Spidey Sense and the Art of Low Risk Chest Pain

As Emergency Physicians, one thing we particularly pride ourselves in is our “gestalt” or general sense about the patient. In a world where we have an extensive tool kit of diagnostic criteria and clinical decision making instruments we still occasionally throw those out the window when we get a sense of something else going on with the patient. This phenomenon has been studied on occasion, with interesting results. In one study regarding the diagnosis of PE, accuracy of gestalt increased with the physician’s years of experience. In a study looking at ACS patients, the combination of initial EKG, troponin level and clinical gestalt had a sensitivity of 100%.

Although these studies were limited and I couldn’t imagine clinical gestalt ever fully replacing diagnostic testing, it is important to remember.  For example, in my 2.5 years of residency I have encountered a handful of patients where the HEART score let me down, but my intuition did not. Highlighted below are a few such cases.

Case #1 Back Pain or NSTEMI?

Back Pain .001

It was a busy fast track shift in my second year of residency. I’d already transferred a kid to the local children’s hospital with appendicitis and another patient to the trauma bay (got to love the extra history that comes out when the leave triage). So I was rather relieved to see an easy complaint on the tracker board, “back pain.” My mind was ready for autopilot – screen for cauda equina, NSAIDs, maybe a lidocaine patch and discharge.

However, once I started talking to the patient, new differentials started forming. He is 44 years-old with no no significant past medical history. He works as a cook and yesterday he developed low back pain radiating down his left leg that started after lifting a box of food. He tried acetaminophen last night but, “it made my chest hurt” so he presented to the ED this morning for better pain control. That seemed weird.

When talking with him further regarding acetaminophen causing chest pain, he admits to mild continued discomfort. He describes central and non- radiating chest pain with no associated symptoms and not exertional in nature. However, he’s still more concerned about his back pain, which he thinks is sciatica. Meanwhile, I’m feeling, well the opposite! So I order an EKG and cardiac enzymes.

His EKG is normal. While waiting for reassessment to see if his lidocaine patch is working, his troponin results at 3.54. Rather quickly the patient is moved to an acute care pod, and the bewildered patient wonders why we are still worried about his heart when he thinks his back is the problem. Ultimately, he went to the cath lab where he was found to have a critical lesion of his circumflex and PCI was performed. I had initially calculated his HEART score as 3.

Case #2 Musculoskeletal Chest Pain

I was seeing a patient with a medical student. He reports back to me that he saw a 57 year-old gentleman with a history of hypertension, tobacco abuse, and COPD who was presenting with 2 weeks of right sided chest pain. The pain had started after helping his father out of bed and had persisted since. He had seen his primary care physician and an urgent care doctor who had both told him his pain was musculoskeletal in nature and to use acetaminophen or ibuprofen as needed. The patient was concerned because he felt there was “something else going on.”

On exam, he had clearly reproducible point tenderness in his anterior right chest wall.  Given this was his third visit for the same complaint, his risk factors, and his concerns, we decided to obtain laboratory studies and a chest x-ray.

His EKG was non-ischemic and his labs were unremarkable. However, his chest x-ray demonstrated a large mass in his right upper lobe. I quickly pulled up an old chest x-ray for comparison, he had small pulmonary nodule in the same spot a few years ago.

CXR.001

Given the now likely diagnosis of cancer, we decide to order a CT scan to further evaluate the mass. The CT showed a lesion consistent with primary lung cancer with local spread, causing a pathologic rib fracture – right at the spot where he had point tender musculoskeletal chest pain.

Given the now likely diagnosis of cancer, we decide to order a CT scan to further evaluate the mass. The CT showed a lesion consistent with primary lung cancer with local spread, causing a pathologic rib fracture – right at the spot where he had point tender musculoskeletal chest pain.

Case #3 Too Young for ACS

The last case is one of the more bizarre scenarios I had this year. A young 26 year-old female presenting with chest pain. She has no known medical problems, no daily medications, and does not smoke, drink, or use drugs. She goes to the gym on a regular basis and is generally athletic. Honestly, she is healthier than I am!

She reports that for the last few weeks she has noticed a “twinge of chest discomfort when doing high intensity cardio training.” Today she experienced severe chest pain during a high intensity interval, and therefore, decided to come to the ED. On my exam, she still has some pain, but it is markedly improved without intervention.

Typically, in a patient this young and healthy I would just check an EKG and maybe a chest x-ray. But… she was basically giving her heart a stress test when the pain occurred! Ultimately, I decided to obtain laboratory studies including cardiac enzymes, and her troponin resulted as slightly elevated at 0.05. I ordered a four-hour troponin and spoke with cardiology who evaluate her and recommend a CT coronary study. Her CT study demonstrates no significant narrowing of the visualized coronary arteries, no dissection, and no signs of PE. Following the CT, cardiology recommended outpatient follow up.

However, her repeat troponin resulted at 3.62. At which point, neither cardiology or I am comfortable discharging this woman regardless of her CT. She was admitted for serial troponin and EKGs. During her hospital course, her troponin levels continue to rise, peaking at 22. Given these findings, cardiology performed a heart catheterization and discovered a small lesion in the OM with stenosis and a distal dissection. Granted there were some areas on the initial CT which were not visualized well, but was thought to be an overall unremarkable study.

Conclusion

Moral of the story – we have amazing tools at our disposal to help guide our decision making process, however, medicine is a frequently humbling profession and diseases often don’t play by the rules. So while you should always follow the HEART score, make sure you follow your heart as well.

Author: Alanna O’Connell, DO – PGY3      twitter icon  @AlannaOConnell8

References

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