Chest Pain ========== Can adolescents, even without drug abuse, get spasm that will cause an MI? Yes. Lane, J. R. and G. Ben-Shachar (2007). "Myocardial infarction in healthy adolescents." Pediatrics 120(4): e938-43. OBJECTIVE: Chest pain in children and adolescents is a frequent cause for office or emergency department visits. However, it is unclear whether myocardial infarction occurs in children with no anatomic abnormality presenting with chest pain. METHODS: Clinical history, electrocardiography, echocardiography, and cardiac enzyme levels were evaluated in patients presenting to the emergency department over a period of 11 years (June 1995 to May 2006). Patients in whom findings were suggestive of acute myocardial infarction, in addition, underwent drug screening, serum lipid profile, and hypercoagulability workup and, when myocardial infarction was diagnosed, heart catheterization with coronary angiography. RESULTS: Nine patients (8 boys; age range: 12-20 years; mean: 15.5 years) met established criteria for myocardial infarction. Abnormal electrocardiograms were found in 8 patients (6 with ST elevation and 2 with nonspecific ST-T abnormalities), abnormal cardiac enzyme levels in all, and echocardiographic abnormalities in 3. Cardiac dysrhythmias were found in 4 patients, 3 with nonsustained ventricular tachycardia. Drug abuse, lipid profile, and hypercoagulability studies were negative in all. Left ventricular focal hypokinesia was seen by echocardiogram or angiography in 5 patients and abnormal coronary anatomy in none. Cardiac function normalized in 8 patients. One patient had a persistent focal inferior hypokinesis. Calcium channel blocker therapy was initiated in all of the patients with no recurrence of anginal chest pain on follow-up. One patient complained of chest pain distinct from anginal pain. CONCLUSIONS: Myocardial infarction can occur in adolescents with normal coronary arterial anatomy. Adolescents who present for emergency care with typical chest pain need electrocardiographic and cardiac enzyme workups. Those with results that are suggestive of acute infarction require additional workup. Coronary vasodilation therapy seems helpful, but given the lack of coronary thrombosis in these patients, thrombolytic therapy seems unwarranted. Long-term follow-up is necessary, and adjustments in therapy may be required with time. þ Does having a normal EKG while you're having chest pain protect you? No. - [Chase, M., A. M. Brown, et al. (2006). "Prognostic value of symptoms during a normal or nonspecific electrocardiogram in emergency department patients with potential acute coronary syndrome." Acad Emerg Med 13(10): 1034-9.] OBJECTIVES: Emergency department (ED) patients with symptoms concerning for acute coronary syndrome (ACS) and a normal electrocardiogram (ECG) are at risk for adverse cardiovascular events. The authors hypothesized that patients with a normal or nonspecific ECG during symptoms have a lower risk for ACS than do those who are asymptomatic. METHODS: This was a prospective cohort study of ED patients with potential ACS. Outcomes were acute myocardial infarction (AMI), ACS, and 30-day cardiovascular events (death, AMI, revascularization). Fisher's exact test, t-tests, and logistic regression were used for data analysis. RESULTS: Of 2,593 patient visits, 2,007 patients had normal or nonspecific ECG findings. There were 1,196 who had symptoms during ECG, whereas 811 did not. Patients with symptoms at ECG acquisition were younger (49.9 vs. 55.2 years; p < 0.001) and were more likely to be black (70% vs. 64%; p = 0.002), female (63% vs. 58%; p = 0.03), and to have used cocaine (5% vs. 2%; p = 0.004). They were less likely to have hypertension (49% vs. 58%; p < 0.001), and diabetes (22% vs. 17%; p = 0.002). Patients with and without symptoms were equally likely to have AMI (both 2.8%; p > 0.99), ACS (10.1% vs. 11.5%; p = 0.34), and 30-day adverse outcomes (both 5.3%; p > 0.99). After adjustment for baseline cardiovascular-risk factors, odds ratios for patients with symptoms at the time of ECG acquisition were not significantly different for any of the outcomes: AMI (1.1; 95% confidence interval [CI] = 0.6 to 1.9); ACS (1.1; 95% CI = 0.8 to 1.4); or 30-day events (1.2; 95% CI = 0.8 to 1.9). CONCLUSIONS: Patients who are symptomatic during acquisition of a normal or nonspecific ECG have rates of adverse cardiovascular events similar to those of patients without symptoms. Clinicians should not rely on the absence of ECG abnormalities during symptoms to help exclude ACS. þ Judd Hollander: - "in" terminology: ST elevation MI (STEMI) vs. other coronary syndromes - Lee 1985 Arch IM 1985;145:65: age alone doesn't stratify as low-risk - <1% to send home - 122 patients meeting ARA definition of costochondritis: 6% ruled in for MI. [Disla et al. Arch Int Med 1994;154:2466.] - repeat EKGs: no help in diagnosing MI. [] - risk factors (cholesterol, hypertension, family history) do not affect likelihood of MI in 1700 patients. In men only, DM does make a slight difference (2.4) as does +FH (2.1) [Jayes et al. J Clin Epidemiology 1992;45:621] - In young patients (<40) with chest pain, can send home: + if no cardiac risks and no prior cardiac history (N=210, 1 had MI and died); or, + if normal EKG and no prior cardiac risks [Walker et al AEM 2001;8:703.] - neural networks and decision trees do work: ACA-TIPI [Pozen et al NEJM 1994;310:1273.] þ Things that may simulate MI - Pericarditis may sometimes show EKG changes suggestive of MI - PEs may cause enough RV strain to cause a small MI - endocardial sloughing leads to mildly elevated Troponin. þ Musculoskeletal Chest Pain þ Pneumomediastinum - Panacek's article showed that spontaneous pneumomediastinum can be treated conservatively and do well. þ Cocaine-Associated Chest Pain þ Neurogenic Chest Pain - See chest pain from brachial plexopathy - Dejerine's Sign: exacerbation of chest pain of radicular origin by coughing or sneezing. Ref: Tintinalli 3rd ed. p 131 þ Hyperventilation Chest Pain - Poor correlation between subjective symptoms and objective manifestations - pCO2 will be lower than 35 torr in only about 50% of cases; may be due to variability in respiratory pattern of patients. Ref: Tintinalli 3rd ed. p 132 þ Tachycardia as a predictor that chest pain is a PE - In a group of patients with angiographically proven pulmonary embolism, more than half (56%) had a heart rate less than 100 bpm. On this basis, one might consider the presence of tachycardia to be the exception in pulmonary embolism, rather than the rule. (Rosen 3rd ed. p 1290) þ Classic MI symptoms - in 1912, Herrick described pressure or tightness in the chest or epigastrium with or without radiation and associated sx of N/V, diaphoresis and dyspnea. [Herrick JB. Clinical features of sudden obstruction of the coronary arteries. JAMA 1912;59:2015-2021.] þ Quality of Chest Pain in MI - pressure: 60% - aching: 10% - burning: 10% - sharp/ stabbing: 10% [Lee TH, et al. Acute chest pain in the emergency room: Identification and examination of low risk patients. Arch Intern Med 1985;145:65-69.] Abstract: þ clinical diagnosis of MI suggested by: - sudden onset (70%) - lasting longer than 60 minutes (88%) - constriction and squeezing pain (79%) - previous angina (51%) - male sex (72%) - age > 60 (74%) - abnormal cardiac auscultation (62%) - EKG changes (98%) - CPK-MB > 6% (63%) (but one study found that burning or indigestion as common (20%) as squeezing or "tight" chest pain. ) þ Using Risk Factors to analyze a patient with chest pain - The only risk factors that count for the individual are being male and having a family history or diabetes. All other factors only increase the statistical chance on a population basis and not for the individual. [Jayes RL Jr, Beshansky JR, D'Agostino-RB, Selker-HP. Do patients' coronary risk factor reports predict acute cardiac ischemia in the emergency department? A multicenter study.] Abstract: þ Radiation Patterns of Chest Pain - Radiation of pain to the arm, jaw or neck increases the liklihood of MI by a factor of three to four fold compared to pain that is localized to the chest alone. [Goldman L. Acute Chest Pain: Emergency Room Evaluation. Hosp Prac 1986 (July) 94A-94T.] [Goldman et. al. A computer-derived Protocol to Aid in the Diagnosis of Emergency Room Patients with Acute Chest Pain NEJM 1982:307;588-596.] Abstract: - There has been disagreement over this, however. The latter study, which done by a gastroenterologist, may have suffered from selection bias, however. [Davies HA, Jones DB, Rhodes J, Newcombe RG. Angina-like esophageal pain: differentiation from cardiac pain by history. J Clin Gastroenterol 1985; 7(6):477-81.] Abstract: - Radiation of pain to right arm 94% specific, with 41% sensitivity Coronary disease diagnosed in 94% with radiation to right arm. Radiation of pain to left arm 76% specific, 55% sensitive [Berger JP, Buclin T, Haller E, Van Melle G, Yersin B. Right arm involvement and pain extension can help to differentiate coronary diseases from chest pain of other origin: a prospective emergency ward study of 278 consecutive patients admitted for chest pain. J Intern Med 1990;227(3):165-72.] Abstract: [Beunderman R, Sramek M, Koster RW, Garssen B, van Dis H. [Criteria for differential diagnosis in cardial symptoms; left- or right-sided chest pain?] Ned Tijdschr Geneeskd 1990;134(46):2249-52. Abstract: - If you are interested in ED risk analysis in patients with chest pain you might do a Medline search on Goldman, L. He has published about 30 or 40 articles on just this subject alone in the last decade. If you don't have the time to read the original reseach and would, instead like a summary I highly recommend the following somewhat dated, but excellent, review articles. --H. Louzon MD [Murata. Evaluating Chest Pain in the Emergency Department. West J Med 1993;1159:61-68 [Hedges et. al. Detection of Myocardial Ischemia/Infarction in the Emergency Department Patient with Chest Discomfort. Emer Med Clin 1988;6(2):317-340.] [Bresler et. al. Acute Myocardial Infarction in the Emergency Department. ACEP Monograph ?date.] þ Nausea/Vomiting with Chest Pain - clasically association with inferior MI but according to one study seems to be associated with different locations of MI equally. [Gnecchi Ruscone T, Guzzetti S, Lombardi F, Lombardi R Lack of association between prodromes nausea and vomiting, and specific electrocardiographic patterns of acute myocardial infarction. Int J Cardiol 1986 Apr;11(1):17-23.] Abstract: þ GI Cocktail and Antacids in Diagnosis of MI - GI cocktail relieves MI pain as much as other pain. [Wrenn K, Slovis CM, Gongaware J. Using the "GI Cocktail": A descriptive study.] [Servi RJ, Skiendzielewski JJ. Relief of myocardial ischemia pain with a gastrointestinal cocktail. Am J Emerg Med 1985; 3(3):208-9.] þ NTG can relieve esophageal pain as well as coronary ischemia - [Millaire A, Ducloux G, Marquand A, Vaksmann G. [Nitroglycerin and angina with angiographically normal coronary vessels. Clinical effects and effects on esophageal motility]. Arch Mal Coeur Vaiss 1989; 82(1): 63-8.] Abstract: þ "Linked Angina" -- of both coronary and GI origin - "There also exists the phenomenon of "linked angina" whereby the occurrence of esophageal reflux precipitates 'true' angina related to myocardial ischemia either by reducing coronary blood flow..." [Chauhan A, Petch MC, Schofield PM. Effect of oesophageal acid instillation on coronary blood flow. Lancet, May 22 1993; 341(8856): 1309-10.] Abstract: " ...or by increasing the double product... " [Mellow MH, Simpson AG, Watt L, Schoolmeester L, Haye OL. Esophageal acid perfusion in coronary artery disease. Induction of myocardial ischemia. Gastroenterology, 1983;85(2):306-12.] Abstract: "... That the phenomenon of linked angina occurs is indisputable. How common it is, however is a matter of controversy." --H. Louzon, MD [Lam HG, Dekker W, Kan G, van Berg Henegouwen GP, Smout AJ. Esophageal dysfunction as a cause of angina pectoris ("linked angina"): does it exist=? Am J Med 1994;96(4): 359-64.] Abstract: þ "Gas" (air in the esophagus with belching) can cause chest pain in some [Gignoux C, Bost R, Hostein J, Turberg Y, Denis P, Cohard M, Wolf JE, Fournet J. Role of upper esophageal reflex and belch reflex dysfunctions in noncardiac chest pain. Dig Dis Sci 1993; 38(10): 1909-14.] Abstract: - Rarely, "belch dysfunction" can cause severe chest pain. [Kahrilas PJ, Dodds WJ, Hogan WJ. Dysfunction of the belch reflex. A cause of incapacitating chest pain. Gastroenterology, 1987; 93(4): 818-22.] Abstract: þ Psychological and Financial Effects of Chest Pain - None of this is likely to influence physician's admitting patterns, however. They are going to continue to admit patients with chest pain, indiscriminately, until patients become neurotic [Dart AM, Davies HA, Griffith T, Henderson AH. Does it help to undiagnose angina? Eur Heart J 1983;4(7):461-2.] Abstract: and the country goes bankrupt. [Lee TH, Pearson SD, Johnson PA, Garcia TB, Weisberg MC, Guadagnoli E, Cook EF, Goldman L. Failure of information as an intervention to modify clinical management. A time-series trial in patients with acute chest pain. Ann Intern Med 1995;2(6):434-7.] Abstract: [Lee TH, Cook EF, Weisberg M, Sargent RK, Wilson C, Goldman L. Acute chest pain in the emergency room. Identification and examination of low-risk patients. Arch Intern Med 1985; 145(1): 65-9.] Abstract: þ Likelihood ratios for chest pain with varoius asssociated symptoms: - Murata [Murata. Evaluating Chest Pain in the Emergency Department. West J Med 1993;1159:61-68.] Abstract: revises an earlier study by Lee and Goldman [Lee TH; Cook EF; Weisberg M; Sargent RK; Wilson C; Goldman L. Acute chest pain in the emergency room. Identification and examination of low-risk patients. Arch Intern Med, 145: 1, 1985 Jan, 65-9.] Abstract: and defines a likelihood ratio (L) that represents the ratio of the number of patients with MI exhibiting a sign or symptom to the number of people without MI who have that sign or symptom. If the pretest probability of an MI is P then the presence of a symptom (or sign) with likelihood ratio L would give one a post-test probability of P^ = L*P. Taking all comers, they observe that an average pre-test probability for acute MI is about 0.15. If the likelihood ratio is less than unity then the presence of that symptom lowers the likelihood of MI. If greater than unity then the opposite. Here is a table from Goldman's study with L values for different pain characteristics: Chest Pain Quality Likelihood Ratio Pressure 1.8 Aching 0.67 Burning or Indigestion 1.4 Sharp or Stabbing 0.23 Partially or completely 0.20 reproduced by palpation Partially or completely 0.18 pleuritic Partially or completely 0.33 positional Fully reproduced by chest 0.18 palpation, pleuritic or evoked by changes in position or movement It can be seen that an L of 0.2 with a pre-test probability of 0.15 still leaves one with a 3% chance of MI (0.2*0.15). Comfortable enough for me but not for a lot of other people. Also it is observed that the Ls for most uncommon symptoms hovers around 0.2 meaning that unless your pre-test probability is substantially less than 15%, the presence of any of these symptoms will be unable to reduce your post-test probability to less than 3%. I.e., you can't rely on any *one* of them to exclude MI with enough sensitivity. However, taken *together* pain that is 1) Sharp or stabbing AND 2) positional or pleuritic or reproducible AND 3) no h/o MI identifies a group with vanishingly small risk of MI or angina (0/48 in this series). --H. Louzon MD - "A combination of three variables--sharp or stabbing pain, no history of angina or myocardial infarction, and pain with pleuritic or positional components or pain that was reproduced by palpation of the chest wall--defined a very-low-risk group in which ECGs did not add accuracy to the evaluation and were potentially misleading; however, only 48 patients (8%) fell into this category." [Lee TH, Cook EF, Weisberg M, et al. Acute chest pain in the emergency room. Identification and examination of low-risk patients. Arch Intern Med 1985; 145:65-9.] Abstract: þ Physician Patterns of Chest Pain Admission - The longer you are in practice, the more cautious you get; but, you don't get any better. [Ting HH, Lee TH, Soukup JR, et al. Impact of physician experience on triage of emergency room patients with acute chest pain at three teaching hospitals. Am J Med 1991; 91:401-8.] Abstract: - Risk-taking type physicians are more likely to send patients home with chest pain. [Pearson SD, Goldman L, Orav EJ, et al. Triage decisions for emergency department patients with chest pain: do physicians' risk attitudes make the difference? J Gen Intern Med 1995; 10:557-64.] Abstract: - Physicians don't use computer-based prediction rules --- they provide little benefit compared to the time that they take. [Pearson SD, Goldman L, Garcia TB, Cook EF, Lee TH. Physician response to a prediction rule for the triage of emergency department patients with chest pain. J Gen Intern Med 1994; 9:241-7.] Abstract: - One computer-based rule might let you send more people home, but doesn't let you identify any more patients with MI. [Goldman L, Cook EF, Brand DA, et al. A computer protocol to predict myocardial infarction in emergency department patients with chest pain. N Engl J Med 1988; 318:797-803.] Abstract: þ Gender, Age, Sex and Insurance Differences in Evaluating Chest Pain - Race: + Given similar presentations, blacks are slightly less likely to have acute coronary syndromes than whites; and have the same access to cardiac care; but get bypass less often. [Johnson PA, Lee TH, Cook EF, Rouan GW, Goldman L. Effect of race on the presentation and management of patients with acute chest pain [see comments] Ann Intern Med 1993; 118:593-601.] Abstract: - Gender: + This study says women with chest pain less likely to be admitted for chest pain. [Johnson PA, Goldman L, Orav EJ, et al. Gender differences in the management of acute chest pain. Support for the "Yentl syndrome" J Gen Intern Med 1996; 11:209-17.] Abstract: + "Clinical features that predict myocardial infarction in men predict myocardial infarction in women to a similar extent. However, female gender is associated with about a 40% lower rate of myocardial infarction except when classic electrocardiographic evidence is present on the emergency department electrocardiogram." Women with chest pain had a 10% MI rate as opposed to 19% in men in this study. [Cunningham MA, Lee TH, Cook EF, et al. The effect of gender on the probability of myocardial infarction among emergency department patients with acute chest pain: a report from the Multicenter Chest Pain Study Group J Gen Intern Med 1989; 4:392-8.] Abstract: - Insurance: + This study found that HMO patients were _more_ likely to be admitted than others! [Pearson SD, Lee TH, Lindsey E, et al. The impact of membership in a health maintenance organization on hospital admission rates for acute chest pain. Health Serv Res 1994; 29:59-74.] Abstract: - Age: + Elderly less likely to meet criteria for thrombolytics [Krumholz HM, Friesinger GC, Cook EF, et al. Relationship of age with eligibility for thrombolytic therapy and mortality among patients with suspected acute myocardial infarction J Am Geriatr Soc 1994; 42:127-31.] þ Having a Previous EKG - Yes, just as we thought, having a previous EKG lets you keep a bunch of people out of the CCU. [Lee TH, Cook EF, Weisberg MC, et al. Impact of the availability of a prior electrocardiogram on the triage of the patient with acute chest pain [see comments] J Gen Intern Med 1990; 5:381-8.] Abstract: þ MI with normal or nonspecific EKG - Such people are less likely to have symptoms of a severe MI (e.g., diaphoresis), a lower CPK peak, and probably a better outcome. [Rouan GW, Lee TH, Cook EF, et al. Clinical characteristics and outcome of acute myocardial infarction in patients with initially normal or nonspecific electrocardiograms (a report from the Multicenter Chest Pain Study) Am J Cardiol 1989; 64:1087-92.] Abstract: þ Sensitivity, Specificity and Predictive Value of Thrombolysis Criteria - In this study, standard criteria at the time (age less than 75, pain less than 4 hours, and EKG showing probable MI) identified only 23% of those with acute MI. "Because experience from published studies suggests that about one third of patients who meet these three eligibility criteria have other contraindications to thrombolysis, we estimate that about 15% of patients with acute myocardial infarction would meet the criteria for eligibility for thrombolysis that have been used in clinical trials at the time of emergency room presentation. Further, for every eight patients with true-positive results who are treated, one to two patients with false-positive results may also be treated if decisions are based on the interpretation of a single electrocardiogram." [Lee TH, Weisberg MC, Brand DA, Rouan GW, Goldman L. Candidates for thrombolysis among emergency room patients with acute chest pain. Potential true- and false-positive rates [see comments]. Ann Intern Med 1989; 110:957-62.] Abstract: