Chest Pain. Scott A. Phillips, M.D. AnMed Health Carolina Cardiology

Transcription

1 Chest Pain Scott A. Phillips, M.D. AnMed Health Carolina Cardiology

2 Cardiac Causes -Ischemic vs. Non-ischemic Non-Cardiac Causes -Pulmonary, GI, Musculoskeletal, Dermatology

3 1. Chest Wall Pain Sharp, Precisely localized Reproducible: Palpation, movement 2. Pleuritic or Respiratory CP Somatic pain, Sharp Worse with breathing/coughing 3. Visceral CP Poorly localized, aching, heaviness

4 Non-cardiac Chest Pain

5 Most common cause of non-cardiac chest pain Causes: -Esophagitis/Gastritis -Ulcers -Reflux -Esophageal Spasm (can be relieved with Nitro) -Pancreatitis -Gall bladder

6 Pleuritic (worse with breathing/coughing) Sharp/stabbing pain Causes: -Infections (bronchitis/pneumonia) -Pleural effusions (fluid around the lung) -Pulmonary Emboli (blood clots) -Pneumothorax (collapsed lung) -Malignancy

7 Costocondritis (inflammation of cartilage) Rib fracture Myalgia (muscle pains) Pain is worse with movements. May be reproducible with palpation.

8 Shingles (Herpes Zoster) Focal, dermatomal pain. Constant, burning/tingling pain. Pain starts several days before a rash is present.

9 Shingles

10 Ischemic: -Myocardial infarction (ACS) -Stable angina -Coronary vasospasm -Aortic stenosis -Hypertrophic cardiomyopathy Non-ischemic: -Pericarditis -Aortic dissection

11 Causes: -congenital -calcification -rheumatic fever Symptoms are typically exertional. Often associated with signs of heart failure. May also be associated with passing out (syncope). Loud systolic murmur heard on exam.

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13 Abnormal thickening of the heart muscle. Hereditary Causes outflow obstruction from the left ventricle. Exertional chest pain, shortness of breath, and passing out, death. Loud murmur on exam.

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15 Sudden onset of SEVERE ripping/tearing chest pain Radiates through to the back Associated with high blood pressure. Feeling of doom

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17 Prinzmetal s Angina Spasms of the coronary arteries. More common in women Occurs at rest. Can look like a heart attack on EKG.

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19 Causes -Infections (Viral, tuberculosis) -Kidney failure -Autoimmune diseases -Radiation -Heart attacks (Dressler s Syndrome) Symptoms -Positional/pleuritic chest pain

20 Pericarditis

21 Coronary Artery Disease

22 Plaque Rupture Thrombus Plaque rupture

23 Aspirated blood clot and plaque during MI

24 Characteristics Location Severity Duration Associated symptoms Radiation of pain Triggers (exertion, emotional distress) Relieving features (rest, aspirin, nitro)

25 Chest pain (heavy, burning, tight, pressure, sharp, tingling, stabbing, throbbing) Jaw/neck pain Arm pain/numbness Back pain Shortness of breath Nausea/vomiting, hiccups Sweating

26 Typical Anginal Pain Distribution

27 Class I No angina with ordinary physical activity Class II Angina with strenuous/prolonged exertion Early-onset, limitation of ordinary activity (2 blocks/1 flight) Class III Marked limitation of ordinary activity Class IV Inability to carry out any physical activity without angina Angina occurs at rest

28 Pretest Probability

29 Does the pt fit into one of the following? 1. Noncardiac CP and low pretest probability No further testing needed. Pt does not have angina 2. Diagnosis of angina is established (high pretest prob) No further diagnostic testing needed. Pt needs risk stratification for prognosis 3. Diagnosis is still not clear (intermediate pretest prob) Consider the following tests to make a diagnosis

30 Algorithm for Evaluation and Management of Patients Suspected of Having ACS. Anderson J L et al. Circulation. 2011;123:e426-e579 Copyright American Heart Association, Inc. All rights reserved.

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33 71 w/m with 2 month h/o exertional chest pressure. Presented to PCP office with worsening of symptoms during exertion. PMHx: Hyperlipidemia, HTN, CRI, ED Meds: Crestor, Prilosec, Cialis Allergies: NKDA FHx: None SocHx: smoker Exam: Afeb, 130/82, 85, 16, (Normal exam) Labs: BUN 20, Cr 1.0, Gluc 99, WBC 5, HCT 43, Plt 140 CXR: normal

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36 63 w/m with 3 month h/o mild intermitent exertional chest pain. Worse and more frequent over past week. Severe episode with SOB prompting first time visit to PCP s office. PMHx: HTN Meds: Lisinopril, ASA. Allergies: NKDA FHx: CVA SocHx: non-smoker, rare EtOH, no illicits, pharmacist. Exam: Afeb, 149/98, 115, 18, 95% 2L NC NAD Tachycardic, 1/6 harsh syst murmur RUSB, JVD to jaw Bilateral rales half way up lung fields. Trace pedal edema, warm, 2+ pulses

37 WBC 12, HCT 43, Plt 333 BUN 21, Cr 0.8, Gluc 183 HgA1C 7.8 Chol 177, Trig 161, LDL 115, HDL 30 Trop 0.87, 1.03 CXR: pulmonary edema ECHO: EF 20%, mild AS

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40 86 w/m with 6 month h/o exertional left sided chest pressure and DOE. Worsening over past 2 weeks. Presents to PCP after 2 episodes of resting pain. PMHx: HTN, COPD, Parkinson s, BPH, chronic anemia, OA. Meds: ASA, lisinopril, calcium, eye drops, combivent. Allergies: NKDA FHx: N/C SocHx: Lives with care taker, 3 sons, remains fairly active, non-smoker. Exam: Afeb, 105/70, 70, 14 Thin with mild Parkinsonian features. 2/6 syst murmur LSB. Labs: BUN 19, Cr 0.5, WBC 6, HCT 36, MCV 92, Plt 188 Imaging: CXR normal

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43 76 w/f with 1 month h/o intermittent non-exertional burning mid epigastric/substernal chest discomfort partially relieved with TUMS. PMHx: HTN, hyperlipidemia, borderline DM PSHx: cholecystectomy and hysterectomy. Meds: ASA, Toprol, lisinopril, pravastatin. Allergies: NKDA FHx: CAD (father/brother) SocHx: Quit smoking 25 yrs ago. Exam: Afeb, 164/92 (didn t take a.m. meds), 59, 16 Otherwise normal exam. Labs: Normal Imaging: CXR normal.

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46 Questions??????