Approach to a Patient with Chest Pain

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Approach to a patient with Chest Pain

• Clinical pathways

Dr Saeed Ahmad Chaudhary Medical Officer
ER Recep Tayyip Erdogan Hospital (Indus Hospital
) Muzaffargarh
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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

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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

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CHEST PAIN ASSESSMENT
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INITIAL APPROACH

• Assume the worst!
• Before any Diagnostic studies
• 100 Oxygen
• IV access
• Monitoring
• ECG quickly
• History taking

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Chest Pain Physical Examination

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

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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
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HISTORY

• IS THE KEY TO THE DIAGNOSIS OF ETIOLOGY OF CHEST
  PAIN

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PAIN HOW DESCRIBED?

• STABBING
• BURNING
• TWISTING
• TEARING
• SQUEEZING
• TERRIFYING
• NAUSEATING
• SICKENING

Penetrating or Tissue Destructive Process
Bodily Or Emotional Reaction
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H/O CHEST PAIN IN THE EMERGENCY DEPARTMENT

• HEART ATTACK
• ANSWER IS NO
• RELAX
• IS IT ENOUGH TO RULE OUT
• HEART ATTACK?

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Life Threatening Chest Pain inthe Emergency
Department
Life Threatening Chest Pain inthe Emergency
Department

• Myocardial Infarction
• USA
• Aortic Dissection
• Tension Pneumothorax
• Pulmonary Embolus
• Ruptured Esophagus/Perforated

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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
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CARDIACORNON-CARDIAC PAIN?
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LIFE THREATENING CAUSES OF CHEST PAIN
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ANXIETY

• ANXIOUS THOUGHTS
• AVOIDANCE BEHAVIOUR
• SOMATIC SYMPTOMS
• STRESS
• H/O UNPLEASANT
• INCIDENCE
• HYPERVENTILATION
• BREATHLESSNESS
• PALPITATION
• CHEST PAIN
• HEADACHE
• TINGLING SENSATION
• NAUSEA
• LBM
• URINARY FREQUENCY

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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
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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

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• 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

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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
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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
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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.
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ST-Segment Elevation MI
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ST Depression or Dynamic T wave Inversions
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New LBBB
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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
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• CBC -----------LEUKOCYTOSIS ON 1st DAYPEAKS 2-4
  DAYS
• ESR ------------RAISED WITHIN 3 DAYS
• CRP ------------ELEVATED
• CXR ------------PUMONARY EDEMA,,,CARDIOMEGALY
• ECHO --------WMA?

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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
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Aortic DissectionClinical
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

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• 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
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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

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• CXR

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• 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

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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)
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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
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Investigations

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

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CXR
Specific signs in massive/submassive PE
Fleishers sign distended central pulmonary
artery
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Fleisher Lines long bands of focal atelectasis
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Hampton Hump pleural wedge shaped consolidation
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• 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

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• 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
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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
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Tension Pneumothorax when a pneumothorax (primary
spontaneous, secondary spontaneous, or traumatic)
leads to significant impairment
of Respiration and/or Blood Circulation
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Diagnosis

• CLINICAL
• CXR

Diagnosis can be difficult in patients of COPD
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Esophageal Rupture BoerhaaveSyndrome

• 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

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

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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
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• ECG

wide spread ST elevation with PR depression
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• CXR
• MAY SHOWS FLUID
• COLLECTION
• MAY BE DRY

• ECHO
• Pericardial effusion

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INFECTIOUS ACUTE MYOCARDITIS

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

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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

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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

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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

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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.

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Thanks