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APPROACH TO CHEST PAIN

EPIDEMIOLOGY
DIAGNOSIS

PRIMARY CARE

EMERGENCY
DEPT

Musculoskeletal

36 %

7%

GIT

19 %

3%

Cardiovascular
Disease

16 %

54 %

Psychosocial

8%

Pulmonary

5%

Nonspecific chest
pain
USA
Statistics

16 %
(Adopted from AAFP)

9%
12 %
15 %

STEPWISE APPROACH TO
CHEST PAIN
Brainstorm for differentials of chest pain
Focused history.
Look for Risk factors for MI /PE/AORTIC
DISSECTION/PNEUMOTHORAX.
Focused physical exam
Labs/Investigations
Management strategy

Establish Differentials

A good way to brainstorm for the differentials


is to visualise the chest and think what could
be wrong.
Hence the pain could be due to pathology of
the heart, aorta,lungs,pulmonary
vessels,oesophagus,thoracic nerves,bones
and muscles, and finally from
subdiaphragmatic structures such as liver/gall
bladder and pancreas with the pain radiating
to chest.

CAUSES OF CHEST PAIN

Myocardial ischemia or infarction /Coronary spasm secondary to cocaine


Pericarditis /Myopericarditis(post infarction)/
Aortic aneurysm/dissection,Aortic stenosis
Pulmonary embolus
Pneumothorax
Pneumonia/Pleurisy
Esophageal spasm
Esophagitis due to GERD or Hiatus Hernia (in the elderly)
Boerhaaves esophageal perforation.
Gastritis, peptic ulcer disease
Musculo-skeletal
Shingles
Liver abscess(subdiaphragmatic abscess)
Cholecystitis
Pancreatitis
Anxiety

CAUSES WHICH NEED TO BE


RULED OUT & REQUIRE
IMMEDIATE Mx

Acute Coronary syndrome


Aortic dissection
Pneumothorax
Pulmonary embolism
Boerhaaves perforation

KEY HISTORY CLUES


Characterise the pain .Use SOCRATES
approach to pain
Past history to look for relevant risk
factors
Review of Systems : especially
symptoms of CVS, RS ,GIT
Medications(OCP),Allergies,Family
History,Travel history,Occupational &
Social History

PHYSICAL EXAMINATION

General Appearance
Vital Signs
CVS
RS
Abdomen

KEY LABS
ECG
Blood tests: Cardiac Enzymes,
CBC,ESR,D-dimer,RFT,Clotting
studies.
Imaging: CXR,CT Thorax,Spiral CT
with contrast,U/S Doppler Venous
system legs

Acute Coronary Syndrome


History of sudden onset central crushing pain
radiating to either/both arms and jaw especially
in some one with previous history of angina on
exertion or MI and /or cardiac risk
factors.Associated with nausea, diaphoresis,
syncope, shortness of breath
Cardiac risk factors: age, sex, smoking history,
diabetes, hypertension, hyperlipidemia, and
family history

LIKELIHOOD OF MI

Acute Coronary Syndrome

BP indicates cardiogenic shock


JVP, pulsatile liver and peripheral edema seen in right-sided heart failure
Oxygen desaturation, crackles, S3 seen in left-sided heart failure
New murmurs: mitral regurgitation murmur in papillary muscle dysfunction
Signs of systemic atherosclerotic vascular disease ;weak pulses,peripheral
cyanosis,atrophic skin,ulcers,bruits on auscultation of carotid.
Signs of Anaemia : as anaemia can exacerbate ischaemic heart disease
Signs of Hypercholesterolemia: Xanthelesma,Xanthomata and Arcus
Signs of Arrythmia :Arrythmia can cause ischemia in an already poorly
perfused heart due to an underlying ischeamic heart disease .There may be
a irregularly irregular pulse(atrial fibrillation,atrial flutter with variable heart
block or frequent ectopics), a slow pulse(heart block) or a very fast pulse
(atrial fibrillation/flutter induced tachycardia,reentrant
tachycardia,ventricular tachycardia)

Work-up
EKG
CXR to look for signs of congestive heart failure
Cardiac enzymes: CK (will begin to rise 6 hours
after infarct and remain elevated for 24-48
hours), troponin (will begin to rise 12 hours after
infarct and remain elevated for 2 weeks). Need to
follow serially if first set negative.
Others for risk factors and baseline function.

Management Strategy for


NSTEMI
Initial therapy
Morphine for pain
Oxygen if hypoxic
Nitro spray/drip for pain
Aspirin

Management Strategy for


NSTEMI
Stratify/Establish risk level using the TIMI scoring
system(Other risk scores are GRACE,CRUSADE and CHADS2)
:
Low risk(1-2): May be discharged after symptom control
Moderate risk(3-4): Admit for further evaluation; add beta
blockers , Ace inhibitors . Follow cardiac enzyme levels. If MI
ruled out, Exercise or Adenosine stress test before discharge
High Risk: Admit for cardiac
catheterization/thrombolysis(TIMI Score > 5)

TIMI SCORE
TIMI score Mnemonic

AMERICA:
Age > 65
Markers (increased serum cardiac markers)
EKG (ST depression)
Risk factors (3 or more CAD risk factors: patient age (>45
M, > 55 F), family history [CAD in first degree relatives, <55
M, <65 F), hypercholesterolemia, hypertension, smoking,
diabetes, obesity, sedentary lifestyle, metabolic syndrome)
Ischemia (2 or more anginal events over past 24 hours)
CAD (prior coronary stenosis of 50% or more)
Aspirin use within past 7 days

Management Strategy for


STEMI
Morphine, oxygen, nitro, aspirin
Beta blockers, Ace inhibitors
Early invasive strategy with either
thrombolytic therapy or percutaneous coronary
intervention (preferred)

Pulmonary Embolism
Sudden-onset sharp chest pain
Exacerbated by inspiratory effort
Can be associated with hemoptysis, syncope,
dyspnea, calf swelling/pain from DVT
Risk factors: immobilization, fracture of a limb,
post-operative complications, hypercoagulable
states (underlying carcinoma, high-dose
exogenous estrogen administration, pregnancy,
inherited deficiencies of antithrombin III,
activated protein C, S, lupus anticoagulant, prior
history of DVT/PE [Virchows triad]

Pulmonary Embolism
Anxious patient, sense of impending doom
Tachycardia, tachypnea, hypoxia
EKG: sinus tachycardia most common,
S1Q3invertedT3 with large embolus (classic, but
rare!), look for right-axis deviation
V/Q scan very sensitive but not specific
Spiral CT with contrast show large, central emboli
Pulmonary angiogram is gold standard but carries
risk
Consider Doppler U/S of legs

Wells Criteria

. The Wells Score correlates with the probability that a given patient has a pulmonary
embolism. The mnemonic is:Dont die, tell the team to calculatecriteria!
Dont(DVT symptoms) 3 points
Die(Diagnosis most likely PE) 3 points
Tell (Tachycardia) 1.5 points
TheTeam(Three days [at least] of immobilization, or surgery in the pastThirty days)
1.5 points
To (Thromboembolism in the past [DVT or PE]) 1.5 points
Calculate (Coughing up blood [hemoptysis]) 1 point
Criteria (Cancer) 1 point
This is what the scores mean:
> 6Highprobability of PE
2-6Moderateprobability of PE
< 2Lowprobability of PE
The modified Wells Criteria is a bit simpler:
> 4 PE islikely Consider diagnostic imaging.
4 PE isunlikely ConsiderD-dimerto rule out PE.

Pneumothorax
Can be asymptomatic or present with acute
pleuritic chest pain and dyspnea
Primary pneumothorax predominantly in
healthy young tall males
Due to trauma (MVA accidents associated
with rib fractures, iatrogenic during line
placement, thoracentesis)
Increased alveolar pressure from asthma or
barotraumas (BiPAP, ventilator-associated)
Rupture of bleb in COPD patients

Pneumothorax
Decreased expansion of chest
Decreased breath sounds and
Decreased tactile/vocal fremitus on side of
pneumothorax
Hyperresonant percussion note
Usually easily confirmed by CXR

Aortic Dissection
Abrupt onset
The pain usually is described as ripping or tearing
Tearing or ripping pain that is felt in the
intrascapular area
New diastolic murmur, asymmetrical pulses, and
asymmetrical blood pressure measurements
Risk factors: HTN, Marfan syndrome, coarctation of
aorta..
Widened mediastinum on a portable
anteroposterior (AP) radiograph
TEE considered diagnostic test of choice

Boerhaaves Perforation
This is very rare but is associated with a high mortality.
There is a history of sudden onset severe chest pain
immediately after an episode of vomitting
Symptoms may include shortness of breath and pleuritic type
of chest pain (due to subsequent pleurisy and effusion).
Signs of pleural effusion after some hours- dullness to
percussion,absent breath sounds,decreased vocal resonance.
Subcutaneous emphysema in a minority of cases
Abdominal rigidity,sweating,fever,tachycardia and hypotension
may be present as the fever progresses but are non specific.
The way to rule it out if you strongly suspect is to perform a
chest radiograph after swallowing a water soluble contrast
(gastrograffin)

Thank You

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