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 • Pain may last minutes to hours • Melena or hematemesis • Some relief with antacids • Swallowing difficulties (dysphagia or • Regurgitation odynophagia) • Dysphagia • Chest pain → may mimic angina • Nausea / vomiting (rare) • Nonspecific physical exam findings GERD – Treatment
• No alarm symptoms • Lifestyle and dietary modifications combined with 4-8 week trial of PPIs • Alarm symptoms • GI consult (urgent or emergent) Medication Induced Esophagitis • F>M • Mean age 41.5 y/o • Indirect mechanism • Adverse reactions → weakening LES • Disrupting protective barrier → NSAIDs • Medication induced infection → Antibiotics • Direct mechanism • Medication lodged at area of esophageal narrowing → aortic arch • Local caustic injury to adjacent mucosa • Antibiotics: tetracycline, doxycycline and clindamycin • Bisphosphonates • Potassium chloride, quinidine preparations, iron compounds Medication Induced Esophagitis – History & Physical Exam • Sharp retrosternal pain or heartburn • Odynophagia • Dysphagia • Infrequent but alarming symptoms • Inability to swallow saliva • Hematemesis • Abdominal pain • Weight loss • Nonspecific physical exam findings Medication Induced Esophagitis – Treatment
• Discontinue medication or switch to liquid form • +/- acid suppression agents • Endoscopy indications: • Alarm symptoms • Severe pain • Persistent symptoms >1 week after discontinuing medication Pneumonia
• Infection of the lung parenchyma • Bacterial • S. Pneumoniae ~60% of all CAP • Viral • Fungal • Risk factors • Immunocompromised • <2 y/o or > 65 y/o • Alcohol abuse • Tobacco use • Asthma • Lung disease • Heart disease • Institutionalization Pneumonia
• Alveolar inflammation • Accumulation of WBCs, fluid and proteins in the alveolar space • Impairment of gas exchange
Ramirez, JA. Overview of community-acquired pneumonia in adults. In: UpToDate, File, TM (Ed), UpToDate, Waltham, MA, 2018. Pneumonia – History
• Specific (more common) • Non-specific • Cough • Sweats, chills, rigors • +/- sputum • Fatigue, myalgias • +/- hemoptysis • Headache • Pleuritic pain • Chest discomfort • Dyspnea • Abdominal pain • N/V • Anorexia • Mental status changes Pneumonia – Physical Exam
• Asymmetric breath sounds • Rales • Egophony • ↑ tactile fremitus • Local dullness to percussion • Fever > 100.4° F • Tachypnea • Tachycardia • ↓ O2 saturation Pneumonia – Diagnostic Studies
Radiology Masterclass Pneumonia – Treatment (CURB-65)
• CRB-65 (remove BUN) • 0 → outpatient • 1-2 → consider hospitalization • 3-4 → urgent hospitalization Pneumonia – Treatment
• CAP outpatient empiric treatment • Healthy with no antibiotic use in past 3 months • Macrolide or doxycycline • Potential for macrolide resistance or antibiotic use in past 3 months • Respiratory fluoroquinolone or high dose amoxicillin* (or Augmentin*) + macrolide * Ceftin (cefuroxime) alternative option Pulmonary Embolism Pulmonary Embolism Pulmonary Embolism – History & Physical Exam Symptoms Signs • Dyspnea 73% • Tachypnea 54% • Rapid onset within seconds or • LE signs of DVT 47% minutes • Tachycardia 24% • Pleuritic chest pain 66% • Rales 18% • Cough 37% • Decreased breath sounds 17% • Orthopnea 28% • Fever, mimicking pneumonia 3% • Calf or thigh pain and/or swelling 44% • ↓ O2 saturation • Wheezing 21% • Hemoptysis 13% • Pre(syncope) <10% Pulmonary Embolism – Wells Criteria
• Scoring < 2 low probability (3.4%) 2-6 moderate probability (27.8%) > 6 high probability (78.4%) Pulmonary Embolism – Diagnostic Studies
• Electrocardiogram → common but non-specific abnormalities • Sinus tachycardia and non-specific T wave changes → 70%
• Classic S1Q3T3 pattern <10% • S wave in lead I, Q wave in lead III and inverted T wave in lead III • CXR • 50% are normal / non-diagnostic → useful in ruling out other conditions • PE specific abnormalities • Hampton's hump (pulmonary infarction) → wedge shaped consolidation in the periphery w/ base against pleural surface • Westermark’s sign (vasculature collapse) → sharp cut-off of pulmonary vessels with distal hypoperfusion (oligemia) Thompson, BT, et al. Acute pericarditis: Clinical presentation, evaluation, and diagnosis of the nonpregnant adult with suspected acute pulmonary embolism. In: UpToDate, Mandel, J (Ed), UpToDate, Waltham, MA, 2018. Thompson, BT, et al. Acute pericarditis: Clinical presentation, evaluation, and diagnosis of the nonpregnant adult with suspected acute pulmonary embolism. In: UpToDate, Mandel, J (Ed), UpToDate, Waltham, MA, 2018. Spontaneous Pneumothorax
• Primary • M:F 6:1 • Tall, thin young men (20-40 y/o) • Rupture of small blebs, usually located near the apex of the upper lobes • Secondary • Most common: COPD • Other: pneumonia, bronchogenic carcinoma, mesothelioma, sarcoidosis, tuberculosis, cystic fibrosis, iatrogenic Spontaneous Pneumothorax – History
• Pleuritic chest pain (90%) • Sudden onset of sharp pain → progresses to becoming dull after a few hours • Unilateral • Dyspnea (80%) • Cough (10%)
• Symptom severity is related to the size of the pneumothorax Spontaneous Pneumothorax – Physical Exam
• Tachycardia • Tachypnea • ↓ O2 saturation • Diminished breath sounds • Hyperresonance to percussion • Decreased tactile fremitus • Subcutaneous emphysema Spontaneous Pneumothorax – Diagnostic Studies
Radiology Masterclass Spontaneous Pneumothorax – Diagnostic Studies
Radiology Masterclass Spontaneous Pneumothorax – Diagnostic Studies
Radiology Masterclass Panic Disorder
• F>M • Median age 24 y/o • Risk factors • Neuroticism→ proneness to experiencing negative emotions • Anxiety sensitivity → disposition to believe that anxiety symptoms are harmful • Childhood sexual and physical abuse • Smoking • Life stress • Anticipate catastrophic outcome from a mild physical symptom • Chest pain → heart attack Panic Disorder – DSM V Criteria
• Recurrent unexpected panic attacks • Abrupt surge of intense fear or discomfort → peaks within several minutes • 4 or more associated symptoms • Palpitations, pounding heart, or accelerated • Feeling dizzy, unsteady, light-headed, or faint heart rate • Chills or heat sensations • Sweating • Paresthesias (numbness or tingling • Trembling or shaking sensations) • Sensations of shortness of breath or • Derealization (feelings of unreality) or smothering depersonalization (being detached from • Feelings of choking oneself) • Chest pain or discomfort • Fear of losing control or “going crazy” • Nausea or abdominal distress • Fear of dying • Inquire about previous workup Panic Disorder – Treatment
• Cognitive behavioral therapy (CBT) • SSRI or SNRI → considering tapering after ~1 year • Sertraline (Zoloft) – 50mg/day – increase dosage after 6 weeks • Venlafaxine (Effexor) – 37.5 mg/day – increase dosage after 6 weeks • Partial response after 8 – 12 week trial consider adding clonazepam (Klonopin)
Thank You [email protected] References
• UpToDate • Radiology Masterclass (https://www.radiologymasterclass.co.uk/) • Barstow, C, et al. Acute Coronary Syndrome: Diagnostic Evaluation. Am Fam Physician. 2017; 95(3): 170-177. • McConaghty, JR and Oza, RS. Outpatient Diagnosis of Acute Chest Pain in Adults. Am Fam Physician. 2013; 87(3): 177-182. • Proulx, AM and Zryd, TW. Costochondritis: Diagnosis and Treatment. Am Fam Physician. 2009; 80(6): 617-620. • Jameson J, et al. Harrison's Principles of Internal Medicine: Chest Discomfort, 20e; 2018. https://accessmedicine.mhmedical.com/ViewLarge.aspx?figid=192010949