Many Faces of Chest Pain Ian McLeod, MS, MEd, PA-C, ATC Northern Arizona University ASAPA Spring Conference 2019 Disclosures • I have no financial disclosures to report Objectives • Following the presentation attendees will be able to: • Develop a concise differential diagnosis for patients with chest pain including cardiac and non-cardiac causes. • Describe key clinical characteristics and management of the following chest pain etiologies: angina, embolism, gastroesophageal reflux, costochondritis, costochondral dysfunction, anxiety and pneumonia. • Discuss appropriate use of diagnostic studies utilized in the evaluation of patients presenting with chest pain. Chest Pain – Primary Care Setting • ~1.5% of all visits are for chest pain • Musculoskeletal 35-50% • Gastrointestinal 10-20% • Cardiac 10-15% • Pulmonary 5-10% • Psychogenic 1-2% Chest Pain Differentials • Cardiac • Pulmonary • Stable angina • Pneumonia • Acute coronary syndrome • Pulmonary embolism • Pericarditis • Spontaneous pneumothorax • Aortic dissection • Psych • MSK • Panic disorder • Costochondritis • Tietze syndrome • Costovertebral joint dysfunction • GI • Gastroesophageal reflux disease (GERD) • Medication induced esophagitis Setting the stage • Non-traumatic • Acute chest pain • Primary care setting • H&P • ECG • CXR Myocardial Ischemia Risk Factors • Increasing age • Male sex • Chronic renal insufficiency • Diabetes Mellitus • Known atherosclerotic disease → coronary or peripheral • Early family history of coronary artery disease • 1st degree male relative < 55 y/o • 1st degree female relative < 65 y/o • ASCVD risk calculator Myocardial Ischemia – Pain Characteristics • Pain descriptors • Uncharacteristic / unlikely • Deep (retrosternal) • Sharp, knife-like, stabbing • Poorly localized → center or left sided • Change with respiration or body • Oppressive position • Pressure • Provoked / worsened with chest wall • Heaviness palpation • Tightness • Constriction • Radiation • Neck • Jaw • Shoulder • Arms Myocardial Ischemia – Pain Characteristics • Stable angina • Gradual onset and offset • Precipitated by exertion and relieved by rest • Emotional stress • Cold • Sublingual nitroglycerin • Acute coronary syndrome → unstable angina or AMI • Angina at rest • New-onset angina • ↑ angina severity or ↑ duration Myocardial Ischemia – Associated Symptoms • Dyspnea • Atypical presentations→ • Nausea and vomiting females, dementia, older patients • Diaphoresis • Absence of chest pain • Presyncope • Epigastric discomfort • Palpitations • Dyspnea • Indigestion • Nausea and vomiting • Weakness • Pleuritic chest pain Barstow C, et al. 2017 Myocardial Ischemia – Diagnostic Testing • Electrocardiogram • ST Elevation MI (STEMI) • ST segment elevation at the J-point in 2 contiguous leads with the cut-points: • ≥1 mm in all leads other than leads V2-V3 • Leads V2-V3: • ≥2 mm in men ≥40 years • ≥2.5 mm in men <40 years • ≥1.5 mm in women regardless of age • Non-ST Elevation MI (NSTEMI) • Horizontal or downsloping ST-depression ≥0.5 mm in two contiguous leads and/or • T inversion >1 mm in two contiguous leads with prominent R wave Limb and Chest Lead “Views” of the Heart Myocardial Injury – ST Segment Elevation • Zone of injury does not repolarize completely so it remains more positive than surrounding tissue leading to ST segment elevation Myocardial Ischemia – ST Segment Depression • ST segment depression • Area of ischemia is more negative than surrounding tissue Myocardial Ischemia – T Wave Inversion • T wave inversion because ischemic tissue does not repolarize normally • ST-segment elevation myocardial infarction (STEMI) • ST elevations across the precordium (V1-V5) with reciprocal ST depressions inferiorly (II, III, aVF) • Concerning for proximal left anterior descending (LAD) lesion causing ischemia • Episode of chest pain at rest in a patient with unstable angina • ST-segment depression above 1 mm is present in leads V4 to V6 • Chest pain and ST-segment depression disappeared promptly after the administration of sublingual nitroglycerin Acute Pericarditis • M>F • 20 to 50 y/o MC • Causes • Idiopathic (presumed viral) • Infectious • Viral / Bacterial / Fungal / TB / HIV • Non-infectious • Connective tissue disease / autoimmune disorders • Malignancy • Cardiac disorder • Renal failure (uremia) • Radiation • Medication adverse reaction • Trauma Acute Pericarditis – History • Sudden onset of retrosternal chest pain (>95%) • Sharp and pleuritic • ↑ coughing, inspiration and / or swallowing • ↑ lying supine • ↓ sitting and leaning forward • +/- radiating pain → similar to MI • Prolonged duration • +/- Preceding viral syndrome (URI or GI) • +/- Fever • +/- Dyspnea Pericarditis – Physical Exam • Pericardial friction rub • Scratching or grating sound • Highly specific • Loudest left sternal border • Increases with leaning forward • +/- Fever (>100.4°F) • +/- Tachypnea • +/- Tachycardia Yelland, MJ. Outpatient evaluation of the adult with chest pain. In: UpToDate, Aronson, MD (Ed), UpToDate, Waltham, MA, 2018. Acute Pericarditis – Diagnostic Studies • ECG • Diffuse concave ST elevation • PR depression • Blood work • CBC → leukocytosis if infectious • ESR / CRP → elevated • Cardiac troponin → elevation indicates myopericarditis • Additional bloodwork based upon suspected causes • CXR → typically normal Acute Pericarditis – Electrocardiogram Imazio, M. Acute pericarditis: Clinical presentation and diagnostic evaluation. In: UpToDate, LeWinter, M (Ed), UpToDate, Waltham, MA, 2017. Acute Pericarditis – Treatment • High-risk features that necessitate hospital admission • Fever > 100.4°F • Subacute course • Hemodynamic compromise (cardiac tamponade) • Large pericardial effusion • Immunocompromised • Current anticoagulant therapy • Elevated cardiac biomarkers • Failure to clinically improve with 7 days of appropriate NSAID therapy Acute Pericarditis – Treatment • Idiopathic (presumed viral) • Ibuprofen 600 to 800 mg TID or Taper when symptom • Aspirin 650 to 1000 mg TID or free & CRP normalizes • Indomethacin 25 to 50 mg TID • Plus colchicine 0.5 mg QD if < 70 kg or BID if >70 kg x 3 months • Bacterial • Vancomysin 30 mg/kg/day and • Ceftriaxone 3 mg/kg/day • Pericardiocentesis • Restrict from exertional activities until symptoms resolve and labs normalize Aortic Dissection • Acute severe / sharp chest and back pain • +/- ripping or tearing quality • UE peripheral pulses and blood pressures may be diminished or unequal • Surgical emergency Costochondritis • MC cause of MSK anterior chest pain • F=M • > 40 y/o • Idiopathic – hx of preceding illness with coughing or recent strenuous exercise is common • Inflammation of costochondral or chondrosternal junction • Unilateral • 90% > 1 level • 2nd – 5th ribs most common Mayo Clinic Costochondritis – History & Physical Exam • Sharp, aching or pressure like pain • Anterior • May radiate laterally • ↑ deep breathing, coughing, sneezing and laughing • ↑ upper body movements • Reproduction of pain with palpation • No overlying discoloration or swelling • ROM restriction uncommon Mayo Clinic Tietze Syndrome • Rare • F=M • < 40 y/o • Idiopathic – hx of preceding illness with coughing • Inflammation of costochondral or costosternal junction • Unilateral • 70% 1 level only • 2nd – 3rd ribs most common Tietze Syndrome – History & Physical Exam • Sharp, aching or pressure like pain • Anterior • May radiate laterally • ↑ deep breathing, coughing, sneezing and laughing • ↑ upper body movements • Reproduction of pain with palpation • Swelling overlying the involved joints • ROM restriction uncommon Costochondritis & Tietze Syndrome – Treatment • Analgesics • NSAIDs • APAP • Activity modification • Variable course • Weeks to months • Rare to exceed a year • Chest wall tenderness has a tendency to linger • Refractory cases → lidocaine/corticosteroid injection Costovertebral Dysfunction • F>M • Recent history of restricted chest posture • Rib hypomobility / “subluxation” • Functional disruption of the costovertebral and costosternal articulations • Alteration of rib mechanics with inspiration and expiration Costovertebral Dysfunction – History • Sharp stabbing pain • Present upon waking • Unilateral • Anterior and posterior → “feels like a knife is being stabbed through my chest” • May radiate laterally along dermatomal distribution • ↑ deep breathing → subconscious alteration of inspiratory effort • ↑ coughing, sneezing and laughing • ↑ trunk movements Costovertebral Dysfunction – Physical Exam • Reproduction of pain with palpation • PA mobilization of adjacent vertebra • ↑ pain • Hypomobility • Protective muscle spasm • Restricted trunk range of motion • Extension, ipsilateral rotation and ipsilateral flexion → limited by pain • Opposite movements → limited by tightness • Sudden reduction in pain with physical exam → rib relocation Costovertebral Dysfunction – Management • Pharmacologic • Analgesics • NSAIDs or • APAP • Muscle relaxants • Manual therapy • Physical therapy • Chiropractic therapy • Massage therapy GERD • Reflux esophagitis • Abnormal LES function • Reflux of stomach contents into esophagus • Prolonged exposure to gastric acid • Contributing factors • Hiatal hernia • Obesity • Pregnancy (30 to 50%) and exogenous estrogen • Diet and medications Mayo Clinic GERD – History & Physical Exam • Heartburn • Alarm symptoms • Retrosternal burning or squeezing • Anemia • ↑ lying down, bending over • Loss of weight • MC postprandial • +/- nocturnal pain • Anorexia • +/- exacerbation due to emotional • Recent onset of progressive stress symptoms