ACD – 12/11/2014

Chest pain occuring in the hospital

Bayan Mesmar – PGY3

Case:

• A 60 yo pt admitted for chemotherapy for multiple myeloma. Pt has failed

multiple therapies including autlogus bone marrow transplant and started to

follow up here for second opinion regarding alternative treatment options.

• Past medical hx: • ESRD on regular HD TTS.

• HTN

Case

• Labs on admission:

CBC: 9/ 9/30/ 80

Renal chem: Na 144, K 5.0, Cl 93, CO2 32, BUN/Cr 80/9.

Trop 1.4.

LFTs: AST 36, ALT 36, LD 450.

ESR : > 140

CRP 130.

• Some one got a CXR and an ECG on admission for

whatever reason:

ECG:

Case:

• Day 2- D10

Pt was receiving HD, did well.

Started on prophylactic Abx (levaquin+acyclovir) in

preparation for chemo + diflucan for oral thrush.

Underwent staging for Myeloma >> aggressive disease.

Started on (PACMED) on day 10.

Case

• Day 13 pager goes off in the early evening just when you

are having your third cup of coffee and heading toward

the door to the parking lot:

Chest pain!

• Retrosternal chest pains, that pt describes as heaviness

in nature, increased by taking deep breaths. Not radiating.

No associated N/V, no diaphoresis.

• No other symptoms.

Labs drawn by the nurses before you

arrive during the chest painLabs:

CBC: Hb 8.2 , WCC 3.7 , Plts 28

Renal chem : Na 139, K 5.1, Cl 108 ,Co2 28, BUN/CR

65/8.2.

Trop 3.59 ( up from ~1.50) , CK 159 (WNL) , CK- MB 5.2.

ABG: 7.36/33/113 2L nc (baseline).

What now?

Orders??

That’s a big troponin isn’t it?

Straight to cath lab?

Or straight to someone else’s care so you don’t have to

think about it?

So maybe you ordered some of these

things. If so, here you go…CXR: unchanged.

V/Q scan: low probability.

Lower/upper extremity Doppler : negative.

Did you order an ECG? I’m sure you did…

Can you make a diagnosis from this

ECG? Maybe in the PR segment in II?

Maybe from this ECG taken a little later?

Pericarditis:

• Acute Pericarditis:

- Acute inflammation of the pericardial sac, with our without myocarditis.

- Recorded in about 0.1 to 0.2 percent of hospitalized patients and 5 percent of patients admitted to the Emergency Department for non-ischemic chest pain.

- Presentation: varies depending on the cause.

- The vast majority of patients with acute pericarditis present with chest pain (>95% of cases). Maybe minimal or absent in uremic patients.

- Chest pain that results from acute pericarditis is typically fairly sudden in onset and occurs over the anterior chest. Although dull, oppressive pain or radiation of the pain to the shoulders (particularly the trapezius ridges) may occur.

Etiologies:

ECG

ECG changes:

Diffuse ST elevation

(typically concave up)

with reciprocal ST

depression in leads

aVR and V1 There is

also an atrial current

of injury, reflected by

elevation of the PR

segment in lead aVR

and depression of the

PR segment in other

limb leads and in the

left chest leads,

primarily V5 and V6

• Stage 2, typically seen in the first week, is characterized by normalization of

the ST and PR segments.

• Stage 3 is characterized by the development of diffuse T wave inversions,

generally after the ST segments have become isoelectric. However, this

stage is not seen in some patients.

• Stage 4 is represented by normalization of the ECG or indefinite persistence

of T wave inversions ("chronic" pericarditis).

Troponins?

• Acute pericarditis may be associated with increases in serum biomarkers of

myocardial injury such as cardiac troponin I or T secondary to epicardial inflammation

or involvement of adjacent myocardium. Elevation of creatine kinase or its MB fraction

(CK-MB) is very uncommon. On one study series percentage was found to be 32%.

• Inflammatory markers: elevated CRP and ESR.

Pericarditis Vs STEMI: When to wake cath lab

people up from sleep:

• If any of the following is present consider STEMI:• Reciprocal ST depressions in any leads other than V1 or aVR. Pay

particular attention to aVL which, in patients with inferior wall STEMI, may show T- wave inversion or extremely subtle reciprocal ST depression.

• ST segment more elevated in Lead III than in Lead II.

• worsening or new Q-waves.

• Prolonged QTc is often seen with STEMI.

• QR-T complexes (“checkmark sign”)

• Fragmented QRS complexes.

Pericarditis:

- PR-segment dépressions in multiple leads

- Friction rub (60% to 85% of cases)

Treatment:

Admit? Most patients can be treated conservatively in out patient setting. Hospital

admission should be reserved for patients with high fever,, cardiac tamponade,

Immunosuppressed state, severe effusion, myocardial involvement (elevated troponins),

patients who are on anticoagulation.

- NSAIDS

- Aspirin

- Colchicine+ NSAID > ICAP trial (colchicine added to standard anti-inflammatory

therapy significantly reduced the risk of recurrence (17 percent versus 38 percent with

anti-inflammatory therapy alone)

Steroids?

The 2004 European Society of Cardiology (ESC) guidelines recommended that systemic

steroids to be used when:

●Patients with symptoms refractory to standard therapy

●Acute pericarditis due to connective tissue disease

●Autoreactive (immune-mediated) pericarditis

●Uremic pericarditis

• Thank you. –Bayan Mesmar