1. Approach to Chest pain
Dr.Duaa Hiasat

2. Chest Pain Review of causes Clinical approach Diagnostic evaluation
Serious causes & presentation
Management of acutely ill ptn
Clinical cases

3. The prevalence of chest pain etiologies varies according to the population studied.
Differential diagnosis in patients with chest pain:
Musculoskeletal % (costochondritis, Fibromyalgia)
Gastrointestinal % (GERD, E.spasm, cholelithiasis)
Nonspecific chest pain 16%
Stable angina % (MI, Angina pectoris, Pericarditis, AD)
Psychosocial % (somatization, anxiety)
Pulmonary causes 5% (PE, Pneumothorax, pneumonia)
Other causes of chest pain (AD, AS, pericarditis) 4%

4. WHAT LIES IN THE CHEST? SKIN MUSCLES BONES JOINTS HEART AND VESSELS
LUNGS AND AIRWAYS
OESOPHAGUS
NERVES

5. CHEST PAIN ASSESSMENT HISTORY EXAMINATION ECG CARDIAC ENZYMES CXR
OTHERS

6. Clinical Approach to Chest Pain
History: A- Pain
1- Characteristic:
Sharp ➔
Squeezing heaviness pressure ➔
Stabbing ➔
Pleuritic ➔
Tearing ➔
Burning ➔
pericarditis, HZ
MI, Angina
pericarditis
PE, Pneumonia AD
GERD

7. Cont’d.. approach 2- Site of pain: retrosternal, pleural, epigastric)
3- Radiation:
Neck ➔
Back (interscapular) ➔
Neck, jaw, shoulder, Lt arm ➔
4- Onset:
Sudden➔
Gradual ➔
E. spasm AD
MI, Angina
MI, PE, Pneumothorax, AD
MSS, GI, pneumonia, HZ

8. Cont’d.. approach 5- Duration: < 15 min ( 2- 10) min ➔ Angina
Upto 30 min ➔ MI
Upto 60 min ➔ E.spasm
Few hours ➔ PE, pnumothorax
Hours to days ➔ pericarditis
Longer ➔ HZ
NOTE: <1 min or > 30 sec is less likely to be cardiac.

9. Cont’d.. approach 6- Aggravating:
Exertion, cold, stress, meals ➔ ischemia ,angina
Swallowing, postprandial, smoking ➔ GI
Deep breathing, movement ➔ MSS, pericarditis
Deep breathing ➔ PE, pneumothorax
NOTE: HZ is not aggravated by anything

10. Cont’d.. approach 7- Relieving factors: Rest or GTN ➔ angina
Sitting up, leaning forward ➔ pericarditis
Antacid or food ➔ GI causes
GTN ➔ E.spasm
NOTE: Severity doesn’t indicate seriousness.

11. Cont’d.. approach 8- Associated symptoms:
Cough, fever, sputum, dyspnea.
Sweating.
Nausea, vomiting .
Heamoptysis.
Heartburn, regurgitation.
Palpitations.
Psychiatric symptoms: Anxiety, depression, panic attack

12. Cont’d.. approach
B- Risk factors: Trauma to chest, unusually severe muscular activity, any infection, malignancy, Hypertension, Hypercholesteramia, DM, Smoking, prolonged immobilization previous DVT, upper G.I.D (PUD, GERD, spasm) .
C- Family hx : of IHD esp 1st degree

13. Physical examination:
A- Vital signs: - Hypotension can occur in MI, pericardial temponade, PE, GI bleeding. - Fever suggests an infectious disease.
B- Inspection and palpation: - may reveal the rash of shingles, crepitus associated with rib fracture, localized pain, signs of trauma. Hyperesthesia, particularly when associated with a rash, is often due to herpes zoster.
C- Cardiopulmonary examination: -In MI may have audible S4, signs of CHF such as S3, pericarditis may cause friction rub and pulsus paradoxus, BECK’S TRIAD ( JVP, muffled heart sounds, low BP) suggests cardiac temponade. Determine if the breath sounds are symmetric and if there’s wheezes, crackles etc..

14. DIAGNOSTIC EVALUATION:
ECG
Cardiac markers: Troponins are the 1st enzymes to rise and remain elevated for 5 to 14 days.
Echocardiogram: pericardial effusion, valvular heart disease.
Chest X-ray: Pneumothorax, pnuomonia
Spiral CT, if PE is suspected. .

15. Esophageal pH monitoring, if GERD is suspected.
Patients with musculoskeletal chest pain might not require any diagnostic testing
Life threatening causes: P is Pericarditis. A is as Acute myocardial infarction. P is Pneumothorax P is Pulmonary embolism A is Aneurysm.

16. Cont’d.. Life-threatening Causes of Chest Pain
Angina.
Aortic dissection.
Spontaneous pneumothorax.
Perforated viscus.
Cocaine-induced chest pain (accelerates the progression of atherosclerosis, a risk factor for a heart attack.)

17. Chest Pain That Are Not Immediately Life- Threatening Mitral valve prolapse. Pneumonia. GERD. Esophagitis. Costochondritis. Herpes zoster.

18. MYOCARDIAL INFARCTION SIGNS
SIGNS OF SYMPATHETIC ACTIVATION
PALLOR
SWEATING
TACHYCARDIA
SIGNS OF VAGAL STIMULATION
VOMITING
BRADYCARDIA

19. Myocardial infarction and ischemia
Symptoms:
CHEST PAIN
ANXIETY
FEAR OF IMPENDING DEATH
BREATHLESSNESS
VOMITING
COLLAPSE
SYNCOPE
SILENT

20. MI INVESTIGATIONS ECG HELPFUL
DIFFICULT INTERPRETATION IN PREVIOUS MI PATIENTS AND OLD LBBB
RARELY NORMAL ECG
IN 1/3 OF MI CASES INITIAL CHANGES MAY NOT BE DIAGNOSTIC
EARLIEST CHANGE ST ELEVATION
LATER R WAVE SIZE DIMINUTION
Q WAVES IN TRANSMURAL MI
T WAVE INVERSION

21. RED FLAGS :
Abnormal vital signs (tachycardia, bradycardia, tachypnea, hypotension)
Signs of hypoperfusion (eg, confusion, diaphoresis)
Shortness of breath
Asymmetric breath sounds or pulses
New heart murmurs
Pulsus paradoxus > 10 mm Hg

22. Myocardial Ischemia or Infarction(ACS)
Management: (MONALISA)
Morphine for pain(5-10 mg) if no morphine Pethidine ( mg) + anti emetic.PROVIDING systolic BP is more than 90\60.
Oxygen if hypoxic
Nitro spray/drip for pain
Aspirin
Lasix if in congestive heart failure
Inotropes if in cardigenic shock
Streptokinase (thrombolytics)
Anticoagulation (non Q wave MI Heparin or LMWH, Q wave MI Thrombolytic and Heparin/LMWH)
Other drugs: B-blocker ( HR, # CHF) ACEi, CCB (# LV Failure)
NOTE: When immediate percutaneous transluminal coronary angioplasty (PTCA) is available immediate revascularization my be preferable to thrombolytic therapy.

23. Pericarditis AD MI Angina Site Nature Duration Aggravated Relieved
Substernal may radiate to neck or Lt shoulder
Anterior chest may radiate to back
Retrosternal radiates to neck jaw shoulder Lt arm. MORE sever
Retrosternal radiates to neck jaw shoulder Lt arm.
Site
Stabbing
Tearing
Squeezing, pressure, heaviness
Nature
Hours to days
Pt usually had HTN or Marfan
Usually 30 mins
2 – 10 min
Duration
Deep breathing, supine, rotation of chest
Exertion, cold, emotional stress
Aggravated
Sitting, leaning forward
------
Not relived by rest or GTN
Rest or GTN
Relieved
Rub
Neause, vomiting, weakness, sweating
Dysnea
Associated

24. PERICARDITIS
Constant or intermittent sharp pain often aggravated by breathing, swallowing food, or supine position and relieved by sitting leaning forward
Pericardial friction rub
Jugular venous distention.
ECG usually diagnostic ST segment elev., T wave inversion, or PR depression
Serum cardiac markers (showing elevated troponin with normal CPK level

25. AORTIC DISSECTION
TEARING PAIN
ABRUPT ONST
COLLAPSE
Patient APPEARS TO BE IN SHOCK
BP---NORMAL OR RAISED
ASYMMETRY OF PULSES MI
ACUTE ABDOMEN(MESENTERIC CAELIAC)
RENAL FAILURE
ACUTE LIMB ISCHEMIA(LEGS)

26. RESPIRATORY CAUSES

27. Pneumonia Hx: Sharp & pleuritic pain,SOB,cough,fever,hx of URTI.-
PE:dull on percussion,bronchial breathing sound,pleural rub,crackle.
Commonest cause:Strept Pneumonia.
Dx: Sputum samples,blood test(WBCs),CXR,bronchoscopy.
Rx: antibiotics(amoxicillin,penicillin,
clarithrimycin,macrolides)

28. Pulmonary Embolism History: Sudden-onset, sharp
Exacerbated by inspiratory effort
Associated with hemoptysis, syncope, dyspnea, calf swelling/pain from DVT
Physical:
Anxious patient, sense of impending doom.
Tachycardia, tachypnea, hypoxia.
If severe, can get hypotension, syncope, and RV failure (↑JVP, RV heave)

29. MUSCULOSKELETAL CHEST PAIN
VARY WITH POSTURE
VARY WITH POSITION
LOCAL TENDERNESS
ARTHRITIS
COSTOCONDRITIS
INTERCOSTAL MUSCLE INJURY
COXSACKIE VIRAL INFECTION
MINOR SOFT TISSUE INJURIES

30. GIT CAUSES

31. GERD.
Recurrent burning pain radiating from epigastrium to throat that is exacerbated by bending down or lying down and relieved by antacids.
Clinical evaluation
Sometimes endoscopy
Sometimes motility studies

32. OESOPHAGEAL PAIN CAN MIMIC ANGINAL PAIN
MAY GET PRECIPITATED BY EXERCISE
MAY BE RELIEVED BY NITRATES
RELATION WITH SUPINE POSITION,EATING,DRINKING
H/O REFLUX
CAN RADIATE TO BACK