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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

angina characteristics

Diagnoses Not to Miss: “The Serious Six” (3 Heart, 2 Lung, 1 Esophagus)

  • Acute Coronary Syndrome
  • Aortic Dissection/Aneurysm
  • Cardiac Tamponade
  • Pneumothorax
  • Pulmonary Embolus
  • Mediastinitis (e.g, esophageal perforation)

Other Differential Diagnoses

  • 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

Physical Exam

  • 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

Diagnostic Studies

  • 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


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