chest pain and…

the case.

a 41 year old male presents with sudden severe retrosternal chest pain radiating into the right flank.

He also reports 3-4 weeks of intermittent chest tightness & that his doctor told him he “may need a heart valve fixed one day”.

This is his ECG.

[DDET Describe & interpret the ECG…]

• Rate.
  • 66 bpm.
• Rhythm.
  • Regular, sinus.
• Axis.
  • Normal [~ 27*]
• Intervals.
  • PR ~ 160 msec
  • QRS ~ 100 msec
  • QTc ~ 375 msec
• Segments.
  • STE (V2-3) ?BER vs appropriate discordance
  • STD (lead III only) ~1/2mm
  • TWI (III only), plus T-wave flattening in aVF.
• Others.
  • Non-specific intraventricular conduction delay
  • LVH by voltage-criteria;
    • S(V2) + R(V5) > 45mm
    • No strain pattern

Interpretation.

Sinus rhythm with left ventricular hypertrophy (by voltage-criteria).

[/DDET]

[DDET You take an ultrasound to his bedside…]

This is his bedside ECHO.

httpv://www.youtube.com/watch?v=Ki9kYPQhByk

httpv://www.youtube.com/watch?v=d8UHXwx3Wk0

LV hypertrophy visible on the parasternal long-axis and a large aortic regurgitant jet seen on the apical four chamber.

[/DDET]

[DDET What should we worry about here ?!?]

Aortic Dissection.

” There is no disease more conductive to clinical humility than aneurysm of the aorta. ”
– Sir William Osler.

When it comes to aortic dissection, maintaining a high index of suspicion is crucial. Whilst it does not always present in the classical ‘chest pain and…” manner described in textbooks, it is important to keep in mind the risk factors associated with the disease as well as the pertinent features of history, examination and imaging that may lead us to pursue the diagnosis more aggressively.

Traditional risk factors:

• Chronic hypertension
• Bicuspid aortic valve + other congenital cardiac disease
• Coarctation
• Atherosclerosis
• Marfan or Ehlers-Danlos syndrome
• Vasculitis [SLE, syphilis, GCA etc.]
• Prior instrumentation [CABG, valve surgery, IABP]

History.
Note that most episodes of chest pain are acute and severe. Do not rely on migration, radiation etc. Pain can still be atypical.

Physical examination.
Note that the classic pulse deficits and murmur of aortic insufficiency are not always present !!

Basic investigations.

It is important to remember the list of abnormal CXR findings which include;

• widened mediastinum
• abnormal aortic contour including loss of aortopulmonary window
• aortic ‘double-calcium’ sign
• pleural effusion
• left apical cap
• tracheal deviation
• depressed left bronchus
• rightward deviation of nasogastric tube

Advanced imaging.

• CT-aortogram:
  • Ideally the next best test.
  • Confirm the diagnosis, but also demonstrates the extent of the disease & identifies complications.
    • If negative for dissection, may identify alternate pathology.
  • Rapid.
  • Geographically not ideal. Must leave resuscitation bay !!
  • Sn 100% [96-100], Sp 98% [87-99]

• Transoesophageal ECHO:
  • Operator dependent may also be an appropriate test.
  • Consider use in unstable patient & transfer out of ED is not feasible or safe.
  • Identifies AR as well as pericardial effusion ± tamponade.
  • Limited visualisation of arch branches and distal ascending aorta.
  • Sn 98 [95-99], Sp 95% [92-97]

• MRI:
  • No radiation
  • Geographically isolated & takes time [>30mins]
  • Limited availability
  • Sn 98 [95-99], Sp 98 [95-100]

Management.

• Analgesia
  • May help with anxiolysis and blood pressure control
• Ensure adequate IV access & be equipped for massive transfusion
  • Cross-match & notify blood-bank
  • Fluid warmer, rapid-infuser prepped
• Aggressive blood pressure control
  • Goal is to minimise shear stress on the intimal flap.
  • Invasive monitoring [arterial line]
  • First line – beta-blockers:
    • Esmolol infusion
    • Metoprolol boluses
    • Labetalol
    • Target: Pulse 60-80 bpm
  • Second line – vasodilators [ensure adequate rate-control first, to avoid rebound tachycardia]
    • Nitrates [GTN infusion]
    • Sodium nitroprusside
    • Nicardipine
    • Target: SBP < 120 mmHg
• Assess for complications.
  • Rupture
  • Tamponade
  • Cardiac ischaemia secondary to dissection in RCA [0.1-0.2% of all STEMIs]
  • End-organ ischaemia
    • Brain [Stroke symptoms]
    • Limbs
    • Bowel
    • Kidneys
    • Spine [paralysis]
• Urgent surgical consultation
  • Surgery for Type A dissection, those with ongoing pain, aortic branch occlusion, evidence of leak on CT or development of local aneurysms.
• Notify anaesthetics and intensive care of potential incoming patient.

[/DDET]

[DDET What happened next ?]

With chest pain radiating into abdomen & flank and an ECHO demonstrating aortic regurgitation, our patient was sent to radiology for a CT-Aortogram.

Fortunately, this excluded dissection but did demonstrate aneurysmal dilatation of the ascending aorta [to 46mm].

His formal ECHO reported moderately dilated LV w/ mild concentric hypertrophy & normal systolic function. Bicuspid aortic valve with mild-moderate stenosis & moderate regurgitation.

He has discharged home after exclusion of atypical acute coronary syndrome with a referred for outpatient surgical management of his valvular disease.

[/DDET]

[DDET References]

1. Rosenʼs Emergency Medicine. Concepts and Clinical Approach. 7th Edition
2. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 7th Edition.
3. Hagan, P. G., Nienaber, C. A., Isselbacher, E. M., et al. (2000). The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease. JAMA: the journal of the American Medical Association, 283(7), 897–903.
4. Klompas, M. (2002). Does this patient have an acute thoracic aortic dissection? JAMA: the journal of the American Medical Association, 287(17), 2262–2272.
5. Upadhye S, Schiff K. Acute aortic dissection in the emergency department: diagnostic challenges and evidence-based management. Emerg Med Clin North Am. 2012 May;30(2):307-27

[/DDET]