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,
because it promotes dyspnea,
promotes some chest pain,
it can promote a lot of different symptoms.
There is a great tool to help rule out DVT
and pulmonary embolism called the Wells’ criteria.
It’s seven items.
So, that can give you an idea of what the patient's
baseline risk for a pulmonary embolism is.
If they’re low risk, it’s acceptable
to do a D-dimer serum study.
The value of the D-dimer is if it's negative.
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.
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.
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.
They should get a full scan.
Let’s move on to thoracic aortic aneurysms.
The classic is a tearing pain that
goes through to your back.
That's the difference in this one.
It is more rare than either angina or
pulmonary embolism, but it can be just as deadly.
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.
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.
CT scan of the chest is the evaluation of choice.
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.
Pericarditis is more rare.
It’s going to produce kind of a
generalized pain that's persistent.
Not like angina where it comes and goes,
not in a simulated exercise.
Can be related to position.
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.
So, those are signs of pericarditis.
And that really – the pericarditis,
remember, that goes through all the leads.
That’s the thing that separates pericarditis
from other conditions that cause EKG changes.
It’s one of the ones that promotes ST changes
or PR depression across all leads on your EKG.
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.
An EKG is done most of the time in my practice.
It's a simple test to do,
It’s very low risk.
It's cheap and it's available.
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.
But I try to be parsimonious with
my use of other types of studies,
including CT scans, even echocardiography.
I try to be much more selective with those
because many patients don't require them.
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.
So, with that, hopefully, you feel a lot
more confident in managing chest pain.
Look forward to seeing you next time.