Chest Pain¶

Claire Lo

Chest Pain / Angina:¶

Symptoms determine likelihood that chest pain has a cardiac etiology
Cardiac > possible cardiac > noncardiac is more useful than typical vs atypical angina

Skin/subcutaneous: Laceration, herpes zoster, cellulitis, abscess
Musculoskeletal: Costochondritis, rib fracture, myositis, sprain/strain
Pleural space (no pain receptors in the lung): PNA, tumor, pleuritis
Heart: Myocarditis, pericarditis, spontaneous coronary artery dissection (SCAD), coronary vasospasm, aortic stenosis, stress-induced cardiomyopathy (Takotsubo), decompensated heart failure
GI: GERD, esophagitis, rupture, impaction, diaphragmatic hernia
Trachea: Tracheitis, tracheal tear
Nervous system: thoracic radiculopathy

Vitals: BP in both arms (do while interviewing - quick, easy, inexpensive)
Hemodynamic profile (warm/dry, warm/wet, cold/dry, cold/wet)
Palpate chest: evaluate costochondral junction, subcutaneous emphysema, examine skin
Cardiac: murmurs, rub for pericarditis, JVD for heart failure or PE with RV strain
Pulm: absent breath sounds for PTX, crackles for left heart failure, PNA
Abdomen: abdominal pain mistaken or referred as chest pain
Extremities: asymmetric leg swelling (>2 cm difference) for DVT/PE

EKG: ACS (STEMI, new LBBB, ST depressions, TWI, Wellens sign), pericarditis, pericardial effusion
Labs: Troponin (ACS, PE, myocarditis), CBC, BNP, lactate
CXR: PTX, PNA, dissection, esophageal rupture
Bedside ultrasound: pericardial effusion, R heart strain for PE, wall motion abnormality for infarct/ischemia or stress-induced CM, valvular disease, lung sliding/PTX
CTA: gold standard for PE. Dissection can be diagnosed w/ CTA, MRA, or TEE

Evaluation for Coronary Disease
Test	Indications	Benefits	Risks	Considerations
EKG Stress	Low to Intermediate risk patients Do not stress active or suspected ACS Serves as screening with high NPV	Functional status w/ Bruce treadmill protocol	Exercise tolerance limits use	Cannot have LBBB, nondiagnostic if 85% target HR not achieved
Dobutamine Echo Stress		More sensitive than EKG	Contraindicated: arrhythmias, LVOT obstruction, HTN, AS	Can be useful to eval low grade low flow AS Hold BB
SPECT stress		More sensitive than echo, Assess viability	Adenosine or Regadenason contraindicated in reactive airway disease	No caffeine or theophylline prior
PET stress		Better PPV than Echo Assess viability	Better for pts with larger abdominal girth (less diaphragmatic attenuation)
Cardiac MRI		Assesses viability	Can assess nonischemic vs ischemic cardiomyopathy; HR must be < 70, gold standard for structure and function
Coronary CT		Very high NPV for stenosis	Contrast media reactions CIN lower risk than cath	Might have poor lumen visualization if heavy calcium burden HR < 70
Coronary Angiogram	STEMI High risk NSTEMI: Refractory angina, new arrhythmia, cardiogenic shock (HF) Suspected true ACS Diagnostic and Therapeutic	Direct visualization of lumen Therapeutic PCI	CIN with contrast Cath site complications Rare: SCAD, cholesterol emboli	Positive Screen (above) necessitates LHC Case request cath lab NPO MN prior Groin check if femoral access