Garik Misenar, MD, FACEP
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Understand differential diagnosis of chest pain
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Learn key points in the evaluation of chest pain
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Know the key findings associated with chest pain
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Discuss disposition of potentially cardiac chest pain
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Nearly 6 million ED patients annually
5% of all ED visits
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Afferent fibers from heart, lungs, great
vessels, and esophagus enter same thoracic
dorsal ganglia
Visceral fibers produce indistinct quality of
pain
Dorsal segments overlap three segments
above and below
Pain anywhere from jaw to epigastrium
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Cardiovascular
Pulmonary
Gastrointestinal
Musculoskeletal
Neurologic
Psychogenic
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Vital signs
EKG within 10 minutes
Chest x-ray
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Acute MI
Esophageal rupture
Thoracic aortic aneurysm
Pulmonary embolus
Pneumothorax
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Description
Activity at onset
Location
Radiation
Duration
Aggravating/alleviating
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Similar episodes in past
 Misdiagnosis or misattribution
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Risk factors
 Important for populations
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Syncope/Near syncope
Dyspnea
Hemoptysis
Nausea/vomiting
Diaphoresis
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Respiratory distress
Diaphoresis
Vital signs
Heart sounds
Lung sounds
Abdominal exam
Extremity exam
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New injury
 Acute MI
 Aortic dissection
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New ischemic pattern
 Ischemia
 Coronary spasm
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Diffuse elevation
 Pericarditis
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Pneumothorax
 Simple vs. Tension
 Esophageal rupture
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Widened mediastinum
 Aortic Dissection
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Effusion
 Esophageal rupture
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Enlarged cardiac silhouette
 Pericarditis
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Pneumomediastinum
 Esophageal rupture
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D-dimer?
 Marker of fibrinolysis
 Negative rules out if low risk for PE
 Positive test does NOT mean PE/DVT
▪ Acute Coronary Syndrome, Aortic dissection, Atrial
fibrillation, DIC/VICC, Infection, Malignancy, Preeclampsia, Sickle cell, Stroke, Trauma
 False positive:
▪ Elderly, pregnancy, post-op, smokers, AfricanAmericans, decreased mobility
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Troponin I and T
 Identify patients with highest risk of adverse outcome
 Sensitivity at 4 hours is 60%, nearly 100% at 12 hours
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CK-MB
 Sensitivity at 4 hours is 80%; 93% at 6 hours
 Secondary role to troponin currently
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Elevated troponin
New ST depression
Recurrent ischemia
Heart failure with ischemia
Hemodynamic instability
PCI in last 6 months
Previous CABG
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Observation vs. Intervention
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Chest pain resolved
Possible ischemic changes
Normal cardiac markers
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Observation vs. early intervention
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Chest pain resolved
Nondiagnostic EKG
Normal cardiac markers
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Observation
Repeat EKG and cardiac markers
Provocative testing
If all normal, discharge
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There are numerous diagnoses which can
cause chest pain
Rapidly assess and treat imminent life threats
Look for key points on the history and
physical
Use additional studies to help differentiate
among diagnoses
Additional testing required for potentially
cardiac chest pain