Chest Pain

Educational Objectives

The goal of this program is to improve the management of chest pain in adults and children. After hearing and assim­ilating this program, the clinician will be better able to:

1.   Recognize situations in which the diagnosis of acute myocardial infarction or acute coronary syndrome may be missed.

2.   Discuss the advantages and limitations of electrocardiography, enzyme levels, and provocative testing in the diagnosis of chest pain.

3.   Describe the role of computed tomographic coronary angiography in evaluating patients with chest pain.

4.   Review conditions that can cause chest pain in children.

5.   Determine when to refer a child with chest pain to a specialist.

Faculty Disclosure

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning com­mittee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, the faculty and planning committee reported nothing to disclose.

Acknowledgements

Dr. Falk was recorded at 47th Annual Critical Care and Emergency Medicine, held May 17-21, 2009, in Rancho Mirage, CA, and sponsored by the Office of Continuing Medical Education, Keck School of Medicine, University of Southern Cali­fornia, Los Angeles, and the Weil Institute of Critical Care Medicine. Dr. Selbst was recorded at Pediatric Emergency Med­icine, held April 15-18, 2009, in Lake Buena Vista, FL, and sponsored by Nemours. The Audio-Digest Foundation thanks the speakers and the sponsors for their cooperation in the production of this program.

Management of Chest Pain

Jay L. Falk, MD, Clinical Professor of Medicine and Emergency Medicine, University of Florida College of Medicine, Gainesville; Academic Chairman, Department of Emergency Medicine, and Chief Academic Medical Officer, Orlando Regional Healthcare System, Orlando, FL

Diagnosis: 12-lead electrocardiography (ECG) primary tool for initial decision (whether acute coronary syndrome [ACS] or ST elevation myocardial infarction [STEMI]) in field or within 5 min of arrival at emergency department (ED); STEMI  —requires rapid reperfusion (cardiac catheterization or lytic therapy) and adjunctive therapy (eg, as­pirin [ASA], nitroglycerin, b-blockers, heparin, glycoprotein [GP] IIb/IIIa inhibitors); allow cardiologist to select which heparin or GP IIb/IIIa inhibitor to use; non-STEMI  —  ASA; adjunctive therapy if judged beneficial for pa­tient; differential diagnosis  —  need high index of suspicion, inclusive differential diagnosis, and consideration of worst case scenario; “big 3 killers”  —  acute MI (AMI) and ACS; pulmonary embolism; aortic dissection; excluded by computed tomography (CT) if performed correctly

Study data: Thrombolysis in MI (TIMI) risk score  —  accurate scoring system to stratify risk of patients with possible ACS; risk range of 5% to 41% on score of 0 to 7; in ED population, patient with score of 0 still has 2.1% risk and patient with score of 5 to 6 has risk of 45%; likelihood of adverse outcome in patient with TIMI risk score of 0 not 0 (ie, disposition and treatment decisions made simply on that basis not well-advised from perspective of risk man­agement and sound clinical practice); score not as effective in ED population; stratification of risk  —  consortium of investigators (Emergency Medicine Cardiovascular Research and Education Group [EMCREG]); based on data registry (Internet Tracking Registry of ACS [i*trACS]); database of patients presenting to ED with chest pain; data entered from 7 am to midnight (convenient sample), and 7000 of 17,000 patients excluded; highest incidence of presentation of ACS in early morning hours, so large segment of patients with disease excluded from analysis; study concluded that cardiac risk factor burden has limited clinical value, especially in patients ³40 yr of age; ACS not rare in patients <40 yr of age (4% of all AMIs in that age group); risk for ACS dramatically increases in patient <40 yr of age if risk factor added; conclusions  —  clinicians should not use cardiac risk factor burden to define prob­ability of ACS in ED patient >40 yr of age; converse position, ie, if patient <40 yr of age and with paucity of risk factors, physician should not worry or perform work-up on patient; traditional risk factors clearly associated with high risk for coronary artery disease (CAD); other markers include homocysteine levels, Chlamydia infection, and C-reactive protein (CRP); 2000 study  —2.3% of those with unstable angina discharged, and 2.1% of patients with AMI inadvertently sent home; patients most likely to be sent home included young women (odds ratio [OR] 6.7), nonwhites, patients with chief complaint of shortness of breath (OR 2.7), patients with normal ECG (OR 3.3); mor­tality higher in groups sent home inappropriately

Malpractice issue: missed MI or ACS results in highest monetary award per case in ED lawsuits; patients tend to be younger and have atypical presentations; fewer ECGs ordered, with ECG normal in 83% of missed cases, and mor­tality in 82% of cases; ECG misread in 25% of cases and history missed in 25% of cases; among unrecognized MIs, one-third first infarctions in men, one-half first infarctions in women, one-half silent, and one-half atypical presen­tations

Atypical presentations: common in elderly, women, and diabetics; include indigestion or generalized weakness in elderly; sometimes painless or associated with dyspnea, diaphoresis, and lightheadedness; clinical judgment impor­tant; nitroglycerin is muscle relaxant and improves esophageal spasm or biliary colic; if patient improves with treat­ment of ACS, possible that ACS present; study  —  in patients with active CAD (30% of cohort), 35% obtained relief with nitroglycerin; in 60% of cohort with no CAD, 41% obtained relief with nitroglycerin; response to nitroglyc­erin does not indicate presence or absence of CAD; in diagnosis of chest pain, history and physical examination (PE) important in pointing in correct direction; however, once possibilities excluded, further evaluation required to differentiate patients with possible ACS

Electrocardiography: diagnostic in only 25% to 50% of MIs on presentation; normal in 10% to 13% of cases when patient actually having AMI on presentation; interpretation less clear once chest pain resolves; patients symptom­atic during acquisition of normal or nonspecific ECG have rates of adverse cardiovascular events similar to those of patients without symptoms; clinicians should not rely on absence of ECG changes during symptoms to exclude ACS  

Enzymes: primarily rely on troponins and creatine kinase (CK)-MB; myoglobins elevated sooner, but less specific; accelerated CK-MB or troponin (tests repeated at 30, 60, and 90 min) considered positive if any rise in enzyme seen; correlates well with waiting full 6 hr; real question whether myocardial ischemia present if enzymes not ele­vated; patient with ischemia and unstable angina at high risk for sudden death or subsequent infarction

Provocative testing: stress echocardiography or treadmill stress test with or without thallium; mortality and risk of patient reduced if protocol followed; Chest Pain Evaluation Registry  —  study by Graff; in control period, only mi­nority of patients admitted to hospital; 4.5% mortality in those discharged; in subsequent protocol, total number of patients admitted for observation increased; treadmill stress test performed before discharge; mortality reduced to 0.3%; essentially eliminated risk in low-risk patients by performing provocative testing before discharge; approach deemed effective; adopted as standard of care by American College of Cardiology (with recognition of potential for overutilization of testing without good faith effort to select only those patients truly at risk)

CT angiography (CTA): highly sensitive and fairly specific for CAD; enables clinicians to predict which patients at high, intermediate, and low risk; when applied to ED population, almost 8.5% found to have significant CAD (even in low-risk group); small possibility of missing disease even with provocative testing; cardiac CTA (CCTA)  —  acceptable radiation dose (slightly lower than nuclear treadmill stress test); risk for adverse events near zero; accu­racy rate high, and negative predictive value near 100%; if negative, no ischemia present and no risk in sending pa­tient home; if positive, CAD present and possible that chest pain due to CAD; also possible that patient has CAD and indigestion (false-positive for ischemia); positive finding can result in dilemma and overtreatment; for ED phy­sician, allows for safe discharge of patients and reduces admission rate, cost of visit to hospital for chest pain, and risk for malpractice

Child with Chest Pain

  Steven M. Selbst, MD, Professor of Pediatrics, Jefferson Medical College of Thomas Jefferson University; Vice-Chair for Education, and Director, Pediatric Residency Program, Alfred I. DuPont Hospital for Children, Philadelphia, PA

Case: boy, 15 yr of age, presented to ED with 1-wk history of chest pain; hit over right ribs in football game; 4 days later, neck stiffness and pain; chest pain with walking, described as achy, stabbing, and worse with exertion; mild dizziness with standing; unable to run or climb stairs; shortness of breath and diaphoresis when exercising; inter­mittent headache; no upper respiratory symptoms, head trauma, photophobia, fever, or arm pain; vital signs (VS)  —  low-grade fever, increasing heart rate when standing, and slightly elevated blood pressure (BP); PE  —  alert, talk­ative, and somewhat obese; neck slightly tender with decreased range of motion; tenderness over sternum, but no rib tenderness; lungs, heart, abdomen, extremities, and neurologic system normal; tests  —  chest x-ray unremark­able; nonspecific abnormalities on ECG; increasing pain with exertion concerning; ED course  —  VS unchanged, despite intravenous (IV) fluids; cardiology consult by phone, but impression was musculoskeletal pain and chest wall injury; given ibuprofen and advised to return to ED if pain worsens or syncope occurs and for pediatrician to follow BP; 8 hr later, transported by rescue squad to another ED, where patient expired; diagnosis myocarditis

Myocarditis: signs and symptoms  —  vague chest pain for 1 wk, followed by development of respiratory distress, shortness of breath, and chest pain with exertion; possibly abnormal PE (typically tachycardia and tachypnea) and ECG; patient may appear anxious and grunting (late symptom, with presence of rales and rhonchi); orthostatic hy­potension; unexplained tachycardia out of proportion to low-grade fever; unexplained tachypnea more reliable than unexplained tachycardia; arrhythmia and shock eventually develop; chest wall tenderness, back pain, abdominal pain, and vomiting misleading; unexplained tachycardia and unchanged VS after IV fluids should arouse suspicion of cardiovascular instability; obtain chest x-ray and ECG in presence of chest pain with fever; insist that cardiolo­gist examine child

Case: boy, 10 yr of age, complains of chest pain for 3 mo; describes as dull achy pain throughout chest, worse with inspiration; grandfather has heart disease; review of systems negative; sleeps well, but missing school; denies re­cent stress; PE reveals exquisite chest tenderness; likely nonorganic cause of chest pain (psychogenic or idiopathic) due to long course, unusual history, normal examination, and school absences

Idiopathic chest pain: chest pain complaint in 6 of 1000 children who visit urban EDs; no sex or race predilection; children of all ages affected; in office setting, more likely to find chronic chest pain; normal history and PE; labora­tory tests rarely helpful

Musculoskeletal chest pain: most common identifiable cause; history of exercise usually present; usually reproduc­ible; costochondritis  —  accounts for 10% of all chest pain in children presenting to ED; tenderness over costochon­dral junctions of sternum (not rib pain); laboratory tests not helpful; direct chest trauma  —  hemothorax and pneumothorax from major trauma; rib fractures and contusions from minor trauma

Respiratory pathology: pain may be caused by overuse of chest wall muscles while coughing; also true for asthma; children with asthma also at risk for pneumonia and pneumothorax; pneumothorax  —  dyspnea likely, with in­creased work of breathing and decreased breath sounds on one side; sudden onset of pain; usually present to hospi­tal within 48 hr; should consider even in normal child; tall thin child at higher risk; pneumomediastinum  —  seen in children with asthma; able to palpate air tracking up; usually admitted to hospital; once asthma treated, condition improves

Psychogenic chest pain: accounts for »10% of children seen in ED with chest pain; not diagnosis of exclusion; boys and girls equally affected; reasonable to attribute to stressful situation if it correlates with time of onset of chest pain; stress also cause of headaches and abdominal pain in children

Gastrointestinal pathology: reflux esophagitis  —  usually burning pain in mid-chest; worse with lying down or eat­ing certain foods; ask whether child on any medication; doxycycline (tetracycline) for acne common cause of pill-induced esophagitis; other causes caustic or foreign body ingestion (eg, coin in esophagus)

Cardiac disease: MI  —  150 cases reported annually in adolescents; mostly associated with tobacco use and sub­stance abuse; hypertrophic cardiomyopathy  —  chest pain with exercise serious symptom in undiagnosed patient (at risk for MI); Kawasaki disease  —  symptoms include fever and red eyes; injury to coronary arteries seen in some children; MI later development; supraventricular tachycardia  —  chest pain and palpitations; recognized on PE; more on hypertrophic cardiomyopathy  —  autosomal dominant inheritance; positive history in family members; pericarditis; myocarditis; mitral valve prolapse incidental finding

Other causes of chest pain: tumor (eg, lymphoma); breast masses (actually tender breasts [in girl, possibly due to pregnancy]); sickle cell crisis; pulmonary embolism  —  rare in children; higher risk if girl on birth control pills or had recent abortion or teenage boy had leg injury; present with acute onset of pain and possibly tachypnea; respira­tory symptoms usually present; Texidor’s twinge  —  brief episode of pain, usually on left side of chest; improves upon standing and taking deep breaths; improves rapidly; slipping rib syndrome  —  pain when walking and swing­ing arms; clicking sound due to lower ribs hooking onto ribs above, hitting nerve, and causing pain; Marfan’s syndrome  —  risk for serious causes of chest pain (eg, pneumothorax, dissecting aortic aneurysm); in anorexia ner­vosa, chest pain due to electrolyte abnormalities

Tobacco and substance use: smoking major risk factor for MI; exposure to cigarette smoke results in worsening of asthma, pulmonary complications, and chest pain (not well documented); substance abuse risk factor for MI; co­caine use associated with hypertension and pneumothorax

Diagnosis of children with chest pain: musculoskeletal and costochondritis most common causes; psychogenic and stress-related chest pain accounts for »10% of cases; only »4% of chest pain in children related to cardiac disease; history  —  severity, frequency, type, location, and onset of pain; precipitating factors; associated complaints; previ­ous treatment; family history; in children with heart disease or positive family history of heart disease, chest pain not often related to cardiac condition; smoking history; family fears and concerns; important PE findings  —  severe distress; appearance of chronic illness; skin rash or bruising; abdominal pathology; presence of arthritis; apparent anxiety; chest findings

Research findings: organic etiology for chest pain more likely in young children; stress-related chest pain more likely in older children; organic causes  —  being awakened from sleep; acute chest pain, especially if associated with abnormalities on PE (eg, fever); pain associated with fever highly correlated with pneumonia; nonorganic causes  —  chronic pain; family history of chest pain or heart disease; not related to diagnosis  —  sex of patient, type of pain, localization, and school absence

Laboratory studies: obtained in presence of worrisome history, history of heart disease, risk for heart disease, and abnormal examination; ECG and chest x-ray; ECG abnormal in »16%; exercise stress test  —  specialist determines necessity

Management: if due to musculoskeletal condition, usually responds to over-the-counter analgesics, with follow-up recommended; refer to specialist if  —  acute distress; significant trauma; pain with exertion; syncope, dizziness, or palpitations; underlying heart disease; pleural effusion or pneumothorax; esophageal foreign body

Suggested Reading

Bohan JS: Routine stress testing at triage for chest pain. Ann Emerg Med 34:117, 1999; Boyd J et al: Asthma is associated with acute chest syndrome and pain in children with sickle cell anemia. Blood 108:2923, 2006; Chase M et al: Prospective validation of the Thrombolysis in Myocardial Infarction Risk Score in the emergency department chest pain population. Ann Emerg Med 48:252, 2006; Christenson J et al: A clinical prediction rule for early discharge of patients with chest pain. Ann Emerg Med 47:1, 2006; Geg­gel RL: Conditions leading to pediatric cardiology consultation in a tertiary academic hospital. Pediatrics 114:e409, 2004; Graff LG et al: Impact on the care of the emergency department chest pain patient from the chest pain evaluation registry (CHEPER) study. Am J Cardiol 80:563, 1997; Hermann LK et al: The limited utility of routine cardiac stress testing in emergency department chest pain patients younger than 40 years. Ann Emerg Med 54:12, 2009; Lane JR et al: Myocardial infarction in healthy adolescents. Pediatrics 120:e938, 2007; Leung AK et al: Pediatric chest pain. Clin Pediatr 43:863, 2004; Massin MM et al: Chest pain in pediatric patients presenting to an emergency department or to a cardiac clinic. Clin Pediatr 43:231, 2004; Murata GH: Evaluating chest pain in the emergency department West J Med 159:61, 1993; Sequist TD et al: Prediction of missed myocardial infarction among symptomatic outpatients without coronary heart disease Am Heart J 149:74, 2005; Shoyeb A et al: Value of definitive diagnostic testing in the evaluation of patients presenting to the emergency department with chest pain Ann Emerg Med 54:12, 2009.