ER June 16, 2009

CHEST PAIN

Stratification RISK
Risk Factors
Who gets what?

List the risk factors Clinical Suspicion

Testing
2

Chief Complaint
What will be

presenting complaints?
MALE FEMALE

HPI
What are the KILLERS
1. 2. 3. 4. 5. 6. 7. 8.

Myocardial infarction Dissecting aortic aneurysm Pericarditis with tamponade PE Pneumonia Tension pneumothorax Rupture esophagus (Boorhaves syndrome) Cancer

What are the Most Commons

4

Causes

Acute Coronary Syndrome Aneurysm, Abdominal Aneurysm, Thoracic Angina Pectoris

Mitral Stenosis Mitral Valve Prolapse Multifocal Atrial Tachycardia Myocardial Infarction

Torsade de Pointes Transplants, Heart Ventricular Tachycardia Wolff-Parkinson-White Syndrome

Aortic Regurgitation
Aortic Stenosis Atrial Fibrillation Atrial Flutter Cardiomyopathy, Dilated Cardiomyopathy, Restrictive Congestive Heart Failure and Pulmonary Edema Dissection, Aortic Dissection, Carotid Artery Dissection, Vertebral Artery Heart Block, First Degree Heart Block, Second Degree

Myocarditis
Myopathies Congestive Heart Failure Pericarditis and Cardiac Tamponade Peripheral Vascular Disease Premature Ventricular Contraction Pulmonic Valvular Stenosis Shock, Cardiogenic Hypovolemica Sinus Bradycardia Superior Vena Cava Syndrome Syncope Tetralogy of Fallot Thoracic Outlet Syndrome

Heart Block, Third Degree

Mitral Regurgitation

Pulmonary

Pulmonary Asthma Bronchitis Chronic Obstructive Pulmonary Disease and Emphysema Hyperventilation Syndrome Pleural Effusion Pneumonia, Aspiration Pneumonia, Bacterial Pneumonia, Empyema and Abscess Pneumonia, Immunocompromised Pneumonia, Mycoplasma Pneumonia, Viral Pneumothorax, Iatrogenic, Spontaneous and Pneumomediastinum Pulmonary Embolism Pleuritic CP
6

Musculoskeletal Chest Wall Pain

11-50 %

Trauma
Costochondritis

Other
Psychological GI Related
GERD

Undifferentiated

ROS
Killers
Cardio Pulmonary

Associations to DD
Claudication (PAD) increased risk of CAD

Most Common
9

Past Medical History Surgical History

Specifically ask about other disease processes

that increase the risk of whatever you are concerned about

DM HTN When was the last time you saw a doctor? Have you ever seen a doctor for blood pressure, cholesterol, or your heart ?
10

Medications & Allergies

Meds that alert you to increased risk New Meds
Antacids, ASA, when & why did you start taking

that medication

11

Family History
Tell me about your (mother, father, brothers,

sisters) health
Specifically CAD, PAD, Age when problems

started or death

12

Social History
Occupation
Stress

Tobacco
Pack years

Alcohol Do you use any street drugs

If you want to know about Marijuana ? ASK ABOUT COCAINE (re: B-Blocker) UDS? Unopposed alpha receptors Auto matically do a drug screen
13

Physical Exam
Vitals and EKG Constitutional Skin (xanthoma, splinter hemorrhages) Head Eyes (copper wire) ENT (ear creases) Neck

Heart
14

Physical Exam
Lungs Abdomen GU (not examined) Musculoskeletal / Extremities Neuro Heme-Lymph Psychiatric (anxious)

Endocrine (thyroid, DM)

15

Differential
List 10

Think about the HALMARKS of those ten

Have you asked questions or performed a

physical exam that includes or excludes these

If not what test do you need to
Confirm your suspected diagnosis Exclude the KILLERS
16

ER Lab orders

CBC BMP LFT if indicated Lipase CIP Cardiac Enzymes PTT/PTT/ INR
You need all three (unlike monitoring warfarin)

BNP D-Dimer (=/-)

17

ER Orders Radiology
Chest x-ray
What are you looking for? If you think chest pain is muscle pain are not getting a CT

CT Scan-not used in everyone- if think they are

having N,

CT PE Study (CT Pulmonary Angiogram) CT Angiogram of the Aorta CT Angiogram of the Heart-specialized scanner CT TRIPLE RULE OUT-aorta angiogram abd aorta angiogram out PE

Other test as indicated to rule out differentials Pts are taken to cath lab every day on sxs alone.

They are not done emergency, price $1500

18

ER Medication Orders
ASA ON ARRIVAL If EKG changes that indicate MI or Angina, or High Clinical

Suspicion go right to the ACS PROTOCOL and Notify Cardiology

Remember CXR BEFORE Starting Heaprin https://www.musc.edu/cce/ORDFRMS/pdf/cpedadmit.pdf https://www.musc.edu/cce/ORDFRMS/pdf/ah_card_cardiologyhe

parinprotocol.pdf

Nitroglycerine (based on suspicion)

0.4 mg SL-see if it helps pain can also help with esophageal pain

as well 1-2 inches of paste to chest IV Infusion (drip) 5 or 10 micrograms / min

You will titrate this to pain AND BP or hypotensive

19

ER Chest Pain Workup

Oxygen Nitroglycerine (based on suspicion)
0.4 mg

GI Cocktail EKG CXR CMB, BMP, Trop, INR, UDS, D-Dimer

20

21

22

Delta (change)
An approach using the change in biomarkers over two hours was

investigated in a comprehensive strategy of chest pain testing. There was a 93 percent sensitivity for acute myocardial infarction within 24 hours using a two hour strategy incorporating baseline ECG, cardiac markers, two hour delta CK-MB, two hour delta troponin and serial ECGs

In a similar investigation, delta CK-MB was more accurate than

myoglobin for diagnosing early myocardial infarction.

However, the sensitivity of the delta CK-MB varied from 73 to 93 percent depending on the cutoff used, emphasizing the importance of using an appropriate threshold for a positive change

23

Now What?
When you have positive findings its easy What if everything is normal-what do you do, a lot is clinical

suspicion, we can call cardiologist and see if they will hold overnight and stress test the pt. PA may stress them and they send them to

Admit-If having a stemi, unstable angina Discharge

Medicine follow up Cardiology follow up

____ hrs. observation

24

Should I stay or should I go?

CP with identified cause
Depend on the cause

CP with ekg changes CP 1 risk factor CP 2 risk factors CP 3 risk factors CP 4 risk factors

25

Escalating the outpatient workup

H &P / Risk factors REVIEW OF RECORDS

EKG & CXR

Compare to previous Early pathology may not show up

Resting EKG

Functional testing
26

Functional Testing
Stress
Walking or nuclear Stress echo Wall motion abnormality

27

Cardiac Catheterization
Virtual
TRO heart center

Real

28

Outpatient
Stress Testing Holter Monitor (24-48 hrs) Event Monitor (30 days) Tilt Table-look up EP Studies-look up

29

Observation

30

ER Discharge
Follow up

Further testing-OP stress test

B-Blocker for HTN ASA daily until follow up Return for:
31