Welcome to ischemic heart disease. We're going to start this week with a discussion around chest pain, simply because chest pain outside of heart failure will be one of the largest things that you do or you need to get really good at, I guess, is understanding what is cardiac versus non-cardiac chest pain. And there's a little bit of, you know, we call it the science versus the art. There's a little bit of an art to this. I had one of the physicians that I worked with early in my career had this, you've got to have a gestalt or a gut feeling that, yeah, this is the real deal versus this isn't. And part of that is the way patients answer the questions. Part of that is, I literally would think to myself, is this patient sitting in front of me somebody that has heart disease? So whether the symptoms are heart disease or not, first of all, are they even somebody that has enough risk factors that they could have heart disease? And again, it's that concept of the 16-year-old versus the 45-year-old who would be more likely to have heart disease. So let's just kind of jump in. So a few statistics for you. It's the most common cause of chest pain in the outpatient setting are GI and musculoskeletal. So when we look at patients with chest pain that are in the outpatient setting, 33 to 50% of them, it's musculoskeletal, it's costochondritis, it's some other type of musculoskeletal pain. 10 to 20% of them have GI pain, so it's esophageal constriction or peptic ulcer disease or gastritis. 10% have stable angina, so they actually have coronary disease, but it's stable, and we'll talk about that. And only 2 to 4% of them have an acute myocardial ischemia. Herein lies the challenge, though. You do not want to miss the 2 to 4%. So that is the patients that you see that walk out of your clinic or walk out of your urgent care or walk out of your emergency department and drop dead three hours from now from their myocardial infarction. So I think because the risk is high, we spend a lot of time and a lot of dollars working up musculoskeletal pain and GI pain in patients that were really low risk to begin with. So it's definitely a challenge, and it's one of those things that the more you do, the more comfortable you're going to get, and the better you're going to be. So what's your job? Patient walks in with chest pain. Your job is to figure out what is it, cardiac or non-cardiac. So I'm going to start with a cardiac chest pain is. So think about it back to physiologic. When patients have angina, angina is lack of oxygen to the myocardium. So whether that's a demand issue because we've got more workload and we need more blood flow and we've got a stenotic area that doesn't allow for the blood flow, so now we're having chest pain or angina pain, or we have an acute occlusion, and so it's not so much a demand issue as it is we simply even at rest aren't getting enough oxygen. But it's lack of oxygen to the myocardium. Once you move into lack of oxygen, it takes you from an aerobic to an anaerobic metabolism. So what happens when we move to anaerobic? Well, we get acid buildup. We get lactic acid buildup. So we start to get that burning chest discomfort. Some people describe it as grabbing. Some people describe it as sharp, achy. It can be described many different ways, but think about what's happening to cause the pain. Other associated symptoms include being short of breath, having a hard time catching your breath, nausea, and sometimes even vomiting. It's interesting, but the inferior wall, when it's affected, we tend to see a lot more nausea, vomiting. Diaphoresis is the same. That inferior wall, and I don't think I've heard because it sits close to the vagus nerve, but you can get a lot of diaphoresis from that. Again, do not quote me as far as that they're completely connected, but that has been what I've seen in my career. The other interesting thing about these patients is the ones that are truly cardiac will typically have this feeling of pending doom. They will tell you, something is wrong with me. I feel like I'm going to die. And sometimes it isn't even because the pain is so bad. They just know. Some of them just know. I remember I had a patient in his early 30s that presented with really interesting, strange symptoms. I won't go into all of it today, but the one thing he said to me was, and his pain was intermittent, but when he would get it, he's like, when I have it, I feel like I'm going to die. I feel like something really, really wrong is happening. And you know what? He ended up having a left atrial, I'm sorry, a left anterior descending proximal dissection. And what happened, he had a little bit of a flap. And so depending on where the flap was, he would be ischemic versus non-ischemic. And he was only 32. But the thing that really stuck with me was that feeling of pending doom. Sometimes they'll have palpitations, you know, you can get some ischemic arrhythmias and then certainly any presyncope or syncope. The other thing to remember is that myocardial injury occurs in as early as two hours. So the reason that's important is if a patient walks in and they're like, I've been having pain for two weeks and it's constant and never goes away and their troponins are negative, you can't have angina pain and not have myocardial injury if it's lasting longer than several hours. So remember that injury occurs in as early as two hours of lack of oxygen. So cardiac chest pain is not, it's not twinges. So you think about what has to happen. There has to be a switch from aerobic to anaerobic. Then you have to have lactic acid buildup and then the pain starts. This doesn't happen in a matter of a couple seconds. And the other thing is, is when then the demand drops and we start to get oxygen again. So it takes some time for the pain to ramp up and it takes some time for the pain to go away. So when people describe as pain lasting for seconds, that is typically non-cardiac because the physiology simply doesn't make sense. Lasting days to weeks, we talked about you would have seen injury by them. It's not typically reproducible. So if they change positions, if you press on their chest, if they take a deep breath, that's typically can't, doesn't make the pain worse. Now it can be much worse with activity because you're back to that oxygen demand issue. But for them laying in the bed and describing it as, yeah, if I turn a certain way or when you start pressing on their chest and you can reproduce it, that is much more likely to be musculoskeletal. The other thing that I would urge you, because I've just done it long enough and I've seen it enough, pull back their shirt or their gown because patients that get herpes zoster or shingles oftentimes get pain before they break out into the rash. And you'll get people that would be like, I've been having this burning pain for two days. You just got called to the ED to do the chest pain consult. You pull back their gown and they've got blisters. So it's happened enough. Please, please, please take a look at their skin. Other cardiac symptoms that we might see besides just pain would be dyspnea, so shortness of breath, activity intolerance. Sometimes it's weakness. Sometimes it's just nausea, vomiting, palpitations, syncope. The other thing that I do when I evaluate a patient is if they've had an MI in the past or have had ischemia or known coronary artery disease, if they've had an event, they had pain. My question is always, is this anything like what you had when you had your heart attack six months ago or however long it was? If they say no, it's completely different. That's not enough to say that it's non-cardiac, but that is a good indicator that it's less likely. If they say it is exactly like it was, that's a good indicator to say, there's a good chance that here we are doing this all over again and maybe they had some issue. So I always ask, is this anything like what you've had before? So what do you need to know when you take your history? Well, you need to get a good description of the pain. So start with the quality. Is it pleuritic? Is it worse when they take a deep breath? Is it positional? Is it sharp, dull, ripping, tearing, or is it reproducible? What's the location and does it radiate? Is it localized or generalized? Which side is it on and does it radiate? Again, we get a lot of radiation in the left arm, but not always. And sometimes it's the right arm, not often, but is there any radiation associated with it? What are the temporal elements? Is there an abrupt onset? How long does it last? Is that seconds versus minutes versus hours versus weeks? What provokes it? Exertion, cold, emotional stress, meals, sexual intercourse, body position. Again, when you think about those things, go back to that oxygen demand and what's happening. Meals is interesting because you need increased cardiac output after a meal to support the digesting process. And so sometimes people will have postprandial angina. What makes it better? So what's the palliation? In anything you do specifically, is it stopping? When you sit and rest, what makes it better? What's the severity? So we always use that 0 to 10 and then any other associated symptoms. So you take all their symptoms and then you also need to think about, so the question is, are their symptoms consistent with something that could be angina? And then is this a patient that could have cardiac disease? So what are their risk factors? So what are some of the risk factors we look for? Hypertension, diabetes, family history, tobacco abuse, or hyperlipidemia. If they have several of these risk factors, then in your mind you need to think to yourself, this person could have coronary disease. Now I just need to decide if these symptoms are indicative of that or is it something else? But certainly if a patient has some risk factors, they're at a higher risk that this could be cardiac. So fortunately, we do have several risk tools. So your job as part of this is to risk stratify. So here we have a point system. It's the TIMI risk score. It's one of the more common tools that we've seen used. If you're older than 65, you get a point. If you've got more than three of those risk factors we just talked about, you get a point. If you have a history of coronary disease and a known stenosis greater than or equal to 50%, you get a point. And if you've used aspirin in the last seven days, you get a point. And I think the reason you get a point for that is because most of the time, if the patients are using aspirin on a daily basis, they have some sort of vascular disease, whether it was a CBA or coronary disease. And then the presenting symptoms, if they had somewhere in the last 24 hours severe angina, so that chest pain, if it sounds like angina, they get a point. If their biomarkers are increased, they get a point. And then if there's any ST changes more than 0.5 millimeters, either depression or elevation, they get a point. So after you go through your evaluation, you've got, if they have zero to two points, that's considered low risk, three to four points is intermediate risk, and five points to seven is high risk. And you see it's out of a total of seven points. But this predicts risk of all-cause mortality, MI, and severe recurrent ischemia requiring urgent vascularization within 14 days. So again, the concept here is what do I do with this person? If they're high risk, that's easy. They get admitted and they probably get a heart catheterization. If they're in intermediate risk, it may be we don't want to send them home, but an ischemic evaluation is warranted, maybe not a cath, maybe some sort of non-invasive. And then if they're low risk, again, this is that up to 14 days, they're low risk. We're more likely to be able to send these patients home and let them follow up as an outpatient for a risk stratification study or for further evaluation. The second risk stratification option is a heart risk score. So again, we've got a point system here. And this one predicts the risk of all-cause mortality, MI, kind of the same thing within 14 days. And then we have a zero to three is low risk, four to six is intermediate, seven to 10 is high risk. So you can get points for history, for EKG changes, for age, for number of risk factors, and for elevated troponin. So I'll let you kind of read through that. But again, what we're trying to do is create a low, intermediate, or high risk patient. So we're going to let you kind of dig into the content this week and talk more about coronary artery anatomy, different types of stenosis, looking at different locations, therapies, secondary prevention. But I wanted to get you started on a good discussion just around chest pain workup. You know, it's not without risk because we don't want to miss that two to four percent of the acute coronary syndromes, but so much of it is non-cardiac. And we spend a lot of dollars every year ruling out and evaluating patients with non-cardiac chest pain. So good luck. Feel free again to reach out if you have any questions, and we appreciate you being with us.

ischemic heart disease

cardiac chest pain

non-cardiac chest pain

acute myocardial ischemia

risk factors for cardiac disease