CHEST PAINANGINA

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CHEST PAIN/ANGINA

• Joshua M. Crasner, DO, FACC, FACOI

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HISTORY

• location
• radiation
• character
• exacerbating/relieving factors
• duration
• frequency
• recurrence pattern

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QUALITY/CHARACTER

• Pain
• pressing, squeezing sensation
• burning
• constricting
• sine quo non symptoms are band across the chest
  or weight in center of chest

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Anginal Equivalent

• may not be typical symptoms
• indigestion
• dizziness
• diaphoresis
• exhaustion
• faintness
• nausea/vomiting
• palpitations

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DURATION

• angina is usually of short duration 2-10 min
• musculoskeletal etiology typically brief, sharp,
  lancinating pain
• hours-long pain acute MI, pericarditis, aortic
  dissection

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PRECIPITATING FACTORS

• angina usually exertional, except Prinzmetals
• ischemia the patient may become restless, or
  pain much more severe than that of
  angina/MI(viable myocardium)
• postprandial
• postcoitus
• nocturnal/early AM
• cold air exposure
• inclines, steps

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RELIEVING FACTORS

• nitroglycerin esophageal spasm esophagitis,
  angina
• rest
• oxygen
• medicines(at home) nitro, antacids,
  anti-anginals, pain remedies, anxiolytics
• food, beverage
• massage, stretching, position change

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DIFFERENTIAL DIAGNOSIS
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ESOPHAGEAL

• Spasm
• reflux
• esophagitis
• Mallory-Weiss tear
• Symptoms belching, heartburn, spasmodic pain

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BILIARY COLIC

• steady pain lasting 2-4 hrs.
• radiation of pain epigastrium, precordium, right
  shoulder

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CERVICAL RADICULITIS

• constant ache
• related to cervical motion
• brachial plexus
• hands, arm involvement

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SYNDROME X

• angina-like pain with normal coronaries
• females more frequent
• can have ischemic ECG

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ACUTE PULMONARY HYPERTENSION

• similar quality pain as angina
• across entire precordium, more severe
• not usually exertional
• pulmonary embolism, pulmonic stenosis
• Physical exam RV lift, TR, SEM of PS

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ACUTE PERICARDITIS

• usually preceded by URI
• sharp, pleuritic, often left-sided
• aggravated by position, better sitting forward
• hours in length
• not relieved by anti-anginals
• absence of rub does not exclude

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AORTIC DISSECTION

• ripping, tearing sensation
• persistent severe pain with radiation to back
• lasting for hours
• pain usually worse at its onset
• most common in patients with HTN

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MUSCULOSKELETALCOSTOCHONDRITIS/MYOSITIS

• local tenderness
• aggravated by cough, motion
• Tietze syndrome(costrochondral)

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PSYCHOGENIC PAIN

• Da Costa syndrome
• dull persistent ache for hours
• unrelated to exertion
• occurs with fatigue
• other emotionally unstable signs present

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Other Entities

• Anomalous coronary artery
• aortic stenosis
• mitral valve prolapse/stenosis(rare)

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EVALUATION AND TREATMENTAT BEDSIDE

• brief, directed history and physical
• ECG, CXR, ABG, labs where appropriate
• treat the underlying cause, not just the symptoms
• transfer of patient and/or evalution of patient
  by others more experienced
• 2D Echo/Doppler if available and/or TEE where
  appropriate
• oxygen, reposition patient, IV site, monitor