Chest Pain

KEPANITERAAN ILMU PENYAKIT DALAM

FK UNTAR
2019
 Epidemiology

It is helpful to frame the initial

diagnostic assessment and triage of
patients with acute chest
discomfort around three categories:
1. myocardial ischemia;
2. other cardiopulmonary causes
(pericardial disease, aortic
emergencies, and pulmonary
conditions)
3. non-cardiopulmonary causes
Penyebab
 • Myocardial ischemia causing chest discomfort,
termed angina pectoris, is a primary clinical
concern in patients presenting with chest
symptoms.
• Myocardial ischemia is precipitated by an
1. MYOCARDIAL imbalance between myocardial oxygen
ISCHEMIA/ requirements and myocardial oxygen supply,
resulting in insufficient delivery of oxygen to
INJURY meet the heart’s metabolic demands
• When myocardial ischemia is sufficiently severe
and prolonged in duration (as little as 20 min),
irreversible cellular injury occurs, resulting in MI
• Ischemic heart disease is most commonly caused by atheromatous
plaque that obstructs one or more of the epicardial coronary arteries.
• Stable ischemic) usually results from the gradual atherosclerotic
narrowing of the coronary arteries.
• Stable angina is characterized by ischemic episodes that precipitated
by a superimposed increase in oxygen demand during physical
exertion and relieved upon resting. Ischemic heart disease becomes
• Unstable most commonly when rupture or erosion of one or more
atherosclerotic lesions triggers coronary thrombosis
 Unstable angina when there is no
detectable myocardial injury and as non–
ST elevation MI (NSTEMI) when there is
evidence of myocardial necrosis
UNSTABLE ISCHEMIC
HEART DISEASE
CLASSIFICATION
Unstable angina with ST-segment
elevation on the ECG and myocardial
necrosis leading to a diagnosis of ST
elevation MI (STEMI,
 • Myocardial ischemia is typically described as
aching, heavy, squeezing, crushing, or
CHARACTERISTICS constricting, extremely vague, mild tightness, or
numbness or a burning sensation.
OF ISCHEMIC
• The site of the discomfort is usually
CHEST retrosternal, but radiation is common and
DISCOMFORT generally occurs down the ulnar surface of the
left arm; the right arm, both arms, neck, jaw, or
shoulders.
 Stable angina usually begins gradually and
reaches its maximal intensity over a period of
minutes before dissipating within several minutes
with rest or with nitroglycerin

Unstable angina is manifest by self-limited

DIFFERENCES anginal chest discomfort that is exertional but
occurs at increased frequency with progressively
OF ANGINA lower intensity of physical activity or even at rest.

Chest discomfort associated with MI is typically

more severe, is prolonged (usually lasting ≥30
min), and is not relieved by rest.
 1. PERICARDIAL AND OTHER MYOCARDIAL
DISEASES
• Inflammation of the pericardium due to
infectious or noninfectious causes can be
responsible for acute or chronic chest
OTHER discomfort
CARDIOPULMONARY • Therefore, the pain of pericarditis is thoughtto
CAUSES arise principally from associated pleural
inflammation and is morecommon with
infectious causes of pericarditis, which typically
involve the pleura
• is usually pleuritic pain that is exacerbated by
breathing, coughing, or changes in position
• The symptoms of Takotsubo (stress-related) cardiomyopathy often start abruptly
with chest pain and shortness of breath.
• This form of cardiomyopathy, in its most recognizable form, is triggered by an
emotionally or physically stressful event and may mimic acute MI because of its
commonly associated ECG abnormalities, including ST-segment elevation, and
elevated biomarkers of myocardial injury
2. DISEASE OF THE AORTA
• Acute aortic dissection (Fig.
19-1) is a less common cause
of chest discomfort
• Acute aortic syndromes
involving the ascending aorta
tend to cause pain in the
midline of the anterior chest,
whereas descending aortic
syndromes most often present
with pain in the back.
• Proximal aortic dissections that involve the ascending aorta are at high risk for
major complications that may influence the clinical presentation, including
1. Compromise of the aortic ostia of the coronary arteries, resultingin MI
2. Disruption of the aortic valve, causing acute aortic insufficiency;
3. Rupture of the hematoma into the pericardial space, leading to pericardial
tamponade.
3. PULMONARY CONDITION
a. Pulmonary Embolism
• produce dyspnea and chest discomfort that is sudden in onset
• Typically pleuritic in pattern, the chest discomfort associated with pulmonary embolism may
result from
1. involvement of the pleural surface of the lung adjacent to a resultantpulmonary infarction
2. distention of the pulmonary artery
3. possibly, right ventricular wall stress and/or subendocardial
4. ischemia related to acute pulmonary hypertension.
b. Pneumothorax
The symptoms are usually sudden in onset, and dyspnea may be mild; thus, presentation
to medical attention is sometimes delayed.
c. Other Disease
• Chest pain, including pneumonia and malignancy, do so because of involvement of the
pleura or surrounding structures.
• Pleurisy is typically described as a knifelike pain that is worsened by inspiration or
coughing.
• Chronic pulmonary hypertension can manifest angina suggesting right ventricular
myocardial ischemia in some cases
NON-CARDIOPULMONARY CAUSES

1.Gastrointenstinal Conditions
• GERD ,Acid reflux often causes a burning discomfort.
• Esophageal spasm, in contrast, is commonly an intense, squeezing discomfort
that is retrosternal in location and, like angina, may be relieved by nitroglycerin or
dihydropyridine calcium channel antagonists
• Mallory-Weiss tear or even an esophageal rupture (Boerhaave syndrome) caused
by severe vomiting produce chest pain
• Hepatobiliary disorders, including cholecystitis and biliary colic, may mimic acute
cardiopulmonary diseases.
• Although the pain usually localizes to the right upper quadrant of the abdomen,
may be felt in the epigastrium and radiate to the back and lower chest
• The pain is steady, usually lasts several hours, and subsides spontaneously,
without symptoms between attacks.
• Pancreatitis is typically aching epigastric pain that radiates to the back.
B.Musculoskeletal and Other Causes (See also Chap. 393)

Chest discomfort can be produced by any musculoskeletal disorder involving the

chest wall or the nerves of the chest wall, neck, or upper limbs