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Chapter 17. Chest Pain
Intermediate-high pretest
likelihood of CAD
347
Age < 65 years
or
Less obstructive CAD
suspected
CCTA favoured
F . Approach to testing in intermediate–high pretest likelihood of coronary artery disease
Age ≥ 65 years
or
More obstructive CAD
suspected
Stress testing favoured
Treatment ofNon-Life-Threatening Causes
ofChest Pain
Treatment is based on the underlying etiology.
Chest wall pain: Treatment of most causes of chest wall pain is
conservative with pain control with acetaminophen or
NSAIDs. Patients rarely need opioids to manage pain.
Patients with herpes zoster symptom onset within 72h or new
skin lesions should receive antiviral therapy. Patients with
cervical spondylosis benefit from physiotherapy to strengthen
the muscles around the neck (Fig.17.5a) [11, 15, 16].
348
A. Katamreddy
Chest wall pain
Rib
fracture/metastatsis
Costochondritis
Cervical angina
Herpes zoster
CXR
series/CT chest
If suspicion is high-rib
Pain control
Reassurance
Refer to PMR
XR neck lateral/AP
onset
>72 hours since symptom
No new skin lesions
pain control
Early and adequate
No Antiviral therapy
onset
<72 hours since symptom
Pain control
Reassurance
a
Muscular pain
New skin lesions
Antiviral therapy
Antiviral therapy
F . (a) Approach to chest wall pain, (b) Approach to gastroesophageal reflux disease, (c) Approach to pleuritic
chest pain, (d) Approach to life-threatening cardiac causes of chest pain
reflux disease
b
Gastroesophageal
Chapter 17. Chest Pain
inhibitors
Reevaluation
Trial of proton pump
Behavioural modification
Rule out red flag signs
349
F. . (continued)
350
c
A. Katamreddy
Pleuritic
chest pain
CXR
absent
Infiltrate
present
Infiltrate
pleuritis
rash, joint
Examine for
Consider viral
PNA
assess for
swelling to
autoimmune
Check
pneumonia
severity index
etiologies
to decide
inpatient
regarding
and CURB 65
admission
F . (continued)
cardiac causes
d
Non-life threatening
Pericarditis
requires the
• Diagnosis of
acute pericarditis
Echocardiography
Electrocardiogram
• pericarditic
chest pain
two of:
presence of any
Chapter 17. Chest Pain
effusion
pericardial
and/or PR-
depression
or worsening
ST-elevation
• non-trivial new
• saddle-shaped
• pericardial rub
Coronary
angiography
High
351
Stable angina
ECG
Normal
TTE
CXR
Abnormal
probability of
Assess pretest
coronary artery
referral
Cardiology
disease
Intermediate
Low
test or stress echo
CCTA or exercise stress
score
artery calcium
No test/coronary
F . (continued)
352
A. Katamreddy
Gastroesophageal reflux disease: Patients with typical features
of gastroesophageal reflux disease should be evaluated for
red flag signs such as dysphagia, odynophagia, GI bleeding,
weight loss, and early satiety. A trial of proton pump inhibitors can be prescribed in the absence of red flags signs.
Refer to gastroenterology if red flag signs are present or if
esophageal dysmotility is suspected (Fig.17.5b) [9].
Pneumonia: For patients presenting with community- acquired
pneumonia, pneumonia severity based on CURB-65 or
pneumonia severity index needs to be assessed. These
prognostic tools will help decide if patients need inpatient
admission for the management of community-acquired
pneumonia [17]. CURB-65 score of 0 or 1 can be considered for treatment at home. Beta-lactams, alone or combined with macrolides, can be considered for empiric
antibiotic coverage (Fig.17.5c). Detailed discussion about
the choice of antibiotics is available at the Infectious
Disease Society of America (IDSA) guidelines [17].
Chronic stable angina: Patients with chronic stable angina
should have 10-year atherosclerotic cardiovascular disease
risk calculated, and cardiovascular risk factors such as diabetes and hypertension should be aggressively controlled.
LDL cholesterol should be managed using statins. Nitrates
are the cornerstone for symptom relief. Patients should be
referred to cardiology if there is role for revascularization
based on the diagnostic testing with CCTA or stress tests
(Fig.17.5d) [3].
Clinical Pearls
• A thorough history and physical examination are vital for
an accurate diagnosis and management of patients presenting with chest pain.
• Having a broad differential diagnosis is essential for an
accurate diagnosis of chest pain.
• Patients presenting with chest pain should be rapidly
evaluated for life-threatening causes and triaged to the
appropriate level of care.
• Cardiovascular risk factors should be evaluated in patients
presenting with chest pain.
Chapter 17. Chest Pain
353
Don’t Miss
• Inferior myocardial infarction can present as epigastric
discomfort.
• Women, patients with diabetes, and elderly patients can
present with atypical symptoms such as abdominal discomfort, fatigue, syncope, or presyncope in the setting of
acute coronary syndrome.
References
1. Santo L, Okeyode T.National Ambulatory Medical Care Survey:
2018 National Summary Tables. 2021
2. Klinkman MS, Stevens D, Gorenflo DW. Episodes of care for
chest pain: a preliminary report from MIRNET. J Fam Pract.
1994;38:345–52.
3. Gulati M, Levy PD, Mukherjee D, Amsterdam E, Bhatt DL,
Birtcher KK, Blankstein R, Boyd J, Bullock-Palmer RP, Conejo
T, Diercks DB, Gentile F, Greenwood JP, Hess EP, Hollenberg
SM, Jaber WA, Jneid H, Joglar JA, Morrow DA, O’Connor RE,
Ross MA, Shaw LJ. 2021 AHA/ACC/ASE/CHEST/SAEM/
SCCT/SCMR guideline for the evaluation and diagnosis of chest
pain: a report of the American College of Cardiology/American
Heart Association Joint Committee on clinical practice guidelines. Circulation. 2021;144:e368–454.
4. Amsterdam Ezra A, Wenger Nanette K, Brindis Ralph G, Casey
Donald E, Ganiats Theodore G, Holmes David R, Jaffe Allan S,
Jneid H, Kelly Rosemary F, Kontos Michael C, Levine Glenn N,
Liebson Philip R, Mukherjee D, Peterson Eric D, Sabatine Marc
S, Smalling Richard W, Zieman SJ. 2014 AHA/ACC guideline for
the management of patients with non-ST-elevation acute coronary syndromes. J Am Coll Cardiol. 2014;64:e139–228.
5. Fukui T. Management of acute aortic dissection and thoracic
aortic rupture. J Intensive Care. 2018;6:15.
6. Huisman MV, Barco S, Cannegieter SC, Le Gal G, Konstantinides
SV, Reitsma PH, Rodger M, Noordegraaf AV, Klok FA.Pulmonary
embolism. Nat Rev Dis Primers. 2018;4:18028.
7. Sahn SA, Heffner JE. Spontaneous pneumothorax. N Engl J
Med. 2000;342:868–74.
354
A. Katamreddy
8. Swap CJ, Nagurney JT. Value and limitations of chest pain history in the evaluation of patients with suspected acute coronary
syndromes. JAMA. 2005;294:2623–9.
9. Maret-Ouda J, Markar SR, Lagergren J.Gastroesophageal reflux
disease: a review. JAMA. 2020;324:2536–47.
10. Reamy BV, Williams PM, Odom MR. Pleuritic chest pain:
sorting through the differential diagnosis. Am Fam Physician.
2017;96:306–12.
11. Sussman WI, Makovitch SA, Merchant SH, Phadke J.Cervical
angina: an overlooked source of noncardiac chest pain.
Neurohospitalist. 2015;5:22–7.
12. Ismail TF.Acute pericarditis: update on diagnosis and management. Clin Med (Lond). 2020;20:48–51.
13. Valentine RJ, Verstraete R, Clagett GP, Cohen JC. Premature
cardiovascular disease is common in relatives of patients
with premature peripheral atherosclerosis. Arch Intern Med.
2000;160:1343–8.
14. Otto CM, Prendergast B.Aortic-valve stenosis–from patients at
risk to severe valve obstruction. N Engl J Med. 2014;371:744–56.
15. Johnson RW, Bouhassira D, Kassianos G, Leplège A, Schmader
KE, Weinke T. The impact of herpes zoster and post-herpetic
neuralgia on quality-of-life. BMC Med. 2010;8:37.
16. McConaghy JR, Oza RS. Outpatient diagnosis of acute chest
pain in adults. Am Fam Physician. 2013;87:177–82.
1 7. Metlay JP, Waterer GW, Long AC, Anzueto A, Brozek J,
Crothers K, Cooley LA, Dean NC, Fine MJ, Flanders SA,
Griffin MR, Metersky ML, Musher DM, Restrepo MI, Whitney
CG. Diagnosis and treatment of adults with communityacquired pneumonia. An official clinical practice guideline of
the American Thoracic Society and Infectious Diseases Society
of America. Am J Respir Crit Care Med. 2019;200:e45–67.
18. Knuuti J, Ballo H, Juarez-Orozco LE, Saraste A, Kolh P,
Rutjes AWS, Jüni P, Windecker S, Bax JJ, Wijns W. The performance of non-invasive tests to rule-in and rule-out significant
coronary artery stenosis in patients with stable angina: a metaanalysis focused on post-test disease probability. Eur Heart J.
2018;39:3322–30.
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Chapter 18
Anemia
BenjaminCohen
Introduction
Anemia is diagnosed when a patient’s hemoglobin is less than
12 mg/dL in women and less than 13 mg/dL in men [1].
Alternatively, one can use the hematocrit to diagnose anemia.
The typical ratio between RBC, hemoglobin, and hematocrit
is 1:3:9. After determining the patient has anemia, we can look
at the reticulocytes to calculate the reticulocyte index. The
reticulocyte index adjusts the reticulocyte count based on the
degree of anemia. A reticulocyte index>2% indicates hyperproliferation of erythrocytes and that the patient’s anemia is
from acute blood loss or hemolysis. A reticulocyte index<2%
indicates that the anemia is due to hypoproliferation of erythrocytes. Additionally, the MCV will help us to further classify
the cause of anemia into microcytic (<80 fL), normocytic
(80–100fL), and macrocytic (>100fL) [2] (Fig.18.1).
ticulocyte indexreticulocytepatient shct
maturatio
÷
B. Cohen (*)
Jacobi Medical Center/Albert Einstein College of Medicine,
Bronx, NY, USA
e-mail: cohenb4@nychhc.org
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2022
E. Sydney et al. (eds.), Handbook of Outpatient Medicine,
https://doi.org/10.1007/978-3-031-15353-2_18
nn factor 2
355
356
B. Cohen
Hb < 12g/dl in women
History and Physical Examination
RI > 2%
Hereditary Spherocytosis
MCV > 100
(macrocytic)
Reticulocyte Index (RI)
RI < 2%
RI > 2%
(Normocytic)
Hb < 13g/dl in men
MCV 80 to 100
Reticulocyte Index (RI)
RI < 2%
Alcohol Use
Folic Acid Deficiency
Vitamin B12 Deficiency
Myelodysplastic Syndrome
Mixed Anemia
Hemolytic Anemia
MCV < 80
(Microcytic)
Anemia of Chronic Disease
RI > 2%
Thalassemia
Reticulocyte Index (RI)
RI < 2%
Iron Deficiency
Anemia of Chronic Disease
F . Anemia Algorithm