18  Chest Pain

18.1 Note

Chest pain, *** typical/atypical/non-cardiac
- HEART score: ***, TIMI score: ***
- EKG
- Labs
    - Trop/hs-Trop - trend q3-4h/1-2h
    - BMP, CBC
    - A1c
    - Lipids
    - TSH w/ reflex
- Stress test?
  - Consider if clinically stable, no longer having active chest pain and/or non-rising troponins
  - ETT/Echo: if pt can exercise/walk on treadmill, BMI < 40
  - Nuc perfusion: prior MI, obesity, hx of AFib/arrhythmia
  - Dobutamine stress: if hx of lung disease, no arrhythmia, unable to exercise
- ACS protocol?
- Echo?
Note

The base rate for myocardial infarction in pts presenting with chest pain is 15%, i.e. about 15% of pts who arrive at the ED complaining of CP are having an MI. ~33% of those patients who wind up getting admitted with suspicion of an MI are actually having an MI.

Source: 10.1093/eurheartj/ehv320

18.2 Serious 6 causes of Chest Pain

  • Serious 6 life-threatening causes of Chest Pain (PET MAC)

    • PE

    • Esophageal rupture

    • Tension PTX

    • MI

    • Aortic dissection

    • Cardiac tamponade

    • Other emergenct causes: Takotsubo cardiomyopathy, esophageal impaction


18.3 History Elements

  • OLD CARTS
  • Hx:
    • Description: pressure, burning, aching, squeezing, piercing
    • Duration of Sx: acute vs. chronic
    • Denied palpitations. radiation of pain, abdominal pain, nausea, vomiting, diaphoresis, or change in appetite.
    • Pain is not made worse with deep inspiration or sudden movements. No other palliative or provocative features.
    • Denied fevers, chills, cough, no increased sputum production.
    • Denied dysphagia, globus sensation.
  • Hx that decreases the likelihood of MI:
    • pleuritic pain
    • sharp or stabbing pain
    • positional pain

18.4 Cardiac Risk Factors

  • HTN, DM, HLD
  • family history
  • peripheral vascular disease
  • CVA
  • CKD/ESRD
  • Inflammation/Rheum or elevated inflammatory markers
  • Tobacco use
  • Recreational drug use: cocaine
  • Lifestyle
    • poor diet
    • sedentary
    • obesity

18.5 Clinical Decision Rules

  • HEART score
    • History, ECG, Age, Risk Factors, and Troponin
  • TIMI score
  • GRACE score
  • Others:
    • Patient in the ED with chest pain: Sanchis score, Vancouver rule, HEART score, HEARTS3 score, Hess prediction rule
Source: Table 6 of 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain
HEART Pathway EDACS ADAPT (mADAPT) NOTR 2020 ESC/hs-cTn 2016 ESC/GRACE
Target population Suspected ACS Suspected ACS, CP >5 min, planned serial troponin Suspected ACS, CP >5 min, planned observation Suspected ACS, ECG, troponin ordered Suspected ACS, stable Suspected ACS, planned serial troponin
Target outcome ↑ ED discharge without increasing missed 30-d or 1-y MACE ↑ ED discharge rate without increasing missed 30-d MACE ↑ ED discharge rate without increasing missed 30-d MACE ↑ Low-risk classification without increasing missed 30-d MACE Early detection of AMI; 30-d MACE Early detection of AMI
Patients with primary outcome in study population, (%) 6–22 12 15 5–8 9.8 10–17
Troponin cTn, hs-cTn hs-cTn cTn, hs-cTn cTn, hs-cTn hs-cTn cTn, hs-cTn
Variables used

  • History

  • ECG

  • Age

  • Risk factors

  • Troponin (0, 3h)

  • Age

  • Sex

  • Risk factors

  • History

  • Troponin (0, 2h)

  • TIMI score 0-1

  • No ischemic ECG changes

  • Troponin (0, 2h)

  • Age

  • Risk factors

  • Previous AMI or CAD

  • Troponin (0, 2h)

  • History

  • ECG

  • hs-cTn (0, 1 or 2h)

  • Age

  • HR

  • SBP

  • Serum Cr

  • Cardiac arrest

  • ECG

  • Cardiac biomarker

  • Killip class

18.6

Risk Stratification

Source: Table 6 of 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain
HEART Pathway EDACS ADAPT (mADAPT) NOTR 2020 ESC/hs-cTn 2016 ESC/GRACE
Low Risk

  • HEART score <3

  • Neg 0, 3-h cTn

  • Neg 0, 2h hs-cTn

  • EDACS score <16

  • Neg 0, 2h hs-cTn

  • No ischemic ECG Δ

  • TIMI score 0 (or <1 for mADAPT)

  • Neg 0, 2h cTn or hs-cTn

  • No ischemic ECG Δ

  • Age <50

  • <3 risk factors

  • Previous AMI or CAD

  • Neg cTn or hs-cTn (0, 2h)
  • Initial hs-cTn is “very low” and Sx onset >3 h ago

OR

  • Initial hs-cTn “low” and 1 or 2h hs-cTn Δ is “low”
Intermediate Risk
  • HEART score 4-6
 NA
  • TIMI score 2-4
 NA
  • Initial hs-cTn is between “low” and “high”

AND/OR

  • 1 or 2h hs-cTn Δ is between low and high thresholds
  • Initial hs-cTn = 12–52 ng/L

OR

  • 1h Δ = 3–5 ng/L
High Risk
  • HEART score 7-10
 NA
  • TIMI score 5-7
 NA
  • Initial hs-cTn is “high”

OR

  • 1 or 2h hs-cTn Δ is high
  • Initial hs-cTn >52 ng/L

OR

  • Δ 1 h >5 ng/L

18.6.1

Low Risk by Clinical Decision Pathway

  • HEART Pathway

    • HEART score ≤3, initial and serial cTn/hs-cTn < assay 99th percentile

  • EDACS

    • EDACS score ≤16; initial and serial cTn/hs-cTn < assay 99th percentile

  • ADAPT

    • TIMI score 0, initial and serial cTn/hs-cTn < assay 99th percentile

  • mADAPT

    • TIMI score 0/1, initial and serial cTn/hs-cTn < assay 99th percentile

  • NOTR

    • 0 factors

18.6.2 Intermediate Risk Algorithm

Evaluation Algorithm for Patients With Suspected ACS at Intermediate Risk With No Known CAD

Evaluation Algorithm for Patients With Suspected ACS at Intermediate Risk With Known CAD

18.7 Causes of Chest Pain

18.7.1 Cardiac Causes

  • ACS: UA, NSTEMI, STEMI
  • Pericarditis/Myocarditis
  • Stable angina
  • Aortic dissection
  • Expanding aortic aneurysm
  • Pulmonary embolism
Classification Symptoms
Typical angina
  1. Substernal chest discomfort
  2. Provoked by exertion/emotional stress
  3. Relieved by rest or nitroglycerin
Atypical angina meets 2 of the 3
Noncardiac chest pain meets 1 or none of the 3

18.7.2 Non-Cardiac of Chest Pain

Warning

MSK disorders and GERD are common causes of CP that can mimic angina (worse w/ activity, sensation of pressure).

  • MSK: costochondritis, rib fx, precordial catch syndrome, Tietze syndrome, pectoral mm. strain, C4-T6 spondylosis, myositis
  • Breast: fibroadenomas, mastitis, gynecomastia
  • Derm: herpes zoster
  • Esophageal/GI: esophageal rupture, esophageal impaction, esophagitis, esophageal ulcer, esophageal spasm, GERD, PUD, malignancy, GB disease, liver abscess, pancreatitis, liver abscess
  • Pulm: PNA, PE, pleural effusion, lung mass, mediastinal abnormalities, pericardial disease, diaphragmatic hernia
  • Mediastinum: fat necrosis, thymoma, lymphoma
  • Referred pain from abdominal process
  • Psych: panic, anxiety
  • Clues from history regarding esophageal causes of CP:
    • odynophagia -> esophagitis, esophageal ulcer
    • dysphagia -> GERD, esophageal cancer (RFs include smoking, EtOH, chronic reflux)
    • acute pain after retching -> esophageal rupture (Boerhaave syndrome)
    • intermittent CP and dysphagia -> esophageal spasm or motility disorders

Study of 100 patients showing prevalence of history findings in cardiac versus esophageal etiology of CP:

Symptom Among patients with cardiac cause (%) Among patients with esophageal cause (%)
Lateral radiation 69 11
More than 1 spontaneous episode per month 13 50
Pain persists as ache for several hours 25 78
Nighttime wakening caused by pain 25 61
Provoked by swallowing 6 39
Provoked by recumbency or stooping 19 61
Variable exercise tolerance 10 39
Pain starts after exercise completed 4 33
Pain relieved by antacid 10 44
Presence of heartburn 17 78
Presence of regurgitation 17 67
Presence of GI symptoms 46 83
Nitroglycerin response cannot discern cardiac vs other causes of CP

“history cannot differentiate esophageal chest pain from pain due to cardiac ischemia. That said, pain that occurs with swallowing, is persistent, wakes the patient from sleep, is positional, and is associated with heartburn or regurgitation is more likely to be of esophageal origin… The effect of nitroglycerin in relieving chest pain has consistently been found to be useless in differentiating anginal chest pain from esophageal or other causes of chest pain.” (Source: Symptom to Diagnosis)