Clinical Cases_ Chest Pain and Syncope

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Clinical Cases_ Chest Pain and Syncope Powered By Docstoc
					Common Clinical Problems:
Chest Pain
Three Questions?

What do I think this is?

Is there anything else this could be?

What doesn’t fit?
Chest pain: History

You are on call on the first night of your
medicine rotation. Your team is called to
Radiology to assess a 41 year old man who
complained of chest discomfort 10 minutes ago
in the CT scanner, where he was having a CT to
assess the response of his metastatic colon
cancer to chemotherapy.
What is the most likely diagnosis?

 1.   MI
 2.   Aortic dissection
 3.   Pericarditis
 4.   Non-CV
Prevalence in ED patients with Chest

  Unstable angina, MI   16-28%
  Pericarditis          ~2%
  Aortic dissection     .003%
  Non-cardiovascular    72-84%
 O2
 IV
 Request ECG and monitor
He describes the pain as substernal, sharp, 3/10
and radiating to both shoulders.
The pain is not pleuritic.
There is no associated dyspnea or nausea, but he
has had some sweating.
His medical history is notable for Stage 4 colon
cancer, metastatic to the liver and lungs,
resected and being treated with chemo. He also
has hypertension, hyperlipidemia, and DM2.
Which feature of his history would
most increase the likelihood of ACS?

1. Pain radiating to both
2. Described as sharp
3. Diaphoresis

 History in acute MI
 Increases likelihood of AMI
     Pain radiating to R arm >both arms> L arm
     Syncope
     Prior MI
     Diaphoresis
     N/V
 Decreases likelihood of AMI
   Pleuritic
   Reproduced by palpation, sharp or stabbing, or
Chest pain that responds to
nitroglycerin is cardiac in origin
If chest pain improves with nitro, it
is cardiac.
Physical Exam
What else could this be??
Common sources of diagnostic error
 Availability bias
   The diagnosis that springs to mind: the last
    lecture you attended or the last patient you saw

 Premature closure
   Stop thinking about alternate diagnoses once a
    reasonable cause of symptoms is considered
Case 2

 A 72 year old man with a history of diabetes,
 hypertension and smoking is brought to the
 ER with sudden, severe chest pain radiating
 to the back of 25 minutes duration.
Can’t miss

   High mortality (aortic dissection 1% per hour)
   Treatable early (with early surgery, survival
   20%+ still missed on initial evaluation
What are we talking about?
Aortic dissection: History

 Tearing or ripping chest pain (LR 10.8)
 Migrating chest and back pain (LR 7.6)
 Sudden onset pain
 Marfan’s syndrome
 Hypertension
 Aortic Dissection: Exam
 Any “classic” finding present in only half of all
 Diastolic murmur (aortic insufficiency)
 Unequal blood pressure in limbs (> 20 mm Hg)
 Pericardial rub
 Elevated JVP (tamponade)
 Focal neuro deficit
 Shock
Chest x-ray findings

 Overall sensitivity 90%
 Widened mediastinum (Sn ~ 65%)
 Abnormal aortic contour (Sn ~ 70%)
 Pleural effusion (Sn ~ 15%)
Consider aortic dissection:

 Sudden, tearing, or ripping chest pain,
  especially with radiation to back
 Migrating chest, back abdominal pain
 Neuro deficit, pulse deficit, new AI murmur,
 ECG without ST changes in patient you
  thought was having an MI
Case #3

 An 83 year old man with a remote history of a
 liposarcoma of the arm presents with 4 days
 of fatigue, increasing dyspnea, and chest
Temperature - C   36.6 degC
Heart Rate        100 bpm High
Respiratory Rate  14 br/min
SBP - Noninvasive 155 mmHg High
DBP - Noninvasive  83 mmHg
Hypothesis driven physical exam
126             97                          23                    |- Ca 8.2                           ---                ---            ---   |- Ca - -
---------|-------------|------------< 111          |- Mg 2.0                      ---------|-------------|------------< - - -                 |- Mg - -
4.7            22                           0.74                  |- Phos - - -                       ---                ---            ---   |- Phos


                 12.9                                |- PT 13.7                     ---                                  |- PT - - -
1.30 ]----------------------[ 255                    |- INR 1.1                     - - - ]----------------------[ - - - |- INR - - -
                 36                                 |- PTT 30                       ---                                  |- PTT - - -
Temperature - C        37 degC
Heart Rate             115 bpm High
Respiratory Rate       20 br/min
SBP - Noninvasive      102 mmHg
DBP - Noninvasive      62 mmHg
SpO2                   95 %

“The patient appears to be in moderate distress, ill
  appearing, laying in bed with an elevated rr and
  cool washcloth on his forehead.”
Which finding would you seek next?

 1. Pulsus alternans
 2. Pulsus paradoxus
 3. Pulsus parvus et
Pericardial Tamponade
 Fluid increases intrapericardial pressure
 With inspiration, venous return to R
  ventricle increases; it encroaches onto LV
 Chest pain/heaviness/tightness
 Symptoms & signs of poor cardiac output
   Dyspnea
   Elevated JVP
   Tachycardia then hypotension
Pulsus paradoxus

 Increased venous return with inspiration
 Increased fluid in pericardial space restricts
  the ability of RV to stretch; excess venous
  return presses on ventricular septum
 Decreased LV filling
 Decreased blood pressure with inspiration
 Also seen with severe asthma

 Inflate BP cuff to above systolic BP and come
  down veeeerrrrry slowly
 Note the pressure at which you begin to hear
  Korotokoff sounds during expiration
 Decreased very slowly
 Note the pressure at which you hear sounds
  in inspiration and expiration
 > 10 mm Hg is abnormal
During the hospitalization he again had negative
troponins, also negative HIV, and negative
QuantiFERON. The pericardial fluid had 482 white
cells with 77% neutrophils and 11% lymphocytes.
RBC count was less than 3000. Gram stain culture,
AFB, fungal were all negative from pericardial fluid.
Acute Chest Pain: Next diagnostic

  ECG
  CXR
  Cardiac enzymes
  Further imaging as guided by history and
   Cardiac cath?
   Echo to assess wall motion or pericarditis?
   CTA or TEE or MRI to assess for dissection?
Suggestive of non-cardiac chest pain

 Sharp
 Pleuritic
 Well circumscribed
 Lasting seconds at a time
 Lasting hours or days at a time
 Unchanged by exertion
 Associated with waterbrash (acid in mouth)
                        ACS                                  Pericarditis           Noncardiac
Hx             SSCP/L-sided      SSCP                      Anterior chest pain    Any location
               ”Pressure”        Radiation to back         Often pleuritic        ”Sharp”
               Exertional        ”Sharp”, “Tearing”        Better with leaning    Pleuritic
               Radiationarms,   Neurologic deficits       forward                Increases with
               neck, jaw         Abrupt onset                                     movement, palpation
               Nausea            Syncope                                          Inciting event
               Diaphoresis                                                        Preceding illness
Risk factors   Hypertension      Hypertension              Recent URI             Cough
               Diabetes          Older age                 SLE                    Trauma
               FHx early CAD     Connective tissue D/O     Recent MI or cardiac   Reflux
               Tobacco use                                 surgery

               Hyperlipidemia                              Pneumonia
Exam           Usually normal    Any ‘classic’ finding     Friction rub           Tenderness to
               Systolic murmur   present in ~50%           Distant heart sounds   palpation

               Gallop            Diastolic murmur          If tamponade:          Step-offs

               Elevated JVP      Unequal pulses or blood    - tachycardia
                                 pressure (> 20 mm Hg)
               Crackles                                     - hypotension
                                 Pericardial rub
                                                            - pulsus paradoxus
                                 Elevated JVP

  Transient loss of consciousness, with
   associated loss of postural tone and
   spontaneous recovery.
  3% of ED visits and 1% of hospital
  History and exam establish diagnosis in
   about half
  About one-third remain unexplained
Key questions in syncope
 Is this really syncope?
   Seizure will typically have slower return to
    baseline (postictal state)
   Tongue biting, loss of bowel or bladder suggest
   Syncope can be associated with tonic clonic
 What’s most likely?
 What can’t I miss?
Have you ever had syncope?

1. Yes
2. No
3. Abstain
Most common

 Neurocardiogenic AKA vasodepressor AKA
  vasovagal syncope (25-65%)
   Autonomic activation causes decreased BP,
    bradycardia or both
   Emotion, carotid sinus pressure, situational
 Medications (5-15%)
   Vasodilation, bradycardia, volume depletion
 Orthostatic syncope (5-10%)
   Volume depletion
   Autonomic insufficiency
Must not miss

 Arrhythmia
 Ischemia
 Cardiac tamponade
 Pulmonary embolism
 Major acute blood loss
 Valvular disease (aortic or mitral stenosis)
Key questions:
 Prodrome? Suggests neurocardiogenic - sudden
  onset without prodrome suggests arrhythmia
 Situation? Prolonged standing, physical or
  emotional stress, cough, micturition, etc all suggest
  neurocardiogenic. Syncope with exertion suggests
  limited cardiac output (bad).
 Position? Syncope while standing suggests
  orthostasis, prolonged standing suggests
  neurocardiogenic, supine suggests arrhthmia
 Any chest pain or dyspnea?
 History of cardiac disease?
 Family history of cardiac disease or sudden death?
Key exam

 VS
   Include orthostatic VS
 HEENT - tongue laceration suggests seizure
 Cardiac - rate and rhythm, evidence of heart
  failure, evidence of valvular disease
 Lung - evidence of heart failure or PE
 Neurologic - evidence of stroke

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