Chest Pain 101: Fine Tuning Your Differential in the Outpatient Setting

Krysten Pilkington MNSc, APRN, AG-ACNP-BC Where do we start?

Onset Location Duration Characteristics Aggravating & Alleviating factors Radiation Treatment Severity Differentials • CAD • Cholecystitis • Angina • Anemia • Stable • PE • Unstable • Pneumothorax • Microvascular • Pleurisy • Peri/myo/endocarditis • Musculoskeletal • • Arrhythmias Illicit drugs (cocaine, methamphetamine) • Gastric disease • Anxiety • Ulcers/reflux/GIB • Psychosomatic • Obstructive sleep apnea Establish A Baseline

• Risk factors • Family history • Smoking • Obesity • Hypertension • Diabetes • Functional status • History of CAD • Symptoms prior to previous events • Nitrate responsive? • Last ischemic evaluation/echocardiogram • Cardiac symptoms • Angina, dyspnea, palpitations, near syncope, syncope, dizziness, activity intolerance “My chest hurts and I get short of breath with any activity. I am so tired I can barely get out of bed. I think it’s my heart. My father died of a heart attack.” • 80 y/o male with CAD, ischemic CMO EF 35%. • Sub-sternal chest pressure, worsening over 3 weeks. • CP exertionally related, dizziness on standing, no syncope. • He used to walk his dog around the block until he hurt his back, has been taking large doses of ibuprofen and meloxicam. • Has not been paying attention to stool. • Exam: pale, HR 123 ST, BP 96/65 • Differentials: anemia, GIB, unstable angina, worsening heart failure • Lab: H/H 6.4/19. MCV 90 • DX: Anemia • TX: send to hospital for admission, PRBCs, GI consult “My chest still hurts. It hurts right in the middle, usually when I wake up. I sometimes sleep in the recliner, that seems to help. Other times I feel my heart squeezing when I’m not doing anything! ” • 65 y/o female, history of CAD, DM, reflux. • Onset 6 months ago, burning, pressure-like pain. • Not exertionally related, sometimes belching makes it better. It is nitrate responsive. • Last RSE 2 months ago, no ischemia at 80% MPHR. Not a smoker. • Exam: BP normal, HR 80, no EKG changes, unimpressive • Differentials: GERD, PUD, CAD • Diagnostics: NST (negative) Labs (no anemia) • DX: GERD • TX: PPI or H2 blocker, refer to GI for further evaluation Reflux

“My GI doctor sent me here. I was going to have my esophagus stretched, they hooked me up to the heart monitor and noticed I had bigeminy.”

• 57 y/o female, HTN, esophageal strictures. Non-smoker, has heart disease in her family. • Sub-sternal chest pressure when she jogs, better when she slows down, it never lasts more than a few minutes. • Dyspnea on exertion, does not feel palpitations with bigeminy. • Exam: BP normal, HR 80, bigeminy, monomorphic. Otherwise, unimpressive. • Differentials: stable vs unstable angina, CAD, electrolyte imbalance, structural heart disease • Diagnostics: labwork (normal), rest/stress echocardiogram, event monitor • DX: stable angina Circumflex coronary artery, pre and post stenting Left anterior descending coronary artery, pre and post stenting CC: “I woke up with chest pain a few nights ago, felt like pressure, recurred twice since. I sometimes get really dizzy and feel like I am going to pass out.” • 58 y/o male, denies family history of CAD. Has COPD, no longer smokes. • Sub-sternal CP not associated with exertion, no radiation, lasted for about 5 minutes. • Reports some DOE. Dizziness occurs with and without position changes. No palpitations. • Exam: BP normal, SB, breath sounds slightly diminished, otherwise unremarkable • Differentials: stable vs unstable angina, OSA, reflux, arrhythmia, dehydration, anemia • Diagnostics: labs, rest/stress echo, event monitor • Echo revealed 5.7 cm aneurysm of ascending aorta.

“My chest hurts when I walk and I am short of breath.”

• 46 y/o male with significant CAD history, CABG x 3 at age 29. HX HTN, dyslipidemia, GERD, asthma, OSA. Non-smoker. • Onset this week, positive for angina, dyspnea, orthopnea, PND. Denies syncope, near syncope, palpitations. • Sub-sternal CP, worse with exertion, radiating to jaw, nitrate responsive, sometimes takes 3 TNG to alleviate CP. Worsening over the past few days. • Exam: nervous white male patient, distressed. BP 175/71, HR 92, NSR (no ST changes) • Differentials: unstable angina, NSTEMI, CAD, esophageal spasms • DX: Unstable angina • Admit to AHH, troponin not elevated Left main 80% stenosis, pre and post PCI References

• Angina. (2018). Retrieved from https://www.nhlbi.nih.gov/health-topics/angina • Chapman AR, et al. Heart 2017;103:10–18. doi:10.1136/heartjnl-2016-309530 • GERD. (2018). Retrieved from https://zovon.com/drugs/drug- by-condition/gastroesophageal-reflux-disease-gerd-common- drugs/ • Nitrates. (2018). Retrieved from https://www.amboss.com/us/knowledge/Nitrates • Roman, S. & Kahrilas, P. (2013). Management of Spastic Disorders of the Esophagus Gastroenterol Clin North Am. 2013 Mar; 42(1): 27–43. doi: 10.1016/j.gtc.2012.11.002 • https://doctorlib.info/surgery/master-techniques-surgery- thoracic/5.html