Approach to Chest Pain

Approach to Chest PainDone By Abdulwahab K NeyaziMBBS

ContentIntroductionBrain StormingDDxCardiac OriginRespiratory OriginGI Origin

IntroductionChest pain is very common complain either in clinic, ER, or Word.

Taking detailed history Is Important.

You have to take it series.

IntroductionOnset.Duration.Progression. Aggravating and Relieving Factors. Nature.Radiation.Severity of the pain Limitation of the usual activity.

Cautions

SMART patients

Brain Storming

HxDDX

DDx

DDx

DDx

DDx

Musculoskeletal Most Common Cause of Chest pain

Usually pain is localized.

Strained chest muscles from overuse or excessive coughing.

Chest muscle bruising from minor injury.

MusculoskeletalTreatment

Analgesic

Cardio-VascularA - Coronary artery disease

Stable angina pectoris

Unstable angina

Non-ST elevation myocardial infarction.

ST elevation myocardial infarction.

This is defined as substernal discomfort precipitated by exertion, typically radiating to the shoulder, jaw, or inner aspect of the arm, and relieved by rest ornitroglycerinin less than 10 minutes

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A - Coronary artery diseaseCardiac EnzymeECG Chest pain Duration-venormalLess than 10 minAngina-veNo ST Changes> 10 minUnstable Angina+veST depression> 10 minNSTEMI+veST elevation> 10 minSTEMI

A - Coronary artery disease

What Do You Think

ATYPICAL PRESENTATIONOLD Age

DM

TreatmentAcute managements

MONA B (Morphine O2 Nitrates Aspirin Beta blocker )

Clopidogrel

Heparin

PCI or CABG

TreatmentRisk Factors Modification

Smoking

HTN

Hyperlipidemia

DM

Diet

B Aortic Dissection

Severe Tearing/ Stabbing pain

Sudden onset

Anterior radiating to the Back

Clinical Finding

Hypertensive

Pulse or BP asymmetry between limbs

Aortic regurgitation

Predisposing FactorsHTN

Connective tissue disease (Marfans)

Coartation of the Aorta

Trauma

Cocaine

Stanford ClassificationType AInvolve Ascending aorta

Type BInvolve Descending aorta

BA

DiagnosisCXR>8mm

DiagnosisCT or MRI

Diagnosis

TEE ( High Sensitivity and Specificity )

Aortic Angiography

TreatmentInitial therapy

IV B-Blocker

Control BP

TreatmentType ASurgical intervention

Type BControl BP by IV e.g. Labetalol, or Propranolol.Control Pain with morphine.

C - Pericarditis

Define as inflammation of pericardial sac

EtiologyIdiopathic

Infection

Acute MI

Uremia

Neoplasm (Hodgkin Lymphoma, breast and lung Ca)

Clinical FeaturesChest 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.

ExaminationPericardial Friction Rub

DiagnosisECG

Diffuse St elevation and PR depression

DiagnosisEchoPericardial effusion

ComplicationPericardial effusion

Cardiac Tamponade

Becks TriadHypotension - Muffled Heart sound - High JVP

TreatmentSelf limited resolved in 2-6 weeks.

NSAID.

If effusion small, repeat Echo in 1to 2 weeks.

Pericardiocentesis.

Respiratory A - PE

B Tension pneumothorax

Pulmonary Embolism Source of Emboli

A - Lower extremity DVT

B - Upper extremity (drug abusers)

Clinical FeaturesSOB

Pleuritic Chest pain

Cough

Hemoptysis

Tachypnea and Tachycardia

Modified Wells Criteria

DiagnosisABGRespiratory Alkalosis (due to hyperventilation).

Doppler for DVT.

Spiral CT.

V/Q Scan (ventilation perfusion lung).

TreatmentO2

Anticoagulation therapy

Heparin and Warfarin (target INR 2-3)

How to use Warfarin

Warfarin Tips

TreatmentThrombolytic !! (No evidence for improving mortality)

But !Can be considered :Pt with massive PE who are unstable (persistent hypotension )OrPt with evidence of Right heart failure

Tension Pneumothorax

Accumulation of the air within the pleural space

Clinical FeaturesSOB

Chest pain tightness

Hypotension

Distended neck veins

Trachea shifting

Decrease breathing sound on affected side

Hyperresonance on percussion

CausesTrauma

CPR

Mechanical Ventilation with associated barotrauma

Iatrogenic e.g. Central line insertion

DiagnosisDiagnosed Clinically (Hx and Examination)

CXR

TreatmentChest Decompression

Chest tube

Gastro IntestineA Gastro Esophageal Refluxes

B Esophageal Spasm

C Peptic Ulcers

Gastro Esophageal Refluxes

GERD very common.Its prevalence increase with age

Etiology

Multifactorial causes :-In appropriate relaxation of LES.Decrease motility.Hiatal hernia.Gastric outlet obstruction.

Clinical FeaturesHeartburn, retrosternal pain shortly after eating

Aggravated by lying down after meals

Cough

Sore throat

DiagnosisClinically by Hx

24h PH monitoring in the lower Esophagus (Gold Stander)

Endoscopy

Upper GI series barium study

ComplicationsErosive Esophagitis

Esophageal Ulcers

Barrett's Esophagus

Aspirational Pneumonia

TreatmentBehavior modification

H2 blockerPPIMetoclopramide

Surgery

Summary

ReferencesUptodate.comMedscape.orgStep-up medicineWashington

Thanks