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Approach to a Patient with Chest Pain

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Title: Approach to a Patient with Chest Pain


1
Approach to a patient with Chest Pain
  • Clinical pathways

Dr Saeed Ahmad Chaudhary Medical Officer
ER Recep Tayyip Erdogan Hospital (Indus Hospital
) Muzaffargarh
2
Objectives
  • UNDERSTAND THE CAUSES OF CHEST PAIN
  • UNDERSTAND THE IMPORTANCE OF HISTORY TAKING
  • REALIZE THE LIFE THREATENING CAUSES OF CHEST PAIN
  • INVESTIGATIONS
  • LEARN COMMON ECG CHANGES

3
Chest Pain ( Dont Panic)
  • 5 Million emergency department visits
  • 2 million hospitalizations annually with cost of
    more than 8 billion
  • Cardiac etiology found in less than one third
  • 2 of patients with acute MI are unrecognized and
    discharged from the ED
  • Accurate Diagnosis Remains A Challenge

4
CHEST PAIN ASSESSMENT
5
INITIAL APPROACH
  • Assume the worst!
  • Before any Diagnostic studies
  • 100 Oxygen
  • IV access
  • Monitoring
  • ECG quickly
  • History taking

6
Chest Pain Physical Examination
  • _ Vital signs and general appearance
  • _ Carotids and JVP
  • _ Lungs
  • _ Cardiac examination
  • _ Thoracic cage
  • _ Abdominal examination
  • _ Periphery (pulses)
  • _ Skin

7
Chest Pain? Origin?
  • HEART
  • LUNGS
  • OESOPHAGUS
  • MUSCULOSKELETAL STRUCTURES OF THORAX NECK,OR
    SHOULDER
  • ABDOMEN
  • ANXIETY MANIFESTATION

WHAT LIES IN THE CHEST
SKIN MUSCLES BONES JOINTS HEART AND
VESSELS LUNGS AND AIRWAYS OESOPHAGUS NERVES
8
HISTORY
  • IS THE KEY TO THE DIAGNOSIS OF ETIOLOGY OF CHEST
    PAIN

9
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10
PAIN HOW DESCRIBED?
  • STABBING
  • BURNING
  • TWISTING
  • TEARING
  • SQUEEZING
  • TERRIFYING
  • NAUSEATING
  • SICKENING

Penetrating or Tissue Destructive Process
Bodily Or Emotional Reaction
11
H/O CHEST PAIN IN THE EMERGENCY DEPARTMENT
  • HEART ATTACK
  • ANSWER IS NO
  • RELAX
  • IS IT ENOUGH TO RULE OUT
  • HEART ATTACK?

12
Life Threatening Chest Pain in the Emergency
Department
Life Threatening Chest Pain in the Emergency
Department
  • Myocardial Infarction
  • USA
  • Aortic Dissection
  • Tension Pneumothorax
  • Pulmonary Embolus
  • Ruptured Esophagus/Perforated

13
COMMON CAUSES OF CHEST PAIN
  • ANXIETY
  • CARDIAC
  • AORTIC
  • OESOPHAGEAL
  • LUNGS/PLEURA
  • MUSCULOSKELETAL
  • NEUROLOGICAL

MYOCARDIAL ISCHEMIA(ANGINA) MI MYOCARDITIS PERICAR
DITIS MVP
AORTIC DISSECTION AORTIC ANEURYSM
ESOPHAGITIS ESOPH SPASM MW SYNDROME
BRONCHOSPASMPEPI PNEUMONIATBCTDs T
RACHEITIS PLEURITIS PNEUMOTHORAX MALIGNANCY
OA ,RIB I/C MUSCLE INJURY TEITZES
SYND BORNHOLMS DISEASE
PROLAPSED I/V DISC HERPES ZOSTER THORACIC OUTLET
SYNDROME
14
CARDIAC OR NON-CARDIAC PAIN?
15
LIFE THREATENING CAUSES OF CHEST PAIN
16
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17
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18
ANXIETY
  • ANXIOUS THOUGHTS
  • AVOIDANCE BEHAVIOUR
  • SOMATIC SYMPTOMS
  • STRESS
  • H/O UNPLEASANT
  • INCIDENCE
  • HYPERVENTILATION
  • BREATHLESSNESS
  • PALPITATION
  • CHEST PAIN
  • HEADACHE
  • TINGLING SENSATION
  • NAUSEA
  • LBM
  • URINARY FREQUENCY

19
ISCHEMIC CARDIAC PAIN
Site Of Origin of Chest Pain
Central
Character Of Chest Pain
  • TYPICALLY DULL
  • CONSTRICTING IN NECK
  • CHOKING
  • HEAVY
  • DESCRIBED BY PATIENTS AS
  • ---SQUEEZING
  • -------CRUSHING
  • -----------BURNING
  • ---------------ACHING
  • BUT NOT SHARP STABBING
  • BUT NOT PRICKING, KNIFE-LIKE
  • SENSATION CAN BE DESCRIBED AS BREATHLESSNESS

SEVERE PROLONGED ASSOCIATED WITH CLINICAL
EVIDENCE OF ACUTE SERIOUS ILLNESS
20
RADIATION
  • NECK
  • JAW
  • UPPER OR LOWER ARM
  • BACK
  • Because of common/overlapping neural pathways,
    many conditions, both cardiac and extra-cardiac
    can result in chest pain.
  • Cardiac pain is mediated through upper 5 thoracic
    ganglia and spinal roots, but ramifications from
    adjoining spinal roots always exist.
  • Therefore pain in the chest may originate from
    any structure in thorax and upper abdomen
    innervated through lower cervical to D6/D7 spinal
    roots

21
  • ASSOCIATED FEATURES
  • SIGNS OF IMPAIRED MYOCARDIAL FUNCTION
  • HYPOTENSION
  • OLIGURIA
  • COLD PERIPHERIES
  • NARROW PULSE PRESSURE
  • RAISED JVP
  • S3
  • QUIET S1
  • DIFFUSE APICAL IMPULSE
  • LUNG CREPTS
  • SIGNS OF TISSUE DAMAGE-------FEVER
  • SIGNS OF COMPLICATIONS----MR,,,,,,,PERICARDITIS

22
Painless ACS
GRACE Study 8.4 (1763/20,881) patients with
ACS presented WITHOUT chest pain Not initially
recognised as ACS in 23.8 Dyspnoea 49.3
Diaphoresis 26.2 NV 24.3 Syncope 19.1
23
Risk Factors
  • Cardiac Risk Factors
  • Smoking
  • Diabetes
  • HTN
  • Hyperlipidaemia
  • Family History
  • Known Ischemic Heart Disease
  • Male ,
  • Age gt40
  • Chronic cocaine use in the younger pts.

Lesser known cardiac risk factors SLE Rheumatoid
Disease Asian Prothrombotic Disease Cocaine
24
INVESTIGATIONS
Provides documentary evidence of
cardiac ischemia/infarction when positive.
  • ECG

A normal ECG does not exclude an AMI
Normal in 50 initially who are later Dx as
having an AMI.
25
ST-Segment Elevation MI
26
ST Depression or Dynamic T wave Inversions
27
New LBBB
28
PLASMA BIOCHEMICAL MARKERS
Myoglobin CK-MB Isoenzyme Troponin ( T, I)
Specific/Sensitive high sensitivity but poor specificity Less Sensitivity and specificity Most Specific Most Sensitive
Raises in 1 hour 4-6 Hours 4-8 Hours
Peaks in 4-12 Hours 24 Hours 18-24 Hours
Remains Elevated 24-36 hours 36-48 Hours 10-14 Days
Remarks 100 within 3 hrs of AMI predictive of mortality prognostic information
False Positive Skeletal muscle injury, Heavy alcohol, Renal failure , Shock states exercise, trauma, muscle dz, DM, PE renal dz, poly/dermatomyositis
29
  • CBC -----------LEUKOCYTOSIS ON 1st DAYPEAKS 2-4
    DAYS
  • ESR ------------RAISED WITHIN 3 DAYS
  • CRP ------------ELEVATED
  • CXR ------------PUMONARY EDEMA,,,CARDIOMEGALY
  • ECHO --------WMA?

30
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31
Chest Pain Duration ECG ST T wave Cardiac Enzymes Troponin (T,I)
Angina Less than 10 min a) Normal b) Normal -ve -ve
Un-stable Angina gt 10 mins Slight Depression/Elevation Poor/ Inversion -ve /slightly raised -ve
NSTMI gt 20 mins ST Depression ve ve
STEMI gt 20 mins ST Elevation ve ve
32
Aortic Dissection Clinical
Presentation
  • History
  • gt90 with abrupt and severe pain in the chest or
    between the scapulae
  • tearing or ripping
  • Can be dull or pressure-like
  • Anterior chest ascending aorta -Type A Back
    descending aorta Type B
  • Nausea, vomiting, diaphoresis common
  • Definition
  • Intimal tear with entry of blood into the media
  • dissects between the intima and adventitia
  • 1 site ascending aorta at the ligamentum
    arteriosum
  • Stanford Classification
  • A involves Ascending aorta (w/ or w/o
    descending)
  • 80 of dissections
  • B descending aorta only

33
  • Physical Examination
  • BP differential?
  • bilateral arm BPs significant
    if gt20mmHg difference
  • Most commonly normal heart and
    lung
  • Aortic insufficiency murmur in 16-20
  • Unequal, decreased, or absent peripheral pulses
    only found in 50

Associated signs symptoms based on progression
of dissection Carotid arteries stroke Spinal
arteries paraplegia Abdominal aorta/renal
arteries/iliacs Abdominal/flank pain Coronary
arteries pericardial effusion/tamponade Laryngeal
nerve compression hoarseness Tracheal
compression dyspnea/stridor/wheezing Esophageal
compression dysphagia
34
Risk Factors Atherosclerosis, HTN
(uncontrolled), Coarctation of Aorta, Bicuspid
Aortic Valve, Aortic Stenosis, Marfan Syn,
Ehlers-Danlos Syn, Pregnancy
Investigations
  • ECG
  • AMI (new Q or STE) 3.2
  • Ischaemia 15
  • No abnormalities 31.3
  • Non specific T wave changes 41.4
  • LVH 26.1

35
  • CXR

36
  • CXR
  • a)-Mediastinal widening (61.6) , b)- Widening of
    aortic contour (49.9),
  • c)-Pleural effusion (LgtR) (19.2), d)-Apical
    pleural cap, e)-Calcium sign (14), f) Depressed
    left main bronchus , g)-Tracheal or oesophageal
    displacement, h)-No abnormalities noted 12.4
  • TEE ( High Sensitivity and Specificity )
  • Aortic Angiography
  • CT or MR

37
Pulmonary Embolism
Classic Triad Sharp Pleuritic CP, Dyspnea,
hemoptysis in only 20 of pts.
Pain is often pleural Reproduciable with
breathing, palpation
  • Dyspnea (79)
  • Dyspnea at rest (61)
  • Dyspnea exertion (16)
  • Orthopnea (36)
  • Pleuritic chest pain (49)
  • Non pleuritic chest pain (17)
  • Cough (43)
  • Calf or thigh swelling (39)
  • Calf or thigh pain (41)

SIGNS RR gt 20/min (57) Tachycardia
(26) Increased P2 (15) JVP distension
(13) Rales (21) Wheeze (3) Decreased breath
sounds (21) Signs of calf or thigh DVT (47)
38
Risk Factors
Virchows triad
1 Risk Factor Prior DVT/PE
  • 10-15 of patients will have no identifiable risk
    factor at the time of presentation

Pre-test Probability
39
Investigations
  • ECG
  • Tachycardia most common approx. 1/3
    patients
  • T wave inversion
    V1-3 (inferior leads)
  • S1Q3T3 Pattern
    20 patients

40
CXR
Specific signs in massive/submassive PE
Fleishers sign distended central pulmonary
artery
41
Fleisher Lines long bands of focal atelectasis
42
Hampton Hump pleural wedge shaped consolidation
43
  • Biomarkers
  • Markers of right heart strain
  • Troponin
  • BNP
  • Takes time for rise
  • RV smaller muscle mass
    therefore threshold lower
  • gt90
  • D Dimer
  • ve discharge False ve lt1
  • D Dimer ve
  • Many false positives
  • Malignancy Recent surgery Infection DIC
    Trauma ACS CVA AF
  • Vacuities-Superficial phlebitis

44
  • Imaging
  • COLLOR DOPPLER
  • VENTILATIONPERFUSION (VQ) SCAN
  • if normal
    CXR
  • CT PULMONARY ANGIOGRAPHY (CTPA)
  • if
    definitive diagnosis urgent
  • MRI
  • ECHO

RV dilatation RV hypokinesis Pardoxical
septal wall movement Tricuspid regurgitation
45
Tension Pneumothorax
  • Clinical Presentation
  • SUDDEN-ONSET UNILAT. CHEST PAIN,PLEURITIC SHARP
  • BREATHLESSNESS
  • ASYMPTOMATIC (NOT TENSION PNEUMOTHORAX)
  • DEC OR ABSENT BREATH SOUNDS (IF PNEUMOTHORAX MORE
    THAN15).
  • RESONANT ON PERCUSSION
  • MEDIASTINAL DISPLACEMENT TO OPPOSITE SIDE
  • TACHYCARDIA
  • HYPOTENSION
  • CYANOSIS
  • TRACHEAL DISPLACEMENT
  • ASYMMETRIC LUNG EXPANSION.

Risks Factors Sudden Change in barometric
pressure Smokers, COPD, Idiopathic Bleb
DZ Especially tall, thin male smokers Only 10
20 occur with exertion
46
Tension Pneumothorax when a pneumothorax (primary
spontaneous, secondary spontaneous, or traumatic)
leads to significant impairment
of Respiration and/or Blood Circulation
47
Diagnosis
  • CLINICAL
  • CXR

Diagnosis can be difficult in patients of COPD
48
Esophageal Rupture Boerhaave Syndrome
  • Substernal, sharp CP
  • Sudden onset after forceful vomiting
  • Dyspneic, diaphoretic, and ill-appearing
  • Shock
  • Sub-cutaneous Emphysema
  • Causes?
  • Most Common Iatrogenic (Endoscopic Perforation)
  • Malignancy
  • Corrosive Strictures Perforation
  • Post Radiotherapy Strictures

49
  • CXR
  • SQ air, Pleural Effusions, Pneumothorax,
    pneumoperitoneum, pneumomediastinum
  • Water Soluble Contrast Study

50
Pericarditis
Inflammation Of Pericardial Sac
  • Chest pain , Severe Pleuritic localized
  • Aggravated by lying supine, coughing swallowing
    and deep inspiration.
  • Relieved by sitting up and leaning forward.
  • It might be preceded by viral illness.

Causes Idiopathic Infection Acute
MI Uremia Neoplasm (Hodgkin Lymphoma, breast and
Ca lung )
PERICARDIAL FRICTION RUB FEVER LEUCOCYTOSIS
51
  • ECG

wide spread ST elevation with PR depression
52
  • CXR
  • MAY SHOWS FLUID
  • COLLECTION
  • MAY BE DRY
  • ECHO
  • Pericardial effusion

53
INFECTIOUS ACUTE MYOCARDITIS
  • OFTEN FOLLOWS
  • URTI
  • CHEST PAIN
  • S/O HEART FAILURE
  • ECG
  • NON-SPECIFIC ST-T CHANGES
  • CONDUCTION
  • DISTURBANCES
  • VENTRICULAR
  • ECTOPICS
  • CXR CARDIOMEGALY

54
MITRAL VALVE PROLAPSE
  • SHARP LEFT SIDED CHEST PAIN AT APEX
  • DYSPNEA
  • FATIGUE
  • PALPITATION
  • REDUCE BY LYING DOWN
  • FEMALES
  • THIN
  • CHEST WALL DEFORMITIES
  • MID-SYSTOLIC CLICKS AT APEX
  • ECHO
  • CARDIAC CATH

55
Gastroesophageal Pain
CAN MIMIC ANGINAL PAIN
  • BURNING
  • PROLONGED
  • SUBSTERNAL/EPIGASTRIC , CAN RADIATE TO BACK
  • REGURGITATION OF LIQUIDS OR FOOD
  • INCREASED BY CHOCOLATE,COFFEE
  • RELATION WITH SUPINE POSITION, EATING, DRINKING,
    GET PRECIPITATED BY EXERCISE
  • AFTER LARGE MEAL
  • LYING AFTER MEAL
  • OVERWEIGHT
  • MAY BE RELIEVED BY NITRATES

56
MUSCULOSKELETAL CHEST PAIN
  • ARTHRITIS
  • COSTOCONDRITIS
  • INTERCOSTAL MUSCLE INJURY
  • COXSACKIE VIRAL INFECTION
  • MINOR SOFT TISSUE INJURIES
  • RAPID ONSET
  • CONSTANT
  • INCREASES WITH DEEP BREATHING AND CHANGE IN
    POSTURE
  • REPRODUCED/TENDER BY PALPATION
  • HISTORY OF RECENT EXERCISE/EXERTION
  • VITALS ARE STABLE
  • ANXIETY/ATTENTION DEMANDING/MOTIVES
  • TEITZES SYNDROME IDIOPATHIC COSTOCONDRITIS
  • LOCALIZED PAIN/TENDERNESS AT
  • COSTOCONDRAL JUNCTION
  • ENHANCED BY EMOTION,COUGHING,SNEEZING
  • 2nd.RIB MOST AFFECTED

57
Herpes Zoster (Shingles)
  • Chest pain ,Unilateral
  • Burning, tickling, tingling, and/or numbness
    occurs in the left parasternal area, following
    the dermatomes.
  • Flu-like symptoms (without a fever), such as
    chills
  • Swelling and tenderness of the lymph nodes
  • Chest pain from Shingles can occur before the
    onset of vesicles thus making a reliable
    diagnosis difficult.

58
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