Summaries about chest pain units
Summaries about chest pain units.
-Top 10 Take-Home Messages for the Evaluation and Diagnosis of Chest Pain:
1.
Chest Pain Means More Than Pain in the Chest. Pain, pressure, tightness, or discomfort in the chest, shoulders, arms, neck, back, upper abdomen, or jaw, as well as shortness of breath and fatigue should all be considered anginal equivalents.
2.
High-Sensitivity Troponins Preferred. High-sensitivity cardiac troponins are the preferred standard for establishing a biomarker diagnosis of acute myocardial infarction, allowing for more accurate detection and exclusion of myocardial injury.
3.
Early Care for Acute Symptoms. Patients with acute chest pain or chest pain equivalent symptoms should seek medical care immediately by calling 9-1-1. Although most patients will not have a cardiac cause, the evaluation of all patients should focus on the early identification or exclusion of life-threatening causes.
4.
Share the Decision-Making. Clinically stable patients presenting with chest pain should be included in decision-making; information about risk of adverse events, radiation exposure, costs, and alternative options should be provided to facilitate the discussion.
5.
Testing Not Needed Routinely for Low-Risk Patients. For patients with acute or stable chest pain determined to be low risk, urgent diagnostic testing for suspected coronary artery disease is not needed.
6.
Pathways. Clinical decision pathways for chest pain in the emergency department and outpatient settings should be used routinely.
7.
Accompanying Symptoms. Chest pain is the dominant and most frequent symptom for both men and women ultimately diagnosed with acute coronary syndrome. Women may be more likely to present with accompanying symptoms such as nausea and shortness of breath.
8.
Identify Patients Most Likely to Benefit From Further Testing. Patients with acute or stable chest pain who are at intermediate risk or intermediate to high pre-test risk of obstructive coronary artery disease, respectively, will benefit the most from cardiac imaging and testing.
9.
Noncardiac Is In. Atypical Is Out. “Noncardiac” should be used if heart disease is not suspected. “Atypical” is a misleading descriptor of chest pain, and its use is discouraged.
10.
Structured Risk Assessment Should Be Used. For patients presenting with acute or stable chest pain, risk for coronary artery disease and adverse events should be estimated using evidence-based diagnostic protocols.
-AHA …Chest pain is the second most common reason for adults to present to an emergency department in the United States.
noncardiac causes of chest pain account for a large majority of these cases, there are several dangerous and life-threatening causes of chest pain that must be identified and treated promptly. Distinguishing between serious and nonserious causes of chest pain is an urgent imperative.
the term “atypical” is often used to describe noncardiac symptoms, as well as cardiac symptoms not representative of myocardial ischemia (eg, pericarditis), thereby creating ambiguity. The recent chest pain guideline, therefore, recommends using “cardiac,” “possible cardiac,” and “noncardiac” chest pain as the preferred terminology. A comprehensive history and focused physical examination remain pivotal in the evaluation of specific chest pain etiologies and help discern serious cardiovascular causes from more benign ones.
-The two main goals of chest pain units are the early, accurate diagnosis of acute coronary syndromes and the rapid, efficient recognition of low-risk patients who do not need hospital admission. Many clinical, practical, and economic reasons support the establishment of such units. Patients with chest pain account for a substantial proportion of emergency room turnover and their care is still far from optimal: 8% of patients sent home are later diagnosed of acute coronary syndrome and 60% of admissions for chest pain eventually prove to have been unnecessary. We present a systematic approach to create and manage a chest pain unit employing specialists headed by a cardiologist. The unit may be functional or located in a separate area of the emergency room. Initial triage is based on the clinical characteristics, the ECG and biomarkers of myocardial infarct. Risk stratification in the second phase selects patients to be admitted to the chest pain unit for 6-12 h. Finally, we propose treadmill testing before discharge to rule out the presence of acute myocardial ischemia or damage in patients with negative biomarkers and non-diagnostic serial ECGs.
https://www.revespcardiol.org/en-chest-pain-units-organization-and-protoc-articulo-13028607-pdf
-Chest pain units in Northern
General Hospital(Teaching hospital in Sheffield, England ).
https://www.bmj.com/content/suppl/2007/09/18/bmj.39325.624109.AE.DC1/goos472332.ww1.pdf
https://www.ahajournals.org/doi/10.1161/CIR.0000000000001029
Of all ED patients with chest pain, only 5.1% will have an acute coronary syndrome (ACS), and more than half will ultimately be found to have a noncardiac cause.
The discomfort induced by myocardial ischemia is often characteristic and therefore central to the diagnosis. For this reason, features more likely to be associated with ischemia have been described as typical.
Pain—described as sharp, fleeting, related to inspiration (pleuritic) or position, or shifting locations—suggests a lower likelihood of ischemia.
ischemia is characteristically deep, difficult to localize, and usually diffuse. Point tenderness renders ischemia less likely. Reported symptoms lie somewhere on a continuum of higher or lower probability of ischemia based on the presence or absence of specific characteristics (Figure 2). Other clinical elements (eg, duration, provoking and relieving factors, patient age, cardiac risk factors) provide further focus toward or away from ischemia in the diagnostic process. It is essential to ascertain the characteristics of the chest pain directly from the patient for optimal interpretation.1-7 A patient’s history is the most important basis for considering presence or absence of myocardial ischemia, but the source of cardiac symptoms is complex, and their expression is variable. The diagnosis of ischemia may require data beyond history alone. In some patients, what appears to be noncardiac chest pain may be ischemic in origin.
Consider life-threatening conditions in cases of chest pain such as ACS, aortic dissection, and pulmonary embolism (PE), as well as nonvascular syndromes (eg, esophageal rupture, tension pneumothorax)by physical examination & imaging if needed . Chest pain accompanied by a painful, tympanic abdomen may indicate a potentially life-threatening gastrointestinal etiology such as esophageal rupture. PE may result in tachycardia, dyspnea, and accentuated P2(in PE you find “Tachycardia + dyspnea—>90% of patients; pain with inspiration”). Pneumothorax may be accompanied by pleuritic chest pain and unilateral absence of breath sounds. Although the causes of chest pain are numerous, the initial evaluation should focus on those that are life-threatening, such as ACS, PE, aortic dissection, and esophageal rupture, to facilitate rapid implementation of appropriate treatment.
The initial ECG is important to the evaluation, but history, examination, biomarkers, and other aids remain essential. There is frequently a lack of correlation between intensity of symptoms and seriousness of disease and general similarity of symptoms among different causes of chest pain. A comprehensive history that captures all the characteristics of chest pain (including but not limited to its: 1) nature; 2) onset and duration; 3) location and radiation; 4) precipitating factors; 5) relieving factors; and 6) associated symptoms can help better identify potential cardiac causes and should be obtained from all patients).
Anginal symptoms are perceived as retrosternal chest discomfort (eg, pain, discomfort, heaviness, tightness, pressure, constriction, squeezing).
Sharp chest pain that increases with inspiration and lying supine is unlikely related to ischemic heart disease (eg, these symptoms usually occur with acute pericarditis).
Onset and duration
Anginal symptoms gradually build in intensity over a few minutes.
Sudden onset of ripping chest pain (with radiation to the upper or lower back) is unlikely to be anginal and is suspicious of an acute aortic syndrome.
Fleeting chest pain—of few seconds’ duration—is unlikely to be related to ischemic heart disease.
Location and radiation
Pain that can be localized to a very limited area and pain radiating to below the umbilicus or hip are unlikely related to myocardial ischemia.
Severity
Ripping chest pain (“worse chest pain of my life”), especially when sudden in onset and occurring in a hypertensive patient, or with a known bicuspid aortic valve or aortic dilation, is suspicious of an acute aortic syndrome (eg, aortic dissection).
Symptoms on the left or right side of the chest, stabbing, sharp pain, or discomfort in the throat or abdomen may occur in patients with diabetes, women, and elderly patients.
Presence of cardiovascular risk factors, and systemic review( e.g.DVT complicated with PE) family history should complement the assessment of presenting symptoms.
Fever, pleuritic chest pain, increased in supine position, friction rub suggests pericarditis.
Esophagitis, peptic ulcer disease, gall bladder disease are suggested by” Epigastric tenderness
Right upper quadrant tenderness, Murphy sign”.
ECG should be obtained within 10 minutes of arrival ER. ECG), is pivotal in the evaluation because of its capacity to identify and triage patients with STEMI to urgent coronary reperfusion. Other ST-T abnormalities consistent with possible ischemia also mandate prompt evaluation in a hospital setting.
cTn ( high sensitivity cTn preferred) should be measured as soon as possible.
The goals in patients presenting to the ED or office with acute chest pain are: 1) identify life-threatening causes; 2) determine clinical stability; and 3) assess need for hospitalization versus safety of outpatient evaluation and management.
Integrating the examination with other elements of the evaluation and taking any evidence of a life threatening cause are crucial in evaluation.
Transportation is through EMS not private( availability of ECG transmit-ion prehospital, DC shock and trained personnel ).
Patients with stable angina or noncardiac chest pain that is not life-threatening should be managed as outpatients.
Patients with chest pain and new ST-elevation, ST depression, or new left bundle branch block on ECG should be treated according to STEMI and NSTE-ACS guidelines.
An initial normal ECG does not exclude ACS. Patients with an initial normal ECG should have a repeat ECGs, specially if symptoms are ongoing and after pain change or subsides , until other diagnostic testing rules out ACS.
When an ECG is nondiagnostic, it should be compared with previous ECGs, if available.
A normal or unchanged ECG is reasonably useful but not sufficient at ruling out ACS.Thus, decision-making should not be based solely on a single normal or nondiagnostic ECG. Left ventricular hypertrophy, bundle branch blocks, and ventricular pacing may mask signs of ischemia or injury.
Up to 6% of patients with evolving ACS are discharged from the ED with a normal ECG. The timing for repeat ECG should also be guided by symptoms, especially if chest pain recurs or a change in clinical condition develops.
When ST-elevation is present on the initial ECG, management should follow the prescribed STEMI treatment algorithms in associated guidelines.2,22 Furthermore, if ST depression is identified on the initial ECG, management should follow the NSTE-ACS guidelines.
A normal ECG may be associated with left circumflex or right coronary artery occlusions and posterior wall ischemia( changes seen in V7-V8-V9 ECG leads), which is often “electrically silent”; therefore, right-sided ECG leads should be considered when such lesions are suspected.
Chest radiographs are rapid, noninvasive tests that can be useful to screen for several disorders that may present with chest pain, and its use should be guided by clinical suspicion.
the time interval from onset of chest pain to a detectable concentration at patient presentation is shorter with hs-cTn, affording more rapid rule-in and rule-out algorithms.
Comparative studies have confirmed the superiority of cTn over CK-MB and myoglobin for diagnosis and prognosis of AMI.
Dr Jamal Dabbas
