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 Angina Stable Unstable Microvascular Peri/myo/endocarditis Arrhythmias Gastric disease Ulcers/reflux/GIB Obstructive sleep apnea Cholecystitis Anemia PE Pneumothorax Pleurisy Musculoskeletal Illicit drugs (cocaine, methamphetamine) Anxiety Psychosomatic
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/drugby-condition/gastroesophageal-reflux-disease-gerd-commondrugs/ 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-surgerythoracic/5.html