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The Approach to Chest Pain: Epidemiology, Symptoms, Exam, The General Appearance, The six deadly conditions

    Objectives


    • Know the epidemiology of chest pain (cardiac) presentations,
    • List and discuss the important symptoms of the chest (cardiac), disease
    • Review elements of the chest (cardiac) physical exam
    • Review the fundamentals of clinical reasoning concerning chest pain

    Chest_Pain
    Source: www.cedars-sinai.org

    The Epidemiology of Cardiac Presentations


    • There are approximately 120million ED visits per year in the US 
    • Of this, 8-10% are due to chest pain.
    • Using various sources, this translates into around 7-12 million patients per year presenting to the ED for chest pain.
    • In total, there were about 750,000 myocardial infarctions last year. 525,000 of these were a first heart attack
    • 1 in every 4 deaths in the US is due to heart disease
    • Of all heart disease, coronary artery disease is the most common.
    • Heart disease is the leading cause of death for most population
    • groups in the US. It is the second leading cause of death (behind cancer) for Asians, American Indians, Alaskan Natives, and Pacific Islanders.
    • 92% of respondents in a 2005 survey knew that chest pain is a feature of a heart attack.
    • About 50% of sudden cardiac deaths occur outside of the hospital. This suggests people are unaware of early warning signs.
    • The three key risk factors for cardiac disease are high blood pressure, high cholesterol, and smoking.
    • Other risk factors are diabetes, being overweight or obese, physical inactivity, a poor diet, and excessive alcohol use.
    • These are important to know when generating your initial differential diagnosis, as increasing numbers of risk factors increase the chance of cardiac sources of chest pain.

    Symptoms of likely cardiac chest pain on presentation

    Important symptoms of cardiac disease:
    • Chest pain
    • Dyspnea
    • Fatigue
    • Palpitations and syncope 
    • Dependent edema

    Symptom – Chest pain

    • ANGINA is the 'true' symptom. 
    • Retrosternal and diffuse
    • Worsened by activity, emotion or cold, made better by rest or NTG
    • Radiation to left jaw, left arm, or to the back
    • Has a duration of minutes opposed to seconds, hours or days
    • Common adjectives are 'aching', 'dull', 'squeezing', or 'pressure
    • In diabetics, particularly women, the radiation of pain may not be as expected

    Symptom – Palpitations

    Palpitations are common and do not necessarily signal HD.
    Important to evaluate for changes in rx and caffeine intake
    Is there hx of fever, low BG, Y, or endocrine disorders?
    Consider asking these questions:
    • Could you count your pulse during the attack?
    • Did you have to urinate after the palpitations?
    • Do you take any medications for your lungs?
    • Did you flush, sweat, or have a headache during the attack?
    • Did you have any chest pain during the attack?

    Symptom - Dyspnea

    • Dyspnea is almost universally related to a pulmonary or cardiac issue. Rarely, it can be associated with severe anemia.
    • PND is relatively specific for congestive heart failure. It tends to occur 2 hours after reclining and going to sleep.
    • Attempt to quantify the quality of dyspnea, and relate it to the physical exam and diagnostic findings (e.g METS, blocks, etc)

    Symptom – Syncope

    The activity which precedes the syncope is important.
    • For example, if occurs directly after activity, consider aortic stenosis or primary pulmonary hypertension.

    The position which precedes the syncope is important.
    • Did the patient just stand? Were they urinating? Did they sit down and immediately feel better? 

    The most common form of syncope is vasovagal.
    • This is associated with sweating, nausea, vomiting and overall activation of the vagus nerve.

    Elements of a cardiac chest pain exam

    • 2D-ECHO, coronary angiography and catheterization
    • Kidding
    • The general appearance
    • Auscultation
    • Examination for edema
    • The blood pressure

    Exam – The General Appearance

    Inspect the skin
    • Warm = severe anemia, thyrotoxicosis, initial stages of sepsis, Anything which is increasing cardiac output
    • Cold = endocrine disorders, cardiogenic heart failurem, Anything which tends to decrease cardiac output 
    • Are there xanthomatas present?
    • Is a rash present? (such as erythema marginatum - RHD)
    • Congenital heart conditions sometimes present with congenital facies.

    Exam – Auscultation

    With the diaphragm of the stethoscope, press tightly. You can best
    hear valves, events during systole, and regurgitant murmurs.
    With the bell of the stethoscope, press lightly. You can best hear gallops or aortic stenosis.
    Pay attention to breathing: r-sided events tend to accentuate on inspiration (increased preload)
    All murmurs during diastole are pathological.
    Murmur intensity rarely translates to clinical severity.

    Exam – Murmurs

    • Murmurs occur from obstruction to flow or from blood flow from a narrow vessel to a larger-diameter vessel.
    • Harsh murmurs = high gradients + high flow
    • Ejection murmurs are crescendo - decrescendo (diamond)
    • Blowing murmurs = large gradients with variable volumes
    • Rumbling murmurs = small gradients dependent on the flow

    Exam – The Blood Pressure

    • Korotkoff sounds are associated with the turbulent flow of blood
    • Is the person orthostatic?
    • Too small a cuff - false elevation. Too big - declination.
    • If the patient's arm is not rested, this will increase blood pressure. 
    • The auscultatory gap signifies decreased blood flow to the extremities - consider aortic stenosis or severe chronic hypertension. 
    • Increases in paradoxical pulse are associated with tamponade, constrictive pericarditis, pericardial effusions, and any lung condition which increases the effort of ventilation.

    Exam – Edema

    Estimate the jugular venous pressure (normal is 6-8).
    • If Abd-jugular reflux is present, this can suggest L-sided elevation of pressures, and would further suggest a wedge of at least 15mmHg.

    Listen for crackles in the lungs (coarse → larger airway disease, fine → interstitial process)
    Inspect dependent positions for edema
    • If the patient spends a majority of time in the supine position, press at the dimples of Venus to assess.

    If there are crackles in the lungs and jvd/dependent edema, physiologically there is too much fluid in the system and diuresis is almost universally appropriate.

    Chest pain and clinical reasoning

    Consider the six conditions which can quickly lead to morbidity and/or mortality:
    • Myocardial infarction
    • Pulmonary embolus
    • Pneumonia
    • Aortic aneurysms and dissections
    • Pneumothorax
    • Events within the mediastinum (mediastinitis, Boerhaave, etc)

    The six deadly conditions - PNA

    • Consider the amount of reserve the patient has
    • Look for the triad of fever, rales, and sputum
    • Get the procal
    • Risk stratify
    • Always get the image
    • Papers are now suggesting a 1-hour sepsis bundle instead of 3 

    The six deadly conditions - PTX

    • Quantify if primary or secondary
    • Don't let the image delay treatment: ever, for any condition.
    • Stable - continue the examination
    • Unstable - decompress
    • If unexpected sounds on auscultation, look for Beck's triad: distended neck veins, hypotension, distant heart sounds

    The six deadly conditions - A & D

    • Always check blood pressure in both arms in acute chest pain: lower in one arm could implicate subclavian artery involvement
    • Get the image and look for contours
    • If you are concerned both may be present, delay thrombolytics as they can double mortality in a dissection
    • If the pain moves, this can support dx of a dissection
    • A bedside 2D ECHO is invaluable
    • If the objective exam is bland compared to symptoms, strongly consider this etiology

    The six deadly conditions - PE

    • History, history, history
    • Scoring
    • The most common sx is shortness of air
    • The most common sign is tachypnea, then tachycardia and fever
    • Cyanosis and syncope → likely submassive or massive
    • Pleuritic chest pain → likely segmental or smaller
    • ECG - TWI V1-V3, RBBB, peaked P wave in II
    • If severe dyspnea and normal CXR → PE likely

    The six deadly conditions - STEMI

    ACC definition: detection of a rise or fall in cardiac biomarkers (cTn) with one value above the 99th percentile URL AND
    • Symptoms, new q waves, ST elevations, imaging

    If a concern is present, contact your fellow a/o attending.
    Oxygen at 94, no need to make higher.
    ASA (even if intolerant)
    As quickly as possible, differentiate between L-sided and R-sided as management will be different

    The six deadly conditions - mediastinum

    Mediastinitis
    • The patient will usually look toxic
    • Check for history of surgeries in the area, poor dentition

    Esophageal rupture
    • Recent wretching, forceful swallowing, hiccupping, increased discomfort lying flat
    • Hematemesis is usually NOT a predominant symptom

    Chest pain and clinical reasoning

    For suspected lung pathologies, assuming the patient is stable enough, an image is always appropriate.
    For cardiac pathologies, an image may or may not be warranted.
    • Crackles and suspecting heart failure? Yes
    • Troponins and crushing chest pain? No

    If a new murmur is present, the threshold to gather a STAT ECHO is very low.
    If cardiac pathology is suspected, ALWAYS order an EKG.
    If troponins are ordered, order a concomitant EKG.
    In signs of damage biochemically (lactate, CK, troponins, etc) always find the zenith.
    The progression of pain is a strong diagnostic clue:
    • Ischemia and infarction usually present in a crescendo temporal pattern
    • Aortic etiologies, pericarditis and pleuritic chest pain usually present at maximum intensity
    • Pain which goes to the back almost always involves an organ which at some point during embryogenesis passed through the retroperitoneum (duodenum, aorta, head of the pancreas, kidney, etc)

    If pain is positional, it tends to involve architecture.
    If pain is continuous, it tends to involve an ongoing process.
    PNA pain tends not to be severe and continuous.
    If chest pain is present with a large pleural effusion, consider a neoplastic process.
    If severe chest pain is immediate in onset, and
    • the patient has a history of hypertension
    • the patient has a history of collagen-vascular disorders, like EDS 

    that would increase concern for aortic dissection or aneurysm
    If no history of cardiac risk factors, female, and peripartum
    • consider spontaneous coronary artery dissection

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