Mortality at 30 Days among Patients with Acute Cardiac Diagnostic Assessment Ischemia.

• Life threatening – Cardiac Ischemia – Other cardio‐pulmonary and aortic conditions – Other (eg. Esophageal tear)

• Non‐Life threatening

Pope JH et al. N Engl J Med 2000;342:1163‐1170.

Epidemiology of Epidemiology of Chest Pain

• Chest discomfort is the third most common • Fewer than 10% are other life‐threatening reason for visits to the ED cardiopulmonary conditions. • 6 to 7 million emergency visits each year. • Large proportion of patients with transient acute • More than 60% of patients with this presentation chest discomfort the cause is not determined. are hospitalized for further testing. • 2–6% of patients with chest discomfort of • Fewer than 25% of evaluated patients are presumed non‐ischemic etiology who are eventually diagnosed with acute coronary discharged from the ED are later deemed to have syndrome (ACS), had a missed (MI). • Most common diagnoses are gastrointestinal • Patients with a missed diagnosis of MI have a 30‐ causes day risk of death that is double that of their counterparts who are hospitalized. Storrow, A; Annals of Emergency Medicine Storrow, A; Annals of Emergency Medicine Volume 35, Issue 5, May 2000, Pages 449–461 Volume 35, Issue 5, May 2000, Pages 449–461

ED Discharge Diagnoses for Epidemiology of Chest Pain Nontraumatic Acute CP • Missed diagnosis of acute coronary syndrome is a leading cause of malpractice claims • The cost of failure to appropriately diagnose is over $6 billion a year.

Storrow, A; Annals of Emergency Medicine Volume 35, Issue 5, May 2000, Pages 449–461 Outpatient Causes of Chest Pain Cardio‐Pulmonary Causes of CP

• Cardiovascular • Pulmonary – Acute ischemia – PE – Angina (stable) – musculo‐skeletal GI – – Pneumonia respiratory – Valve disorders – Malignancy Stable cardiac – CHF – Asthma/COPD acute ischemia – Aortic disease – Pleuritis other (psych) – Hypertrophic CM – Sarcoid – Stress Cardiomyopathy – PHT Bosner, S Eur J Gen Pract. – Sickle Cell acute CP Klinkman, MS J Fam Pract. 2009;15(3):141. 1994;38(4):345.

Differential Diagnosis Potentially Lethal Causes of CP

Chest wall Gastrointestinal • Acute Coronary Syndromes Cervical disc disease Biliary Costochondritis • Aortic Dissection Cholangitis Fibrositis • Tamponade Herpes zoster Choledocholithiasis (before the rash) • Pulmonary Embolism Colic Neuropathic pain Psychiatric • Esophageal Rib fracture Affective disorders (eg, • Tension Pneumothorax Sternoclavicular depression) Spasm arthritis Anxiety disorders Reflux Hyperventilation Esophageal Tear Panic disorder Primary anxiety Various others: Pulmonary HTN, Myocarditis, Up to Date 2016 Somatoform disorders Pneumonia www.uptodate.com Nonperforating Thought disorders (eg, fixed delusions) Perforating*

Evaluation Myocardial Ischemia Classical Symptoms • History –critical in differentiation life • Central or L sided pressure, heaviness, threatening from non life threatening tightness, constriction – Quality • Exertional, emotional stress, cold – Location and Radiation • Radiation – Temporal Elements • Dyspnea, N/V, diaphoresis, presyncope, – Provocation palpitations – Palliation – Severity Myocardial Ischemia Atypical Symptoms Typical vs. Atypical Chest Pain Atypical (unlikely due to • Women, diabetics, elderly Typical myocardial ischemia) • Dyspnea, weakness, N/V, palpitations, • Characterized as • Pain that can be localized with syncope or presyncope discomfort/pressure rather than one finger pain • Constant pain lasting for days • Abdominal pain especially with inferior wall • Time duration >2 mins • Fleeting pains lasting for a few ischemia • Provoked by activity/exercise seconds • Radiation (i.e. arms, jaw) • Pain reproduced by • Does not change with movement/palpation respiration/position • Pleuritic • Associated with diaphoresis/ • Relieved by rest/nitroglycerin Braunwald’s Heart Disease, Saunders 8th edition, p1195

Chest Pain: Location Character of Chest Pain Likelihood ratios for MI based on components of the chest pain history Aortic dissection Myocardial ischemia Description of pain LR (95%) Intra-peritoneal fluid Boorhave’s Descriptions increasing the likelihood of MI Myocardial ischemia Pericarditis Radiation to R arm/shoulder 4.7 (1.9-12) Pulmonary embolism Pleurisy Radiation to both arms/shoulders 4.1 (2.5-6.5) Pericarditis Exertional 2.4 (1.5-3.8) Radiation to L arm 2.3 (1.7-3.1) Myocardial Associated with diaphoresis 2.0 (1.9-2.2) ischemia Associated with nausea or vomiting 1.9 (1.7-2.3) Worse than previous angina or similar 1.8 (1.6-2.0) Cervical spine to previous MI Thoracic outlet Myocardial ischemia Described as pressure 1.3 (1.2-1.5) CHF Descriptions decreasing the likelihood of MI Pulmonary embolism Pleuritic 0.2 (0.1-0.3) Pancreatitis Pneumonia Positional 0.3 (0.2-0.5) Cholecystitis Sharp 0.3 (0.2-0.5) Myocardial ischemia Peptic disease Reproducible with palpation 0.3 (0.2-0.4) Splenic infarction Inframammary location 0.8 (0.7-0.9) Intraperitoneal fluid Nonexertional 0.8 (0.6-0.9) Peptic disease Swap CJ, Nagurney JT. JAMA. 2005 Nov 23;294(20):2623‐9. Review. Erratum in: JAMA. 2006 May 17;295(19):2250.

Missed Diagnosis of MI Non‐Ischemic Cardiac Chest Pain

• Women less than 55 years old – Aortic Dissection or Ulceration • Nonwhites – Pericarditis • SOB Chief Symptom – Valve disorders – CHF • Nondiagnostic ECG – Hypertrophic CM – Stress Cardiomyopathy

Pope, J et,al N Engl J Med 2000; 342:1163‐1170 Aortic Dissection: etiology Dissection

. Prevalence of major risk factors: . Hypertension 50‐90% Blood violates aortic intimal and . Bicuspid AoV 9‐13% adventitial layers False lumen is created . Marfan syndrome 3‐5% Dissection may extend proximally, distally, or in both directions

Braunwald’s Heart Disease, Saunders 8th edition p.1469

Aortic Dissection Aortic Dissection: clinical presentation

.Sudden severe pain 90% .Migrating pain 31% .Tearing pain 39% (spec. 95%) .Hypertension 49% .Diastolic murmur 28% .Pulse deficits or BP differential 31% .Focal neurologic deficits 17% .Syncope 13% .ECG criteria for AMI 7%

Klompas et al, JAMA 2002; 287:2262-2272. Nallamothy et al, Am J Med 2002; 113:468-471.

Radiographic Signs of Thoracic Dissection Aortic Dissection . Studies suggest up to 90% of patients will have • Bimodal distribution “abnormal” CXR* – Young: Connective tissue (Marfan) or pregnancy . Widened (>8cm on AP film) [50‐65%] – Older: Most commonly > 50 (mean age 63) . Left (hemothorax) . Ring Sign (displaced intimal calcification >5mm) • Risk factors . Blurred aortic knob – Male: 66% of patients . Tracheal deviation to the Right – Hypertension: 72% of patients . Esophageal deviation to the Right (seen via NGT) – Connective tissue disease . Left apical cap • 30% of Marfan’s patients get dissections . Depressed Left mainstem bronchus – Cocaine Use . Loss of paratracheal stripe – Syphilis *Hogg K. Sensitivity of a normal chest radiograph in ruling out aortic dissection. Best Evidence Topics. 9 March 2004. Pulmonary Embolus Dissection Diagnosis Risk Factors • CXR‐ Widened mediastinum, abnormal aortic knob, pleural • Deep vein thrombosis effusions – Prolonged immobilization (eg, long distance travel), – Not sensitive (25% have wide mediastinums) surgery (particularly an orthopedic procedure of the lower • Chest CT‐ Very sensitive and specific extremity lasting more than 30 minutes), central venous – Quickly obtained catheterization, or trauma. – Must think about kidney + contrast – Pregnant patients, – Cancer • Angiography‐ Gold standard – Lung, or chronic heart disease, – Most reliable anatomy of dissection – Hypercoagulability. • Bedside US – evaluate aorta and look at heart to r/o – Oral contraceptives or chemotherapeutic agents that raise tampanode. serum levels of estrogen or progestin also confers increased risk.

Pulmonary Embolus Key Findings • Dyspnea • Tachycardia, . Localized focal wheezing, friction rub, asymmetric extremity enlargement. • ECG – Sinus Tachycardia, S1Q3T3, Right axis deviation, right bundle branch block, right atrial enlargement (ie, "P pulmonale"), and atrial fibrillation • CXR –most are normal or nonspecific. atelectasis, elevated hemidiaphragm, and pleural effusion. Classic but rare findings include: pleural‐based wedge‐shaped defect (representing infarcted lung parenchyma, so‐called Hampton's hump) or paucity of vascular markings distal to the site of embolus (Westermark's sign). • Labs D‐dimer Ho, D. journal of clinical trial results Vol 1 Issue 1, journalofclinicaltrialresults.com

Pericarditis

Pleuritic pain Improved by sitting up and leaning forward

Torbicki, A. European Heart Journal Volume 29, Issue 18 Pp. 2276 ‐ 2315 Pericardial Effusion ‐ Tamponade Pericardial Effusion ‐ Tamponade

●Acute pericarditis (viral, bacterial, tuberculous, or idiopathic in origin) • ●Autoimmune disease Chest pain if pericarditis or acute pericardial ●Postmyocardial infarction or cardiac surgery stretch e.g. trauma ●Sharp or blunt chest trauma, including a cardiac diagnostic or interventional procedure • Beck’s Triad – hypotension, JVD, muffled heart ●Malignancy, particularly metastatic spread of noncardiac primary tumors sounds ●Mediastinal radiation • ECG –low voltage, electrical alternans ●Renal failure with uremia ●Myxedema • CXR Large cardiac silhouette, clear lung fields ●Aortic dissection extending into the pericardium ●Selected drugs • Echocardiography

https://www.uptodate.com/contents/diagnosis‐and‐treatment‐of‐ pericardial‐effusion

Pericardial Effusion Pericardial Effusion

Low voltage with alternating amplitude of QRS complexes

Pericardial Effusion Esophageal Tear

• Iatrogenic injury e.g. and dilatation of strictures. • pharyngoesophageal junction where the wall is weakest. • Infectious and inflammatory response can disseminate easily to nearby vital organs. • Morbidity may be due to pneumonia, , empyema, polymicrobial , and multiorgan failure • Older age (>65 y) and underlying (tumor, stricture) predisposes toward perforation with instrumentation • Spontaneous esophageal rupture (Boerhaave syndrome) from sudden increase in intraluminal pressures, usually due to violent vomiting or retching • Fifty percent have history of GERD

Ugo, A; http://emedicine.medscape.com/article/775165‐overview#a6 Esophageal Tear Esophageal Tear

• The classic presentation is severe vomiting or • ; pain in the neck, upper back, chest, or abdomen; dysphagia; ; dysphonia; or retching followed by acute, severe chest or dyspnea following esophageal instrumentation should epigastric pain. raise suspicion for perforation. • Patients with thoracic or abdominal perforations may • Has also been reported with childbirth, weight present with any of the above symptoms, as well as lifting, fits of coughing or laughing, hiccuping, low back pain, shoulder pain referred from diaphragmatic irritation, increased discomfort lying blunt trauma, seizures, and forceful flat, or true acute abdomen. swallowing • The ingestion of a caustic toxin or foreign body preceding any of the above symptoms may indicate perforation Ugo, A; http://emedicine.medscape.com/article/775165‐overview#a6 Ugo, A; http://emedicine.medscape.com/article/775165‐overview#a6

Esophageal Tear Esophageal Tear

• in the neck or chest in up to • Labs not helpful 60%. • Tachycardia and tachypnea • CXR ‐ and subcutaneous • The Mackler triad, consisting of vomiting, chest pain, emphysema high and subcutaneous emphysema present in about 50% of • Esophagogram cases. • The Hamman sign is a raspy, crunching sound heard • CT over the precordium with each heartbeat caused by • Surgical Consult mediastinal emphysema, • In cases of delayed presentation, patients may be critically ill and present with significant hypotension.

Pneumothorax Pneumothorax Risk Factors • Following trauma or pulmonary procedures. • Tobacco • Underlying lung disease (COPD, Cystic Fibrosis, • HIV infected patients with pneumocystis Asthma) pneumonia. • Younger males who are tall and thin. • Young females with endometriosis may • The accumulation of air in the pleural space experience menses‐related pneumothoraces can lead to tension pneumothorax with • SCUBA diving compression of the mediastinum, causing • Air travel may precipitate recurrence in rapid clinical deterioration and death if patients with an incompletely healed unrecognized pneumothorax Pneumothorax Tension Pneumothorax Findings Chest radiograph • Pleuritic one sided chest pain shows a large collection • Dyspnea of gas in the left hemithorax with • Unilateral decreased breath sounds inversion of the left hemidiaphragm and • CXR diagnostic. Lateral decubitus may be cardiomediastinal shift needed for in determinant studies. to the right. The left intercostal spaces are wider than the right ones.

CharacteristicsCondition of Duration Major of pain Noncardiac Character Chest of pain Pain Visceral, substernal, worse Non‐Ischemic Cardiac Chest Pain with recumbency, no Gastroesophageal reflux 5 to 60 minutes radiation, relief with food, antacids • CHF Visceral, spontaneous, substernal, associated with Esophageal spasm 5 to 60 minutes • Chest discomfort with progressive dyspnea, cough, fatigue cold liquids, relief with and edema nitroglycerin Visceral, burning, epigastric, • Stress Cardiomyopathy (Takotsubo) Peptic ulcer Hours relief with food, antacids, normal ECG • Physical or emotional stress or critical illness. Symptoms Visceral, epigastric, mimic AMI Biliary disease Hours interscapular colic, occurs after meals Superficial, positional, arm, • Valve disease Cervical disc Variable neck • Hypertrophic Cardiomyopathy Superficial, positional, worse Musculoskeletal Variable with movement, local • Typical or atypical with DOE tenderness Visceral, substernal, Hyperventilation 2 to 3 minutes tachypneic, anxious Aggravated by swallowing, Thyroiditis Persistent neck, throat tenderness

Chest Pain Diagnostic Approach

• Prioritize Life Threatening Conditions • Patients should be sent to ER for evaluation – Unstable Vital Signs – Abrupt Onset – Concern for ACS, PE, Dissection, Pneumothorax, Esophageal Tear Other Factors Physical Exam

• Age • Vital Signs • Past Medical History – Unstable – immediate ER referral – Hypoxemia, Fever, Pulse and Respiratory Rate – HTN, DM, Dyslipidemia CAD – BP Both Arms – Cancer PE • Cardiovascular Exam • Risk Assessment – Pulses, Heart Sounds, Murmurs, Rubs, JVD – Tobacco, cocaine, life style • Pericarditis‐ Examen patient laying down and sitting up • – Framingham Risk Score may be helpful Pulmonary Exam – symmetric breath sounds, wheezing, crackles, and evidence of consolidation

Physical Exam for Musculoskeletal Physical Exam Chest Pain Musculoskeletal examination Chest Wall Examination • Musculoskeletal Cervical spine Observation • Palpation with pain reproducibility Shoulders localized swelling • Skin Thoracic spine Palpation • Hyperesthesia and Rash Zoster Localized tenderness AC and Sternoclavicular Joints • Subcutaneous emphysema Boerehaave Syndrome, Mobility Sternum and xiphoid joints pneumothorax Chest expansion Costovertebral joints • Abdominal Lumbar spine Maneuvers • Distension, RUQ tenderness, epigastrium, abdominal aorta Forward flexion crowing rooster maneuver Extremities Sacroiliac tenderness compression horizontal arm flexion Unilateral enlargement, pain and erythema DVT Tender points hooking maneuver Chest wall examination

Chest Pain: Laboratory Evaluation: Cardiac

 EKG ‐ serial • Stable symptoms  Chest x‐ray • Stress test  Blood studies • Echo • CBC • Cardiac enzymes • Consider evaluation in patients with atypical • Liver function symptoms • Lipase – Multiple risk factors • D‐Dimer – Diabetics, elderly, women • BNP  Imaging: Echo, Ultrasound, CT, Nuclear Study Adverse Cardiac Events (12 mo out)

Patients discharged with chest pain of unclear origin: Abnormal ECG OR 9.5 (2.0 - 45.8)

Preexisting DM OR 7.1 (1.8 - 27.2)

Preexisting CAD OR 28.4 (3.5 - 229.0)

Prina, Ann Emerg Med. 2004 Jan;43(1):59-67

Acute Upper Back Pain

. 49 yo man with long standing hypertension . Sudden mid back and Case Presentations interscapular pain . Associated with nausea and sweats . Unrelieved by change of position . Some radiation toward the left chest Wide mediastinum - Dissection

Management Aortic Dissection Wrestler with Chest Pain

• Involve CT surgery early . 18 yo high school • Blood pressure control wrestler develops right‐ – Goal SBP 120‐130 mmHg sided chest pain while – Beta blockers are first line (Labetalol and Esmolol) pinning his opponent. – Can add vasodilators i.e. nitroprusside • Admission to ICU – Ascending dissections will need surgery – If dissection is only descending, management is only medical

Pneumothorax Alcoholic with Chest Pain and Cough Hyperemesis with Chest Pain

. 45 yo alcoholic man . 26yo G1P0 at 10wks with fever, chills and presents with 4 days productive cough refractory emesis and 12 over two days hours progressive, severe substernal chest pain

Pneumomediastinum - Boerhaave’s RUL Pneumonia

Smoker with Chest Pain Chest Pain What is the Diagnosis?

70 male with PMH ‐ asthma/COPD, HTN, HLD, and prostate CA. Substernal, nonradiating chest tightness with shortness . 68 yo former smoker with of breath and vertigo after working out. persistant, non‐ BP and HR were 96/65 and 105. exertional, left substernal No palpitations, nausea, vomiting, diaphoresis, and left shoulder pain Nitrates which helped to relieve the pain. EKG showed sinus tachycardia, RBBB and inferior ST changes Troponins were positive at 0.609 rose to 5.294. ECHO was performed which revealed a mildly depressed EF of 45‐50% with inferolateral hypokinesis. The patient was started on ACS protocol with Heparin, ASA, and Plavix, and the decision was made to transfer him for cardiac cath and possible PCI for NSTEMI.

Baseline ECG Chest Pain Acute Chest Pain What is the Diagnosis? What is the Diagnosis? Answer A. Pulmonary Embolus • 46 year‐old male with history of hypertension and smoking • Was helping a friend move furniture. Developed acute onset sharp chest pain radiating to left arm. • Associated with nausea, vomiting and dyspnea. • Pale and distressed

Acute Chest Pain Acute Chest Pain What is the Diagnosis? What is the Diagnosis • T 98.4*, HR 74, 140/90 in both arms and legs, RR 18, sat 94%. • Normal heart and lung exam. • ECG Acute Chest Pain Acute Chest Pain What is the Diagnosis What is the Diagnosis

Answer E. Esophageal Tear

Acute Chest Pain Acute Chest Pain What is the Diagnosis What is the Diagnosis • A 16‐year‐old boy with no relevant medical or traumatic history presented with 3‐hour history of nonradiating central crushing chest pain. There was no current or past use of cocaine or other stimulants. He was afebrile. His cardiovascular examination was unremarkable. • Initial Troponin was 2 Xs upper normal • Echo – hypokinesis of the inferolateral wall.

Acute Chest Pain Acute Chest Pain What is the Diagnosis What is the Diagnosis Acute Chest Pain Summary What is the Diagnosis  Careful history and physical are imperative  While history or physical exam can suggest likely alternate diagnoses, none can rule out serious etiology  Neither NTG nor GI cocktail response, nor reproducibility on palpation are diagnostic  Post‐prandial pain may be ischemic  Use caution when diagnosing “non‐cardiac” chest pain in patients with CAD or risk for CAD  Atypical may be typical of something else  Observation can be key Answer D. Myopericarditis