Chest Pain

Chest Pain / Angina

Symptoms determine likelihood that chest pain has a cardiac etiology
Cardiac > possible cardiac > noncardiac is more useful than typical vs atypical angina

Skin/subcutaneous: Laceration, herpes zoster, cellulitis, abscess
Musculoskeletal: Costochondritis, rib fracture, myositis, sprain/strain
Pleural space (no pain receptors in the lung): PNA, tumor, pleuritis
Heart: Myocarditis, pericarditis, spontaneous coronary artery dissection (SCAD), coronary vasospasm, hypertensive crisis, aortic stenosis, stress-induced cardiomyopathy (Takotsubo), decompensated heart failure
GI: GERD, esophagitis, rupture, impaction, diaphragmatic hernia
Trachea: Tracheitis, tracheal tear
Nervous system: thoracic radiculopathy
Hematologic: Acute pain crisis (sickle cell)

Vitals: BP in both arms (difference in SBP >20 mm Hg is high risk feature for aortic dissection)
Hemodynamic profile: warm/dry, warm/wet, cold/dry, cold/wet
Palpate chest: evaluate costochondral junction, subcutaneous emphysema, examine skin
Cardiac: murmurs, rub for pericarditis, JVD for heart failure, pulsus paradoxus for tamponade
Pulm: absent breath sounds for PTX, crackles for left heart failure, PNA
Abdomen: abdominal pain mistaken or referred as chest pain
Extremities: asymmetric leg swelling (>2 cm difference) for DVT/PEE

EKG: ACS (STEMI, new LBBB, ST depressions, TWI, Wellen’s sign), PE (RAD, right precordial or inferior TWI, S1Q3T3), pericarditis, pericardial effusion
Labs: Troponin (ACS, PE, myocarditis), CBC, CMP, BNP, lactate
CXR: PTX, PNA, dissection, esophageal rupture
POCUS: pericardial effusion, R heart strain for PE, wall motion abnormality for infarct/ischemia or stress-induced CM, valvular dx, lung sliding/PTX
CTA: gold standard for PE, versus V/Q scan if CKD or contrast allergy. Dissection can be diagnosed w/ CTA, MRA, or TEE

Test	Indications	Benefits	Risks	Considerations
EKG Stress	Low to Intermediate risk pts Do not stress active or suspected ACS Serves as screening with high NPV	Functional status w/ Bruce treadmill protocol	Exercise tolerance limits use	Cannot have LBBB, nondiagnostic if 85% target HR not achieved
Dobutamine Echo Stress		More sensitive than EKG	Contraindicated: arrhythmias, LVOT obstruction, HTN, AS	Can be useful to eval low grade low flow AS; Hold BB
SPECT stress		More sensitive than echo, Assess viability	Adenosine or Regadenoson contraindicated in reactive airway disease	No caffeine or theophylline prior
PET stress		Better PPV than Echo; Assess viability	Better for pts with larger abdominal girth (less diaphragmatic attenuation)
Cardiac MRI		Assesses viability	Can assess nonischemic vs ischemic cardiomyopathy; HR must be < 70, gold standard for structure and function
Cornary CT		Very high NPV for stenosis	Contrast media reactions; CIN lower risk than cath	Might have poor lumen visualization if heavy calcium burden Does not assess functional status
Coronary Angiogram	STEMI High risk NSTEMI: Refractory angina, new arrhythmia, cardiogenic shock (HF) Suspected true ACS	Direct visualization of lumen Therapeutic PCI	CIN with contrast Cath site complications Rare: SCAD, cholesterol emboli	Positive Screen (above) necessitates LHC LHC is diagnostic and therapeutic