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Chest Pain: Pulmonary Embolism and Thoracic Aorta Aneurysm

by Charles Vega, MD
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    00:01 And one thing to always think about, it's another great imitator, is pulmonary embolism because it can mimic angina, chest pain, but it can also mimic things like heart failure, even COPD because it promotes dyspnea, promotes some chest pain, it can promote a lot of different symptoms.

    00:22 There is a great tool to help rule out DVT and pulmonary embolism called the Wells’ criteria.

    00:30 It’s seven items.

    00:31 So, that can give you an idea of what the patient's baseline risk for a pulmonary embolism is.

    00:37 If they’re low risk, it’s acceptable to do a D-dimer serum study.

    00:41 The value of the D-dimer is if it's negative.

    00:44 If it's positive, it doesn't really tell you a lot, but if it's negative and they have a low pretest probability for PE, the patient doesn't necessarily need any further workup.

    00:54 This is a patient you’ve evaluated, you’ve listened to them, they don't have any of the other symptoms or signs they would need to have, say, a CT of the chest to evaluate for pulmonary embolism.

    01:05 So, that's a quick way that you can rule out pulmonary embolism without having to do the extra step of imaging studies, but everybody who is more complex or a higher risk of some kind of thrombosis, D-dimer is not an option.

    01:23 They should get a full scan.

    01:26 Let’s move on to thoracic aortic aneurysms.

    01:28 The classic is a tearing pain that goes through to your back.

    01:32 That's the difference in this one.

    01:34 It is more rare than either angina or pulmonary embolism, but it can be just as deadly.

    01:40 One thing to look out for, depending on where the tear is, you might actually get to measure a difference in the brachial blood pressures.

    01:50 So, therefore, if this is suspected, always get a blood pressure in both arms and a differential of 20 points or more is significant and should merit further evaluation.

    02:01 CT scan of the chest is the evaluation of choice.

    02:06 Some other considerations, just briefly, among patients with chest pain, just remember, panic attacks – having chest pain with panic attacks, very, very common overall and a lot of people have panic disorder.

    02:16 Pericarditis is more rare.

    02:18 It’s going to produce kind of a generalized pain that's persistent.

    02:24 Not like angina where it comes and goes, not in a simulated exercise.

    02:27 Can be related to position.

    02:29 What you want to see on EKG is either the classic diffuse ST segment elevation or you can also see diffuse PR depression with no T-wave elevation as well.

    02:40 So, those are signs of pericarditis.

    02:42 And that really – the pericarditis, remember, that goes through all the leads.

    02:46 That’s the thing that separates pericarditis from other conditions that cause EKG changes.

    02:51 It’s one of the ones that promotes ST changes or PR depression across all leads on your EKG.

    02:59 So, overall, just to summarize, a good history looking at those cardiovascular risk factors, a good description of the type of pain that patients are having, how persistent it is, the character of the pain and then a focused physical examination, particularly focusing on chest wall tenderness can be really helpful.

    03:18 An EKG is done most of the time in my practice.

    03:21 It's a simple test to do, It’s very low risk.

    03:24 It's cheap and it's available.

    03:26 And so, many patients get an EKG and that will tell us a little bit more about what's going on, put their risk stratification in the appropriate place.

    03:35 But I try to be parsimonious with my use of other types of studies, including CT scans, even echocardiography.

    03:44 I try to be much more selective with those because many patients don't require them.

    03:48 But certainly the ones who are – who appear ill where it just doesn't seem like things are adding together and they do have at least some probability of one of these more serious diagnoses, aneurysm, PE, unstable angina, they should be transferred to the emergency department for further evaluation.

    04:09 So, with that, hopefully, you feel a lot more confident in managing chest pain.

    04:12 Look forward to seeing you next time.


    About the Lecture

    The lecture Chest Pain: Pulmonary Embolism and Thoracic Aorta Aneurysm by Charles Vega, MD is from the course Acute Care. It contains the following chapters:

    • Pulmonary Embolism
    • Thoracic Aorta Aneurysm
    • Summary of Chest Pain

    Included Quiz Questions

    1. Obtain a D-Dimer to rule out pulmonary embolism
    2. Obtain a D-Dimer to rule in pulmonary embolism
    3. Obtain a CT- angiogram to confirm there is no pulmonary embolism
    4. Perform a bedside echocardiogram to evaluate for right heart strain due to multiple small pulmonary emboli
    1. Diffuse ST segment elevation
    2. Diffuse ST segment depression
    3. Diffuse R wave low amplitude
    4. Lateral wall lead ST segment depression
    5. Diffuse PR elevation
    1. CT scan of the chest demonstrating aneurysm
    2. Pathognomonic clinical symptom of chest pain that radiates into the back
    3. EKG with diffuse ST segment elevation
    4. Echocardiogram demonstrating low ejection fraction
    5. Brachial blood pressure discrepancy of at least 15 points between arms

    Author of lecture Chest Pain: Pulmonary Embolism and Thoracic Aorta Aneurysm

     Charles Vega, MD

    Charles Vega, MD


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