Determining the Cause

A 45-year-old man began having chest pressure with exertion that was relieved with rest. He did not have diabetes, high blood pressure, or high cholesterol and had never had a myocardial infarction. His examination and resting ECG were normal. On the basis of the testing modalities available, he was scheduled for exercise stress testing. After a positive test, he underwent coronary angiography that demonstrated a significant stenosis in the left coronary artery (Figure 48-1). He underwent a stenting procedure and was placed on aspirin and cholesterol-lowering medication.

 

a.

Pivotal Assessments one after the other	Finding
History	Chest pressure with exertion that was relieved with rest
EKG	ST Segment Elevation  Non ST Elevation Indeterminate Normal
History	High suspicion for a pulmonary embolism (PE) is based on a combination of clinical symptoms, risk factors, and objective scoring systems like the Wells' Criteria or PERC (Pulmonary Embolism Rule-out Criteria). Here’s what raises concern: Symptoms and Signs Sudden-onset dyspnea (most common symptom) Pleuritic chest pain (sharp pain that worsens with breathing) Tachypnea (rapid breathing) Tachycardia (often unexplained) Hypoxia (low oxygen saturation, especially if unexplained) Cough or hemoptysis (less common but concerning) Syncope or near-syncope (suggests large PE) Signs of DVT (unilateral leg swelling, pain, erythema) High-Risk Factors Recent immobilization or surgery (especially orthopedic) Active cancer History of prior PE or DVT Hypercoagulable states (e.g., Factor V Leiden, antiphospholipid syndrome) Hormone use (oral contraceptives, hormone replacement therapy) Pregnancy or postpartum state Clinical Decision Tools Wells' Score for PE ≥6 points → High probability 2-6 points → Moderate probability <2 points → Low probability Criteria (with points): Signs of DVT (3) PE is the most likely diagnosis (3) Immobilization >3 days or surgery within 4 weeks (1.5) Tachycardia >100 bpm (1.5) History of DVT/PE (1.5) Hemoptysis (1) Active cancer (1) PERC Rule (Pulmonary Embolism Rule-out Criteria) If all 8 criteria are met, PE is very unlikely (rule-out without further testing): Age <50 Pulse <100 bpm SaO₂ ≥95% No hemoptysis No estrogen use No history of DVT/PE No recent surgery/trauma No clinical signs of DVT Next Steps if High Suspicion CT Pulmonary Angiography (CTPA): Gold standard for diagnosis D-dimer: Useful in low-risk patients; negative result rules out PE Lower extremity ultrasound (if DVT suspected) Would you like to discuss specific risk factors or symptoms?
Bedside Echocardiography (Hemodynamically unstable patients → Bedside echocardiography (to detect right heart strain) or immediate empiric anticoagulation if high suspicion.

Rule out three must not miss diagnosis: Acute Coronary Syndrome, Pulmonary Embolus, Acute Aortic Sydrome

 

 

- CT pulmonary angiography for suspected pulmonary embolism

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The quickest way to establish the diagnosis of pulmonary embolism (PE) depends on the clinical setting and available resources:

1. CT Pulmonary Angiography (CTPA) – This is the gold standard for rapid and definitive diagnosis. It provides direct visualization of emboli within the pulmonary arteries and is widely available in most hospitals.

2. D-dimer Test – If the clinical probability of PE is low or intermediate, a negative D-dimer test can effectively rule out PE, avoiding unnecessary imaging.

3. Point-of-Care Ultrasound (POCUS) – If CTPA is not immediately available, bedside echocardiography or venous ultrasound (looking for deep vein thrombosis, DVT) can provide indirect evidence of PE, especially in critically ill patients.

4. Ventilation-Perfusion (V/Q) Scan – Used when CTPA is contraindicated (e.g., kidney failure, contrast allergy), but it takes longer and may be nondiagnostic.

Approach Based on Stability:

• Hemodynamically unstable patients → Bedside echocardiography (to detect right heart strain) or immediate empiric anticoagulation if high suspicion.
• Stable patients → CTPA is the fastest and most definitive test.

Would you like guidance on the next steps after diagnosis?

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In a hemodynamically unstable patient with suspected pulmonary embolism (PE), rapid diagnosis and immediate intervention are critical. Here’s the stepwise approach:

1. Immediate Stabilization

• Oxygenation: High-flow oxygen or intubation if respiratory failure occurs.
• Hemodynamic Support:
  • Fluids: Administer cautiously (500 mL bolus) if hypotensive, but avoid excessive fluids to prevent worsening right ventricular (RV) strain.
  • Vasopressors/Inotropes: Use norepinephrine or dobutamine if shock persists despite fluids.

2. Rapid Bedside Assessment

• Point-of-Care Ultrasound (POCUS):
  • Echocardiography: Look for right ventricular (RV) dilation, septal bowing, or McConnell’s sign (RV dysfunction with apical sparing).
  • Lower limb venous ultrasound: DVT presence strongly supports PE.
  • If high suspicion of PE, move directly to treatment.

3. Definitive Diagnosis (if patient tolerates)

• CT Pulmonary Angiography (CTPA) – If the patient is stable enough for transport, CTPA is the gold standard.
• Bedside Echocardiography – If CTPA is not feasible, a severely dilated RV with no other explanation strongly suggests PE.

4. Immediate Treatment

• Empiric Anticoagulation:

  • Unfractionated Heparin (UFH) is preferred over LMWH in unstable patients due to its reversibility.

• Thrombolysis (if no contraindications):

  • Alteplase (tPA): 100 mg IV over 2 hours or 50 mg IV push in cardiac arrest.
  • Consider half-dose thrombolysis in intermediate-risk patients.

• Mechanical Thrombectomy (if thrombolysis contraindicated or fails):

  • Catheter-directed or surgical embolectomy in centers with expertise.

5. Consider ECMO in Refractory Cases

• If cardiac arrest or severe shock persists, ECMO (extracorporeal membrane oxygenation) can be a bridge to further intervention.

Would you like a breakdown of thrombolysis indications and contraindications?

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Thrombolysis in Pulmonary Embolism (PE)

Thrombolytic therapy is indicated in patients with massive (high-risk) PE and select cases of submassive (intermediate-high risk) PE when the benefits outweigh the risks.

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1. Indications for Thrombolysis

A. Absolute Indications (Massive PE)

• Hemodynamic instability (shock or hypotension)
  • SBP < 90 mmHg for >15 minutes or requiring vasopressors
  • Signs of obstructive shock (cold, clammy, altered mental status)
• Cardiac arrest from suspected PE
  • Administer 50 mg Alteplase IV push immediately, repeat if needed
• Severe right ventricular (RV) dysfunction with impending collapse

B. Relative Indications (Submassive PE)

(Consider case-by-case, balancing bleeding risk)

• RV dysfunction on echocardiography (RV/LV ratio > 1.0, septal bowing)
• Elevated cardiac biomarkers (troponin, BNP)
• Severe hypoxemia (PaO₂ < 60 mmHg on room air)
• Clot-in-transit seen on echocardiogram
• Deteriorating despite anticoagulation

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2. Contraindications to Thrombolysis

A. Absolute Contraindications

(Thrombolysis is prohibited due to high bleeding risk)

• Active internal bleeding (excluding menses)
• History of hemorrhagic stroke
• Ischemic stroke within the past 3 months
• Recent major trauma, surgery, or head injury (within 3 weeks)
• Suspected aortic dissection
• Intracranial neoplasm, arteriovenous malformation, or aneurysm

B. Relative Contraindications

(Weigh risk-benefit carefully)

• Recent ischemic stroke (3-6 months)
• Uncontrolled hypertension (SBP > 180 or DBP > 110)
• Recent major surgery or trauma (2-4 weeks)
• Active peptic ulcer disease
• Pregnancy or postpartum (within 1 week)
• Advanced liver disease with coagulopathy
• Recent internal bleeding (within 2-4 weeks)

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3. Thrombolytic Dosing

Standard Alteplase (tPA) Dosing

• 100 mg IV over 2 hours (most common)
• Alternative: 50 mg over 2 hours for lower bleeding risk (e.g., elderly)
• Cardiac arrest (PEA/asystole): 50 mg IV push, repeat once if no ROSC

Catheter-Directed Thrombolysis (CDT)

• Lower doses (5-25 mg tPA over 12-24 hours)
• Used in patients with contraindications to systemic thrombolysis

Would you like guidance on post-thrombolysis management?

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Post-Thrombolysis Management in Pulmonary Embolism (PE)

After thrombolysis, close monitoring and ongoing anticoagulation are essential to prevent recurrent embolism and complications.

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1. Immediate Post-Thrombolysis Monitoring

A. Hemodynamic & Respiratory Monitoring

• Continuous cardiac monitoring in ICU
• Blood pressure (BP) monitoring every 15-30 minutes initially
• Monitor for signs of bleeding (especially intracranial hemorrhage):
  • Altered mental status (early sign of brain bleed)
  • Severe headache
  • Hematuria, gastrointestinal bleeding
• Oxygen support as needed (wean gradually if improving)

B. Repeat Imaging (as needed)

• Echocardiography to assess RV function if no improvement
• CT Pulmonary Angiography (CTPA) if persistent instability
• Follow-up Doppler ultrasound for DVT

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2. Anticoagulation After Thrombolysis

• Start heparin infusion (UFH) after thrombolysis (unless contraindicated)
  • Wait at least 24 hours if high bleeding risk
  • Target aPTT 1.5-2.5x control
• Transition to long-term anticoagulation
  • Low Molecular Weight Heparin (LMWH) (e.g., enoxaparin 1 mg/kg BID) if malignancy or pregnancy
  • Direct Oral Anticoagulants (DOACs) (e.g., apixaban, rivaroxaban) preferred for most patients
  • Warfarin (INR 2.0-3.0) in special cases (e.g., mechanical heart valves, severe kidney disease)

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3. Management of Complications

A. Bleeding After Thrombolysis

• Minor bleeding → Supportive care (hold anticoagulation temporarily)
• Major bleeding (intracranial, GI, or hemodynamically significant)
  • Stop anticoagulation immediately
  • Reverse tPA with cryoprecipitate, fresh frozen plasma (FFP), or tranexamic acid
  • Neurosurgery consult if intracranial hemorrhage

B. Persistent Hemodynamic Instability

• Consider repeat thrombolysis (half-dose if high bleeding risk)
• Mechanical thrombectomy or catheter-directed thrombolysis
• ECMO (Extracorporeal Membrane Oxygenation) in severe cases

---

4. Long-Term Management & Secondary Prevention

• Minimum anticoagulation duration:
  • 3-6 months for provoked PE
  • Indefinite for unprovoked or recurrent PE
• Investigate underlying causes:
  • Malignancy screening in unprovoked PE
  • Hypercoagulability workup if young, recurrent, or unusual location
• Follow-up echocardiography (in 3-6 months) if severe RV dysfunction

Would you like recommendations on transitioning to outpatient care?

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Transitioning to Outpatient Care After Pulmonary Embolism (PE)

Once a patient has stabilized following thrombolysis and initial anticoagulation, transitioning to outpatient care involves ensuring continued anticoagulation, monitoring for complications, and preventing recurrence.

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1. Criteria for Safe Discharge

Patients may be discharged if they meet the following criteria:
✅ Hemodynamically stable (SBP > 90 mmHg without vasopressors)
✅ Oxygen saturation > 90% on room air
✅ No ongoing bleeding or significant risk of major bleeding
✅ Stable right ventricular (RV) function on follow-up echocardiography
✅ Appropriate anticoagulation plan established
✅ Adequate patient education and follow-up arranged

---

2. Anticoagulation Plan for Outpatient Care

🔹 Duration of anticoagulation:

• Provoked PE (surgery, trauma, immobilization) → 3-6 months
• Unprovoked PE (no clear trigger) → Indefinite (reassess annually)
• Recurrent PE or underlying thrombophilia → Lifelong anticoagulation
• Cancer-associated PE → LMWH or DOAC until cancer is in remission

🔹 Choice of Anticoagulant:

• Direct Oral Anticoagulants (DOACs) (preferred for most patients)
  • Apixaban (Eliquis) 10 mg BID for 7 days, then 5 mg BID
  • Rivaroxaban (Xarelto) 15 mg BID for 21 days, then 20 mg daily
• Warfarin (for kidney disease or specific cases)
  • Bridged with LMWH until INR 2.0-3.0
• LMWH (e.g., enoxaparin) if contraindications to DOACs

---

3. Patient Education Before Discharge

🔹 Anticoagulation Adherence:

• Importance of strict medication compliance
• Signs of bleeding (e.g., bruising, hematuria, black stools)
• Avoid NSAIDs and alcohol (increased bleeding risk)

🔹 When to Seek Medical Help:

• Sudden worsening shortness of breath or chest pain → Call 911
• Severe headache, confusion, or weakness (possible brain bleed)
• Excessive bleeding (nosebleeds, gums, heavy periods)

🔹 Lifestyle Modifications:

• Stay active but avoid high-impact activities (fall risk)
• Hydration and frequent movement to prevent recurrence
• Compression stockings if post-thrombotic syndrome is a concern

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4. Follow-Up Plan

📅 1-week follow-up: Check for medication adherence, side effects, and bleeding risk
📅 3-month follow-up: Reassess need for continued anticoagulation
📅 6-month follow-up: Evaluate for chronic thromboembolic pulmonary hypertension (CTEPH) if symptoms persist (echocardiography)
📅 Annual review: If on lifelong anticoagulation, reassess risk-benefit

Would you like guidance on long-term complications such as CTEPH?

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Chronic Thromboembolic Pulmonary Hypertension (CTEPH) After Pulmonary Embolism

CTEPH is a serious long-term complication of pulmonary embolism (PE) that results from persistent thrombotic obstruction of pulmonary arteries, leading to pulmonary hypertension (PH) and right heart failure. It affects about 2-4% of PE survivors.

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1. Risk Factors for CTEPH

Patients at higher risk of developing CTEPH include:
🔹 Recurrent or large PE episodes
🔹 Inadequate anticoagulation after PE
🔹 Unprovoked PE (idiopathic)
🔹 Young age (<50 years) at first PE event
🔹 Chronic inflammatory states (e.g., autoimmune diseases)
🔹 Thrombophilic disorders (e.g., antiphospholipid syndrome)

---

2. Signs & Symptoms of CTEPH

CTEPH often develops gradually over months or years after an acute PE.

Early Symptoms (Mild Disease)

✔️ Progressive shortness of breath (exertional dyspnea)
✔️ Fatigue, weakness
✔️ Mild exercise intolerance

Advanced Symptoms (Severe Disease)

⚠️ Exertional chest pain or syncope (suggests severe pulmonary hypertension)
⚠️ Peripheral edema, ascites (right heart failure)
⚠️ Loud P2 heart sound (sign of pulmonary hypertension)
⚠️ Cyanosis (late-stage disease)

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3. Diagnosis of CTEPH

If symptoms persist ≥3-6 months after PE, suspect CTEPH and evaluate:

A. Initial Screening

• Echocardiography (to assess pulmonary pressures and right ventricular function)
  • Signs: RV enlargement, elevated pulmonary artery systolic pressure (PASP)

B. Definitive Diagnosis

• V/Q Scan → Best screening test (shows mismatched perfusion defects)
• Right Heart Catheterization → Gold standard (confirms elevated pulmonary pressures)
• Pulmonary Angiography or CT Pulmonary Angiography (CTPA) → Identifies chronic thrombi

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4. Treatment of CTEPH

A. Pulmonary Endarterectomy (PEA) – First-Line Treatment

• Definitive cure in operable cases
• Requires specialized surgical centers
• Removes chronic thrombotic material from pulmonary arteries

B. Medical Therapy (if inoperable or residual disease)

• Riociguat (soluble guanylate cyclase stimulator) → First-line medication for inoperable CTEPH
• Pulmonary vasodilators (e.g., bosentan, sildenafil) → Used if pulmonary hypertension persists

C. Balloon Pulmonary Angioplasty (BPA)

• For patients not candidates for surgery
• Catheter-based procedure to widen obstructed pulmonary arteries

D. Long-Term Anticoagulation

• Mandatory lifelong anticoagulation to prevent further emboli

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5. Prognosis & Follow-Up

📅 Follow-up echocardiography every 6-12 months
📅 Right heart catheterization if worsening symptoms
📅 Lifelong anticoagulation with DOACs or warfarin

CTEPH is potentially curable with surgery but can be fatal if untreated due to progressive right heart failure.

Would you like information on specialized CTEPH centers or treatment options in your area?

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Chronic Thromboembolic Pulmonary Hypertension (CTEPH) is a serious condition that requires specialized care. In the Silver Spring, Maryland area, several reputable centers offer advanced treatments for CTEPH:

1. University of Maryland Medical Center (UMMC) – Baltimore, MD

UMMC specializes in treating CTEPH using a procedure called pulmonary thromboendarterectomy (PTE), the only known cure for CTEPH. They are among the few medical centers in the country offering this complex surgery. citeturn0search0

2. Inova Fairfax Hospital – Falls Church, VA

Inova Fairfax Hospital is the only hospital in Virginia, Maryland, and Washington, D.C., to offer Balloon Pulmonary Angioplasty (BPA), an emerging treatment for patients with chronic clots that are inoperable or do not improve after surgery. The procedure improves blood flow to the lungs, reduces shortness of breath, and increases exercise tolerance by opening blood vessels that have been chronically narrowed or blocked. citeturn0search1

3. MedStar Health – Washington, D.C.

MedStar Health's Pulmonary Hypertension Clinic offers comprehensive care for CTEPH patients. Their specialists work to develop effective treatment plans, which may include medication management or surgical interventions like PTE. citeturn0search2

4. Temple Health – Philadelphia, PA

Temple Health offers one of only five programs in the nation specializing in CTEPH care. They provide pulmonary thromboendarterectomy (PTE), the only treatment option proven to correct CTEPH, with a 96% overall success rate. citeturn0search4

5. UVA Health – Charlottesville, VA

UVA Health is one of the few centers in the United States with the expertise and experience to diagnose CTEPH and treat it with surgery. They offer comprehensive diagnostic services and surgical treatments for CTEPH patients. citeturn0search6

Given the complexity of CTEPH, it's crucial to consult with a specialized center to determine the most appropriate treatment plan. These centers have the expertise and resources to provide comprehensive care tailored to your needs.

 

 

 

 

 

- Bedside ultrasound if pericardial tamponade is a concern[1]

## Risk Stratification

Classify patients into low, intermediate, or high-risk categories based on clinical presentation, ECG findings, and initial test results[4].

## Management Based on Risk and Diagnosis

### Acute Coronary Syndrome (ACS)

- For ST-elevation MI: Immediate reperfusion therapy (PCI preferred within 90 minutes, or thrombolytics if PCI unavailable)[1].
- For non-ST elevation ACS: Admit for cardiology consultation and further workup[1].

### Pulmonary Embolism

- Stable patients: Start anticoagulation
- Unstable patients: Consider thrombolysis[1]

### Other Conditions

- Pneumothorax: Chest tube decompression
- Pericardial tamponade: Pericardiocentesis
- Aortic dissection: Urgent surgical consultation[1]

## Ongoing Care

- Provide appropriate pain management
- Consider oxygen therapy if indicated
- For stable angina, outpatient workup may be appropriate[1]

## Shared Decision-Making

Involve patients in treatment decisions, providing information about risks, benefits, and alternatives[4].

## Discharge and Follow-up

For low-risk patients not requiring admission, ensure appropriate follow-up and provide clear instructions on when to seek further medical attention[3].

Remember, chest pain can be a sign of a life-threatening condition. When in doubt, it's crucial to err on the side of caution and seek immediate medical attention, especially if symptoms are severe, worsening, or lasting more than 10 minutes[3].

Citations:
[1] https://www.ncbi.nlm.nih.gov/books/NBK470557/
[2] https://www.healthline.com/health/chest-pain
[3] https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/chest-pain
[4] https://www.ahajournals.org/doi/10.1161/CIR.0000000000001029
[5] https://www.mayoclinic.org/first-aid/first-aid-chest-pain/basics/art-20056705
[6] https://www.aafp.org/pubs/afp/issues/2020/1215/p721.html
[7] https://www.nhlbi.nih.gov/health/angina/treatment

+++++++++++++++++++

 

Chief Complaint: Chest Pain

Note: Even in the stable patient, immediate life threatening conditions must be diagnosed

Pivotal Assessments (One after the other)	Finding
EKG	ST Segment Elevation	Non ST Segment Elevation	Indeterminate	Left bundle branch block	Presence of Q waves	T-wave inversion	Normal
Portable Chest X-Ray	Pneumothorax	Pneumonia	White opacity with obliteration of the costophrenic angle	Widened mediastinum (>8.0-8.8 cm at the level of the aortic knob)  wide aortic contour, tracheal deviation, aortic kinking, and displacement of previous aortic calcification. Chest x-ray has limited sensitivity (64%) and specificity (86%) in the diagnosis of aortic diseases. It also worth mentioning that a normal chest x-ray may not rule out the diagnosis of aortic dissection.			Normal
Echocardiogram	Pericardial Effusion
D-Dimer*	Elevated, Greater than .05	< .05

++++++++++++++++++++

## Risk Stratification

Classify patients into low, intermediate, or high-risk categories based on clinical presentation, ECG findings, and initial test results[4].

## Management Based on Risk and Diagnosis

### Acute Coronary Syndrome (ACS)

- For ST-elevation MI: Immediate reperfusion therapy (PCI preferred within 90 minutes, or thrombolytics if PCI unavailable)[1].
- For non-ST elevation ACS: Admit for cardiology consultation and further workup[1].

### Pulmonary Embolism

- Stable patients: Start anticoagulation
- Unstable patients: Consider thrombolysis[1]

### Other Conditions

- Pneumothorax: Chest tube decompression
- Pericardial tamponade: Pericardiocentesis
- Aortic dissection: Urgent surgical consultation[1]

## Ongoing Care

- Provide appropriate pain management
- Consider oxygen therapy if indicated
- For stable angina, outpatient workup may be appropriate[1]

## Shared Decision-Making

Involve patients in treatment decisions, providing information about risks, benefits, and alternatives[4].

## Discharge and Follow-up

For low-risk patients not requiring admission, ensure appropriate follow-up and provide clear instructions on when to seek further medical attention[3].

Remember, chest pain can be a sign of a life-threatening condition. When in doubt, it's crucial to err on the side of caution and seek immediate medical attention, especially if symptoms are severe, worsening, or lasting more than 10 minutes[3].

Citations:
[1] https://www.ncbi.nlm.nih.gov/books/NBK470557/
[2] https://www.healthline.com/health/chest-pain
[3] https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/chest-pain
[4] https://www.ahajournals.org/doi/10.1161/CIR.0000000000001029
[5] https://www.mayoclinic.org/first-aid/first-aid-chest-pain/basics/art-20056705
[6] https://www.aafp.org/pubs/afp/issues/2020/1215/p721.html
[7] https://www.nhlbi.nih.gov/health/angina/treatment

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Differentiating GERD (gastroesophageal reflux disease) from MI (myocardial infarction) is crucial, as both can present with chest pain, but one is life-threatening.

Here’s a clear comparison to help distinguish them:

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⚖️ GERD vs MI: Key Differences

Feature	GERD	Myocardial Infarction (MI)
Pain character	Burning, pressure-like	Pressure, squeezing, heavy, crushing
Pain location	Substernal, epigastric, may radiate upward	Substernal, may radiate to jaw, neck, shoulder, arm (esp. left)
Timing	Often post-meal, worse lying down	Sudden, may occur at rest or with exertion
Duration	Variable, minutes to hours	Usually >20 minutes, persistent
Relieved by	Antacids, sitting up	Rest, nitroglycerin (sometimes not relieved)
Associated symptoms	Sour taste, regurgitation, bloating	Dyspnea, sweating, nausea, lightheadedness, feeling of doom
ECG changes	Normal	ST changes, Q waves, arrhythmias
Troponins	Normal	Elevated
Physical exam	Usually normal	May show signs of heart failure, hypotension
Risk factors	Obesity, hiatal hernia, spicy foods	Diabetes, hypertension, smoking, hyperlipidemia

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⚠️ Red Flags Suggesting MI (go to ER):

• Chest pressure with radiation to left arm, jaw, or back

• Shortness of breath, especially on exertion or at rest

• Cold sweats, palpitations, nausea

• Unrelieved pain >15–20 minutes

• History of cardiac disease or risk factors

---

🧪 Diagnostic Workup:

• If in doubt → ECG + troponins stat

• If cardiac ruled out → consider GI studies like endoscopy, pH testing, etc.

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Would you like a visual chart or flowchart for quick triage use (e.g., for clinic or teaching)?

Stable Patient

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