patient visiting with chest pain

1. 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 ( Don’t 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
A
• History
• Examination
B
• ECG
• CARDIAC EZYMES
C
• CXR
• OTHERS

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. IS THE KEY TO THE
DIAGNOSIS OF ETIOLOGY
OF CHEST PAIN
HISTORY

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

13. COMMON CAUSES OF CHEST PAIN
 ANXIETY
 CARDIAC
 AORTIC
 OESOPHAGEAL
 LUNGS/PLEURA
 MUSCULOSKELETAL
 NEUROLOGICAL
MYOCARDIAL
ISCHEMIA(ANGINA)
MI
MYOCARDITIS
PERICARDITIS
MVP
ESOPHAGITIS
ESOPH SPASM
MW SYNDROME
AORTIC DISSECTION
AORTIC ANEURYSM
BRONCHOSPASM:::PE:::PI
PNEUMONIA:::::TB:::::CTDs
TRACHEITIS PLEURITIS
PNEUMOTHORAX
MALIGNANCY
OA ,RIB #
I/C MUSCLE INJURY
TEITZE`S SYND
BORNHOLM`S DISEASE
PROLAPSED I/V DISC
HERPES ZOSTER
THORACIC OUTLET
SYNDROME

14. CARDIAC
OR
NON-CARDIAC PAIN?

15. LIFE THREATENING CAUSES OF CHEST PAIN

17. 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

18. RADIATION
 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
•NECK
•JAW
•UPPER OR LOWER ARM
•BACK

19. ASSOCIATED FEATURES
SINGS
SYMPATHATIC
STIMULATION
PALLOR
SWEATING
TACHYCARDIA
VAGAL
STIMULATION
NAUSEA
BRADYCARDIA
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

20. 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%
– N&V 24.3%
– Syncope 19.1%
Diabetic
Females
Elderly

21. Risk
Factors
Cardiac Risk Factors
•Smoking
•Diabetes
•HTN
•Hyperlipidaemia
•Family History
•Known Ischemic Heart Disease
•Male ,
•Age >40
•Chronic cocaine use in the
younger pts.
Lesser known cardiac risk factors
•SLE
•Rheumatoid Disease
•Asian
•Prothrombotic Disease
•Cocaine

22. INVESTIGATIONS
ECG Provides documentary evidence of cardiac
ischemia/infarction when positive.
Normal in ~ 50% initially who are later Dx as having an AMI.
A normal ECG does not exclude an AMI

23. ST-Segment Elevation MI

24. ST Depression or Dynamic T wave Inversions

25. New LBBB

26. 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/dermatomyo
sitis
PLASMA BIOCHEMICAL MARKERS

27. CBC -----------LEUKOCYTOSIS ON 1st DAY—PEAKS 2-4
DAYS
ESR------------RAISED WITHIN 3 DAYS
CRP------------ELEVATED
CXR------------PUMONARY EDEMA,,,CARDIOMEGALY
ECHO--------WMA?

29. Chest Pain
Duration
ECG
a) ST
b) T wave
Cardiac
Enzymes
Troponin
(T,I)
Angina Less than 10 min a) Normal
b) Normal
-ve -ve
Un-stable
Angina
> 10 mins a) Slight
Depression/
Elevation
b) Poor/
Inversion
-ve /slightly
raised
-ve
NSTMI > 20 mins ST Depression +ve +ve
STEMI > 20 mins ST Elevation +ve +ve

30. Aortic Dissection
Clinical Presentation
 History:
 >90% 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

31. 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
Physical Examination:
•BP differential?
bilateral arm BPs – significant if >20mmHg difference
Most commonly: normal heart and lung
•Aortic insufficiency murmur in 16-20%
•Unequal, decreased, or absent peripheral pulses only found in 50%

32.  ECG
– AMI (new Q or STE) – 3.2%
– Ischaemia – 15%
– No abnormalities – 31.3%
– Non specific T wave changes – 41.4%
– LVH – 26.1%
Investigations
Risk Factors – Atherosclerosis, HTN (uncontrolled),
Coarctation of Aorta, Bicuspid Aortic Valve, Aortic
Stenosis, Marfan Syn, Ehlers-Danlos Syn, Pregnancy

33. CXR

34. CXR
a)-Mediastinal widening (61.6%) , b)- Widening of aortic contour (49.9%),
c)-Pleural effusion (L>R) (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

35. 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 > 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%)

36. Hypercoagulability
Pregnancy; malignancy; estrogen
therapy; deficiencies of protein C,
protein S, AT III
Endothelial
damage
Recent surgery, trauma
Venous stasis
Prolonged travel;
bed Ridden
#1 Risk Factor = Prior DVT/PE
Risk Factors;
Virchow’s triad:
 10-15% of patients will have no
identifiable risk factor at the time of
presentation
Pre-test Probability

37. Investigations;
 ECG
– Tachycardia most common • approx. 1/3 patients
– T wave inversion • V1-3 (inferior leads)
– S1Q3T3 Pattern • 20% patients

38. CXR; Specific signs in massive/submassive PE
Fleisher’s sign – distended central pulmonary artery

39. Fleisher Lines – long bands of focal atelectasis

40. Hampton Hump – pleural wedge shaped consolidation

41. Biomarkers
– Markers of right heart strain
– Troponin
– BNP
• Takes time for rise
• RV smaller muscle mass therefore threshold lower
• >90
D Dimer
–ve – discharge False –ve <1%
D Dimer +ve
– Many false positives
Malignancy– Recent surgery– Infection– DIC– Trauma– ACS– CVA– AF
Vacuities-Superficial phlebitis

42. ECHO
– RV dilatation
– RV hypokinesis
– Pardoxical septal wall movement
– Tricuspid regurgitation
Imaging
•COLLOR DOPPLER
•VENTILATION–PERFUSION (VQ) SCAN
if normal CXR
•CT PULMONARY ANGIOGRAPHY (CTPA)
if definitive diagnosis urgent
•MRI

43. 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

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

45. Diagnosis;
CLINICAL
CXR
Diagnosis can be
difficult in patients of
COPD

46. 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

47. CXR;
SQ air, Pleural Effusions, Pneumothorax, pneumoperitoneum, pneumomediastinum
Water Soluble Contrast Study

48. Pericarditis
 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.
Inflammation Of Pericardial Sac
Causes;
Idiopathic
Infection
Acute MI
Uremia
Neoplasm
(Hodgkin
Lymphoma,
breast and Ca
lung )
PERICARDIAL FRICTION RUB
FEVER
LEUCOCYTOSIS

49. ECG
wide spread ST elevation with PR depression

50. CXR
• MAY SHOWS FLUID
COLLECTION
•MAY BE DRY
ECHO
Pericardial effusion

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

52. 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

53. Gastroesophageal 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
CAN MIMIC
ANGINAL PAIN

54. MUSCULOSKELETAL CHEST PAIN
 •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
•ARTHRITIS
•COSTOCONDRITIS
•INTERCOSTAL MUSCLE
INJURY
•COXSACKIE VIRAL
INFECTION
•MINOR SOFT TISSUE
INJURIES
TEITZE`S SYNDROME
IDIOPATHIC COSTOCONDRITIS
•LOCALIZED PAIN/TENDERNESS AT
COSTOCONDRAL JUNCTION
•ENHANCED BY
EMOTION,COUGHING,SNEEZING
•2nd.RIB MOST AFFECTED

55. 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.