1

Getting to the root of Chest PainDifferential Diagnosis

Cardiac & Non Cardiac

By: Ms. Shanta Peter

2

Chest Pain-- cardiac or Not• Treat patient as though he is critical --- until

proved otherwise History• Risk factors, H/O IHD, previous Rxs , Previous chest pain • Pain- Heart burn - burning sensation – chest pain with

pressure /tightness

Remember ---– ……………treat with cause… there are many causes

3

Accuracy of Chest Pain Diagnosis Using the History and Physical Examination

 

Determining whether pain is • Sub-sternal, • Provoked by exertion• Relieved by rest or nitroglycerin helps to clarify whether it is ……………………1. Typical anginal pain (has all 3characteristics) 2. Atypical anginal pain (has 2 characteristics3. Nonanginal pain (has 1 characteristic).

4

Common Causes of Chest Pain • Aortic

• Esophageal/GI        

• Lungs & Pleura

• Musculo-Skeletal

• Neurological        • Psychological/ others

•                          

Aortic dissection, Aortic aneurism

Esophagitis, Esop. Spasm , esophageal tearPancreatitis, Biliary /GB disease , GERD, Peptic

Ulcer

Bronchospasm, PE, Pneumonia ,TB, Trachitis, Pleuritis, PneumThorax ,

Malignancy , Asthma.

Ost. Arthritis, Rib#, I. Costal Muscle injury, Costochondritis, Cerv. Disc Disease

Prolapsed disc, Herpez Zoster, Thoracic Outlet Syndrome

Panic Attack/Anxiety Disorders , Cocaine abuse

5

Chest Pain That Can Kill ….

• Acute Coronary –

Syndrome• Pulmonary- Embolism• Aortic- Dissection• Esophageal Rupture• Pneumothorax• Pneumonia

6

Sudden & Instantaneous Chest Pain

Tension Pneumthorax • Spontaneous

• Open

Pulm. Embolism DVT, Obesity, Pregnancy, Prolonged

immobilization, CHF ….

7

Pneumothorax 

8

Pneumothorax Sharp C. Pain. Dyspnea ,absence of breath- sound in the affected side • Radionuclide studies – Gated pool • SPECT – Single proton emission computed Tomography • PET – Positron Emission Tomography Pulm. Embolism Sudden pleuretic substernal pain with dyspnea , T cardia , fever or cough , diaphoresis – mimic MI/angina • VQ Scan • D DIMER • Spiral CT-- best Diag – (Pneumonia )

9

Pneumonia • Infection of pulm. tissue – Interstitial spaces,

alveoli, bronchioles • Chest pain – pleuritic , come sin suddenly • Febrile – chills , cough with copious/blood

stained sputum • Rales--- rhonchi wheezes • Hypoxia

(Ca)

10

Sub sternal – epi-gastric Chest Pain intensified with swallowing

11Pan . C Cys.G U,DU

12

G IntestinalPancreatitis : Pain in the LUQ, substernal. Radiate to

back , difficulty in breathing, tachycardia, vomiting, worse in supine , better while leaning forward

• Cholecystitis : Pain in RUQ – precipitate by meal • Gastric Ulcer Pain Lt Epigastrium – radiation to back • Duodinal Ulcer Mid Epigastric pain – cramping- 2-4 hrs after meal (E rupture )

13

Esophageal Rupture Mallory–Weiss syndrome Sudden severe C. Pain – followed by vomiting, or UGI tract procedure 

CXR: ( early )shows mediastinal or free peritoneal airHours to days later: widening of mediastinum, pleural effusion

 

14

Coronary Arteries

15

16

H .Disease begins when cholesterol, fatty material & Ca deposit

in the arteries. Atherosclerosis

17

18

19

Cardiac Chest Pain

• Dissecting Aortic aneurisms

• Cardiac Tamponade * Heart Failure• Peri/endo/myocarditis • Cardiogenic shock• MVP /M.stenosis

Acute Coronary Syndromes

*Myocardial Ischemia *Stable Angina *Unstable Angina

*Myocardial Infarction

*Pericarditis

20

ANGINA PECTORIS . Myocardial ischemia Expected companion of IHD …….

21

Accuracy of Chest Pain Diagnosis Using the History and Physical Examination

 

Determining whether pain is • Sub-sternal, • Provoked by exertion• Relieved by rest or nitroglycerin helps to clarify whether it is ……………………1. Typical anginal pain (has all 3characteristics) 2. Atypical anginal pain (has 2 characteristics3. Non-anginal pain (has 1 characteristic).

22

Levine’s sign

23S Ang

24

25

Angina ..Myocardial ischemia

A. Stable Angina(Exertional Angina)Stable pattern of onset ……………… relieved by Rest/GTN

B. Unstable Angina(PreinfarctionAngina)unpredictable, NOT relieved by GTN C. Variant Angina ( Prinzmetal- vasospastic) , without relation to effort, Occur at REST- between midnight & early morning ST Elevation ---

26

D. Intractable Angina – Chronic, incapacitating, unresponsive to treatment E. Pre-infarction Angina( Last more than 15 mts) F. Post infarction Angina ( after MI ,residual ischemia)

27

PERICARDITIS 

28

Pericarditis

• Sharp Pre-cordial pain, deep and diffuse• Worse in supine position- relieved while

leaning fore ward• Aggravated during inspiration coughing • H/O viral infection , MI…….

29TAA

30

T. Aortic Dissection of Aneurism Blood violates aortic intimal and adventitial layersFalse lumen is createdDissection may extend proximally, distally, or in both directions

31

T.A Aneurism dissection • Constant and boring chest pain• Deep diffuse – in supine position • Cough, dyspnea, stridor • Aphonia ( loss of voice) --

32

H Attack signs in Women

1. Pain or discomfort in one or both arms, the back, neck, jaw or stomach.

2. Shortness of breath with or without chest discomfort.

3. breaking out in a cold sweat, nausea or lightheadedness.

4. As with men, women’s most common heart attack symptom is chest pain or Chest dis comfort, other common symptoms, particularly shortness of breath, nausea/vomiting and back or jaw pain.

33

Complications Cardiac arrest ----------------------

34

Possible Factors -6Hs & 5Tscardiac arrest  

• Hypovolemea • Hypoxia • Hypothermia• Hypoglycemia• Hypo- Hyperkalemia• Hydrogen ion ( Acidosis)• Toxins• Trauma• Thrombosis ( coronary- pulmonary)• Tension pneumothorax

35

21 yrs old young male – was lifting weights –in the GIM . He had sudden onset of sharp chest pain, and SOB … Brought him to ER …

HR 122. RR 34, BP 70/? Sat 88% Decreased breath sounds on left side of the chest .. ???????

36

• Mr. Mohd in CCU with Ext Ant MI, complicated with vent arrhythmia treatments are continuing. No more chest pain

• Today is the 4th day , he is febrile 38- 39C since 3rd day , ESR and WBC is high, He suddenly complaining of severe sharp precordial pain, cannot breath-in or cannot lie down. He is bending down his chest and crying

37

• Ms .A 61yrs,had severe Asthmatic attack ,as the O2 sat was 89% . Put on Mech Ventilator Mode : PEEP .

• 3rd day sedations stopped and started to wean her. Suddenly she screamed of severe chest pain and dyspnea

What will be the possible condition ?

38

• OPD – Endoscopy roomMs K had gastroscopy ? D.Ulcer , she is in the recovery room after the procedure. BP and other vital signs stable. She is coming out of the sedation . Suddenly she is complaining of pain holding her chest , breathless. ???????