoptysis (1), Cancer (1).
• Likely PE (>4) → do CT. Unlikely (≤4) → do D-dimer.
• Treatment: Anticoagulation (Heparin/LMWH). Thrombolytics in hypotensive/massive PE. IVC filter if bleeding risk.

Diagnostic testing

• Pulmonary angiography (Gold standard)
• Spiral CT (CT-PE protocol)
• V/Q scan (helpful for detecting chronic VTE)
• D-dimer (<500ng/ml helps exclude PE in patient with low/moderate pre-test probability)

Treatment of PE

• Anticoagulant therapy is primary therapy for PE2

  • Unfractionated heparin3
  • LMWH4

• For unstable patients, catheter embolectomy or surgical embolectomy are options5

• For patients at risk for bleeding, IVC filter is an alternative6

• thrombolytic or fibrinolytic (Streptokinase) in Hypotensive

• if massive with normal BP only heparin

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Case 2: Pericarditis

• Presentation: 24M with PMHx of SLE/Asthma. Sharp, pleuritic pain (2 days), worse lying supine, better leaning forward. Recent viral URI.

• Vitals: T 38.1, HR 104.

• Exam: Leaning forward, WBC 14.

• ECG Findings: Diffuse ST elevation and PR depression (elevated in aVR).

• Diagnosis Criteria: Requires 2 of 4 (Typical pain, Friction rub, ECG changes, Effusion).

• Management: Echo, Aspirin, NSAIDs/Colchicine (“Nidwage” [sic]).

• EKG Findings:

  • PR depression (elevated avR)
  • Diffused ST elevation*

• Diagnostic Steps & Management:

  • Order troponin
  • If troponin is positive, the diagnosis is Myopericarditis (they may develop HF)
  • With troponin -ve: do echo, give aspirin/NSAIDs, and discharge

pericarditis:

• Refers to inflammation of pericardial sac
• Preceded by viral prodrome, i.e. flu-like symptoms
• Typically, patients have sharp, pleuritic chest pain relieved by sitting up or leaning forward

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Case 3: NSTEMI vs Aortic Dissection both normal ecg

• Presentation: 67M with DM/CAD. Retrosternal pain (7/10), nausea, diaphoresis, jaw radiation. Similar to prior MI.
• Vitals: HR 108, BP 105/60, Sat 93%.
• Exam: Rales at bilateral bases. tachycardic, nl s1/s2 no murmurs or rub
• Labs: Troponin + 3.2. ckmb = 9 ck = 345
• Clinical Notes: “Sever between scapula pain” [sic].

Management of UA/NSTEMI

• Aspirin,

  • inhibit platelet aggregation

• Statin,

• Nitroglycerin (SL).

  • use if patient having active chest pain
  • Caution: Do NOT use Nitroglycerin if RV infarct concern.

• HR control (Beta-blocker, goal to titrate ~60 bmr ).

• Plavix

  • P2Y12 receptor blocker
  • Inhibits platelet aggregation

• Anticoagulation

  • Heparin/LMWH
    • Inhibits thrombus formation

• Oxygen

  • For O₂ sat < 90%

• Morphine

  • For refractory chest pain, unrelieved by NTG SL

Pit for cath or CABG depend on his case

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Case 4: Aortic Dissection

• Presentation: Crushing chest pain radiating to the back.
• Key Finding: BP discrepancy (R: 193/112, L: 160/99).
• Classification: Type A (Ascending - Surgical), Type B (any other part of aorta).
• Diagnostics: CXR, CT chest with contrast, MRI chest, TEE

Management of Aortic Dissection

• Type A dissection – Surgical
• Type B dissection – Medical
• Mainstay of medical therapy
  • Pain control
  • HR and BP control
    • Goal HR = 60 beats/min, goal SBP = 100-120 mmHg
    • Use IV beta-blockers (i.e. Labetalol, Esmolol)
    • Can also use Nitroprusside for BP control
    • AVOID Hydralazine

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Case 5: Pneumothorax

• Presentation: 45M post-thoracentesis (1.5L removed). Develops sudden R-sided chest pain.
• Management:
  • Stable < 3cm: Supplemental O2 and observation.
  • Stable > 3cm: Needle aspiration.
  • Failure or Unstable: Chest tube. if >3cm or failed aspiration or unstable patient

Summary

• Chest pain is a very common complaint that has a broad differential
• Always try to rule out the life-threatening causes of chest pain
• It is important to remember that troponin elevation DOES NOT always mean ACS
• Use the history, physical exam, labs, EKG and imaging to reach a diagnosis (Good H is the most important)
• Whenever you are stuck, ask for help. Your seniors are there to help you!!