IN THE NAME OF ALLAH THE MOST GRACIOUS,THE MOST MERCIFUL

DIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSISOFOF

CHEST PAINCHEST PAIN

DR.MUHAMMAD FAROOQUE

MB BS DTCD

Chest PainChest Pain

5 Million emergency department visits5 Million emergency department visits2 million hospitalizations annually with cost 2 million hospitalizations annually with cost

of more than $8 billionof more than $8 billionCardiac etiology found in less than one Cardiac etiology found in less than one

thirdthird2% of patients with acute MI are 2% of patients with acute MI are

unrecognized and discharged from the EDunrecognized and discharged from the ED

GoalsGoals

1.1. Rapid recognition of management of true Rapid recognition of management of true ACSACS

2.2. Recognition of other life-threatening causes Recognition of other life-threatening causes of chest painof chest pain

3.3. Minimize cost and hospitalization in patients Minimize cost and hospitalization in patients with chest pain of benign etiology.with chest pain of benign etiology.

Chest Pain DiagnosisChest Pain Diagnosis

Clinical diagnosisClinical diagnosisDiagnosis using computer algorithmsDiagnosis using computer algorithmsChest pain centersChest pain centers

CHEST PAIN (1429)CHEST PAIN (1429)

TOTAL PATIENTS=544TOTAL PATIENTS=544 IHD= 518IHD= 518CCF= 19CCF= 19MI MI DIAGNOSED ON ECGDIAGNOSED ON ECG =7 =7

COURTESY:HAMAD RASHID AL-MONAJAM

PAINPAINJUST A CURSEJUST A CURSE

ORORA MERCY OF GODA MERCY OF GOD

PAIN?PAIN? UNIVERSALLY UNDERSTOOD AS UNIVERSALLY UNDERSTOOD AS

“DISEASE SIGNAL”“DISEASE SIGNAL” MOST COMMON SYMPTOM THAT MOST COMMON SYMPTOM THAT

BRINGS A PATIENT TO A BRINGS A PATIENT TO A PHYSICIAN`S ATTENTION.PHYSICIAN`S ATTENTION.

AN UNPLEASANT SENSATION AN UNPLEASANT SENSATION LOCALIZED TO A PART OF THE LOCALIZED TO A PART OF THE BODYBODY

ITS BOTH SENSATION AND ITS BOTH SENSATION AND EMOTIONEMOTION

ITS BOTH ITS BOTH SENSATION SENSATION

AND AND EMOTIONEMOTION

ACCOMPANIED BY ANXIETYACCOMPANIED BY ANXIETYACCAMPANIED BY URGE TO ESCAPE ACCAMPANIED BY URGE TO ESCAPE

OR TERMINATE THE FEELINGOR TERMINATE THE FEELING

DUALITY OF PAIN

PAIN

PAINPAINHOW DESCRIBED?HOW DESCRIBED?

STABBINGSTABBINGBURNINGBURNINGTWISTINGTWISTINGTEARINGTEARINGSQUEEZINGSQUEEZINGTERRIFYINGTERRIFYINGNAUSEATINGNAUSEATINGSICKENINGSICKENING

PENETRATINGOR

TISSUE-DESTRUCTIVEPROCESS

BODILYOR

EMOTIONAL REACTION

ACUTE PAINACUTE PAIN

BEHAVIORAL AROUSALBEHAVIORAL AROUSAL STRESS RESPONSESTRESS RESPONSE

LOCAL MUSCLE CONTRACTIONLOCAL MUSCLE CONTRACTION

INC BPINC HRINC PUPIL DIAMETERINC PLASMA CORTISOL LEVEL

ASSOCIATED ASSOCIATED WITHWITH

PAIN IN THE CHESTPAIN IN THE CHESTBUTBUT

ORIGIN??ORIGIN??

HEARTHEART LUNGSLUNGS OESOPHAGUSOESOPHAGUS MUSCULOSKELETAL STRUCTURES OF MUSCULOSKELETAL STRUCTURES OF

THORAX NECK,OR SHOULDERTHORAX NECK,OR SHOULDER ABDOMENABDOMEN ANXIETY MANIFESTATIONANXIETY MANIFESTATION

CHEST PAIN CLASSIFICATIONCHEST PAIN CLASSIFICATIONFROM CLINICAL VIEW POINT:FROM CLINICAL VIEW POINT:

RECURRENTOFTEN PAROXYSMALMILD OR MODERATE

ANGINAMUSCULOSKELETAL PAINS

SEVERE PROLONGED

ASSOCIATED WITHCLINICAL EVIDENCE OF ACUTE

SERIOUS ILLNESS

1 2

WHAT LIES IN THE CHEST?WHAT LIES IN THE CHEST?

SKINSKINMUSCLESMUSCLESBONESBONESJOINTSJOINTSHEART AND VESSELSHEART AND VESSELSLUNGS AND AIRWAYSLUNGS AND AIRWAYSOESOPHAGUSOESOPHAGUSNERVESNERVES

CHEST PAIN ASSESSMENTCHEST PAIN ASSESSMENT

HISTORY HISTORY EXAMINATIONEXAMINATIONECGECGCARDIAC ENZYMESCARDIAC ENZYMESCXRCXROTHERSOTHERS

INITIAL APPROACHINITIAL APPROACH

Assume the worst!Assume the worst!100% Oxygen100% Oxygen IV accessIV accessMonitoringMonitoringECG quicklyECG quicklyDone in tandem with history takingDone in tandem with history taking

TIME IS VITALTIME IS VITAL

CHEST PAINCHEST PAIN

COMMON PRESENTATION TO A&ECOMMON PRESENTATION TO A&E

TRIVIAL TO LIFE-THREATENING CAUSESTRIVIAL TO LIFE-THREATENING CAUSES

KEY TO DIAGNOSIS IS HISTORYKEY TO DIAGNOSIS IS HISTORY

NEGATIVE BASELINE INVESTIGATIONS DO NEGATIVE BASELINE INVESTIGATIONS DO NOT RULE OUT SERIOUS CONDITIONS NOT RULE OUT SERIOUS CONDITIONS

HEART ATTACKHEART ATTACK

ANSWER IS ANSWER IS NONO…………

RELAXRELAX IS IT ENOUGH TO RULE OUT HEART IS IT ENOUGH TO RULE OUT HEART

ATTACK?ATTACK?

LIFE THREATENING CHEST PAIN INTHE EMERGENCY DEPARTMENT

Life Threatening Chest Pain inthe Emergency Department

• Myocardial Infarction • USA• Aortic Dissection• Tension Pneumothorax• Pulmonary Embolus• Ruptured Esophagus/Perforated Ulcer

COMMON CAUSES OF CHEST PAINCOMMON CAUSES OF CHEST PAIN ANXIETYANXIETY

CARDIACCARDIAC

AORTICAORTIC

OESOPHAGEALOESOPHAGEAL

LUNGS/PLEURALUNGS/PLEURA

MUSCULOSKELETALMUSCULOSKELETAL

NEUROLOGICALNEUROLOGICAL

MYOCARDIAL ISCHEMIA(ANGINA)MIMYOCARDITISPERICARDITISMVP

AORTIC DISSECTIONAORTIC ANEURYSM

ESOPHAGITISESOPH SPASMMW SYNDROME

BRONCHOSPASM:::::PE:::PIPNEUMONIA:::::TB:::::::CTDsTRACHEITIS PLEURITISPNEUMOTHORAX MALIGNANCY

OARIB #I/C MUSCLE INJURYTEITZE`S SYNDBORNHOLM`S DISEASE

PROLAPSED I/V DISCHERPES ZOSTERTHORACIC OUTLET SYNDROME

CARDIACCARDIACOROR

NON-CARDIAC PAIN?NON-CARDIAC PAIN?

Chest Pain: HistoryChest Pain: History

P: pattern (temporal sequence)P: pattern (temporal sequence) A: associated features A: associated features

SOB, N/V, diaphoresisSOB, N/V, diaphoresis fever, cough, chillsfever, cough, chills abdominal painabdominal pain

I: initiation and improvementI: initiation and improvement N: nature (quality)N: nature (quality)

CHEST PAIN ASSESSMENTCHEST PAIN ASSESSMENT

History History VITALLY IMPORTANTVITALLY IMPORTANT

PAIN PAIN NATURENATURE SITESITE SEVERITYSEVERITY RADIATIONRADIATION ONSETONSET EXAC/RELIEVING FACTORSEXAC/RELIEVING FACTORS ASSOCIATED FEATURESASSOCIATED FEATURES DURATIONDURATION PREVIOUS SIMILAR PAINSPREVIOUS SIMILAR PAINS

Chest Pain: Physical ExamChest Pain: Physical Exam Vital signs and general appearanceVital signs and general appearance Carotids and JVPCarotids and JVP LungsLungs Cardiac examCardiac exam Thoracic cageThoracic cage Abdominal examAbdominal exam Periphery (pulses)Periphery (pulses) SkinSkin

CHEST PAIN ASSESSMENTCHEST PAIN ASSESSMENT

ExaminationExaminationGeneral ExaminationGeneral Examination

((sweaty clammy pale cyanosed, anaemic etc pulse BP)sweaty clammy pale cyanosed, anaemic etc pulse BP)

Cardiovascular /Respiratory examinationCardiovascular /Respiratory examination

? Failure ( crackles ,oedema, raised JVP)? Failure ( crackles ,oedema, raised JVP)

Heart SoundsHeart Sounds - - rate , nature ,?quiet ? added heart sounds, ?rate , nature ,?quiet ? added heart sounds, ?

murmurs murmurs

Chest Pain: LocationChest Pain: LocationMyocardial Myocardial ischemiaischemiaPericarditisPericarditisPleurisy, Sub-diap Pleurisy, Sub-diap abscessabscess

Myocardial ischemiaMyocardial ischemiaCervical spineCervical spineThoracic outletThoracic outlet

Pulmonary embolismPulmonary embolismPneumoniaPneumoniaSplenic infarctionSplenic infarctionSubdiap. abscessSubdiap. abscess

Myocardial ischemiaMyocardial ischemiaPericarditisPericarditisAortic dissectionAortic dissectionMediastinal lesionMediastinal lesionPulmonary embolismPulmonary embolismEsophageal spasmEsophageal spasm

CholecystitisCholecystitisHepatic distensionHepatic distensionPeptic diseasePeptic diseasePancreatitisPancreatitisMyocardial ischemiaMyocardial ischemia

LOCATIONLOCATION CENTRAL,CENTRAL,

DIFFUSEDIFFUSE

PERIPHERALPERIPHERAL

LOCALIZEDLOCALIZED

RADIATIONRADIATION JAW/NECK/SHOULDER/ JAW/NECK/SHOULDER/ OCCASIONALLY BACKOCCASIONALLY BACK

OTHER OROTHER OR

NO RADIATIONNO RADIATION

CHARACTERCHARACTER TIGHTTIGHT

SQUEEZINGSQUEEZING

CHOKINGCHOKING

SHARPSHARP

STABBINGSTABBING

CATCHINGCATCHING

PRECIPITATIONPRECIPITATION EXERTIONEXERTION

EMOTIONEMOTION

SPONTANEOUSSPONTANEOUS

NOT RELATED TO EXERTIONNOT RELATED TO EXERTION

PROVOKED BY POSTURE,PROVOKED BY POSTURE,

RESPIRATION OR PALPATIONRESPIRATION OR PALPATION

RELIEVINGRELIEVING

FACTORSFACTORS

RESTREST

NITRATESNITRATES

NOT RELIEVED BY RESTNOT RELIEVED BY REST

SLOW OR NO RESPONSE BY SLOW OR NO RESPONSE BY NITRATESNITRATES

ASSOCIATED ASSOCIATED FEATURESFEATURES

BREATHLESSNESSBREATHLESSNESS RESP; GIT,LOCOMOTOR, ORRESP; GIT,LOCOMOTOR, OR

PSYCHOLOGICALPSYCHOLOGICAL

ISCHEMIC CARDIAC PAIN NON-CARDIAC PAINV/S

MYOCARDIAL ISCHEMIA(ANGINA)MIMYOCARDITISPERICARDITISMVP

AORTIC DISSECTIONAORTIC ANEURYSM

ESOPHAGITISESOPH SPASMMW SYNDROME

BRONCHOSPASM:::::PE:::PIPNEUMONIA:::::TB:::::::CTDsTRACHEITIS PLEURITISPNEUMOTHORAXMALIGNANCY

OARIB #I/C MUSCLE INJURYTEITZE`S SYNDBORNHOLM`S DISEASE

PROLAPSED I/V DISCHERPES ZOSTERTHORACIC OUTLET SYNDROME

ANXIETYANXIETY

ANXIOUS THOUGHTSANXIOUS THOUGHTS AVOIDANCE BEHAVIOURAVOIDANCE BEHAVIOUR SOMATIC SYMPTOMSSOMATIC SYMPTOMS STRESSSTRESS H/O UNPLEASANT INCIDENCEH/O UNPLEASANT INCIDENCE HYPERVENTILATIONHYPERVENTILATION BREATHLESSNESSBREATHLESSNESS PALPITATIONPALPITATION CHEST PAINCHEST PAIN HEADACHEHEADACHE TINGLING SENSATIONTINGLING SENSATION NAUSEANAUSEA LBMLBM URINARY FREQUENCYURINARY FREQUENCY

ISCHEMIC CARDIAC PAINISCHEMIC CARDIAC PAINORIGIN?ORIGIN?

SITE OF ORIGIN OF PAIN CENTRAL

ISCHEMIC CARDIAC PAINISCHEMIC CARDIAC PAIN

MAY RADIATE TO NECKMAY RADIATE TO NECK JAWJAW UPPER OR LOWER ARMUPPER OR LOWER ARM BACKBACK

RADIATION

ISCHEMIC CARDIAC PAINISCHEMIC CARDIAC PAIN

PLEURAL PROBLEMSPLEURAL PROBLEMS LUNG PROBLEMSLUNG PROBLEMS MUSCULOSKELETAL MUSCULOSKELETAL ANXIETYANXIETY

PAIN RADIATION OTHER POSSIBILITIES

ISCHEMIC CARDIAC ISCHEMIC CARDIAC PAINPAINOROR

DISCOMFORTDISCOMFORT

TYPICALLY DULLTYPICALLY DULL CONSTRICTINGCONSTRICTING CHOKINGCHOKING HEAVYHEAVY USUALLY DESCRIBED BY USUALLY DESCRIBED BY

PATIENTS AS---SQUEEZING— PATIENTS AS---SQUEEZING— CRUSHING---- CRUSHING---- BURNING------- ACHING BURNING------- ACHING BUT NOT SHARP BUT NOT SHARP BUT NOT STABBING BUT NOT STABBING BUT NOT BUT NOT PRICKING BUT NOT PRICKING BUT NOT KNIFE-LIKEKNIFE-LIKE

SENSATION CAN BE DESCRIBED SENSATION CAN BE DESCRIBED AS BREATHLESSNESSAS BREATHLESSNESS

CHARACTER OF PAIN

ISCHEMIC CARDIAC ISCHEMIC CARDIAC PAINPAINOROR

DISCOMFORTDISCOMFORT

EXERTIONEXERTION EMOTIONSEMOTIONS LARGE MEALSLARGE MEALS COLD WINDCOLD WIND UA AT RESTUA AT REST LYING DOWN LYING DOWN

(DECUBITUS ANGINA)(DECUBITUS ANGINA)

PROVOCATION

PLEURAL OR PERICARDIAL PAINPLEURAL OR PERICARDIAL PAIN

MUSCULOSKELETAL PAINMUSCULOSKELETAL PAIN

PROVOCATION

CHEST PAINOTHER THAN

CARDIAC CAUSES

SHARP OR CATCHING SENSATIONEXACERBATED BY COUGHMOVEMENT

PAIN ASS WITH SPECIFIC MOVEMENT

ISCHEMIC CARDIAC ISCHEMIC CARDIAC PAINPAINOROR

DISCOMFORTDISCOMFORT

GRADUAL ONSET GRADUAL ONSET OVER MINUTES OVER MINUTES DURING EXERTIONDURING EXERTION

PATTERN OF ONSET

MUSCULAR PAINOCCURS AFTER

EXERTION

SUDDENSUDDEN INSTANTANEOUSINSTANTANEOUS

CHEST PAINPATTERN OF ONSET

DISSECTING AORTIC ANEURYSM

TENSION

PNEUMOTHORAX

MASSIVE P E

ISCHEMIC CARDIAC ISCHEMIC CARDIAC PAINPAINOROR

DISCOMFORTDISCOMFORT

SWEATINGSWEATING NAUSEANAUSEA VOMITINGVOMITING BREATHLESSNESSBREATHLESSNESS COUGHCOUGH WHEEZEWHEEZE

ASSOCIATED FEATURES

MASSIVE PULM EMBOLISM AND

AORTIC DISSECTION ALSO ACCOMPANIED BY

AUTONOMIC DISTURBANCES

CLASSIC GI SYMPTOMSOESOPHAGEAL REFLUXOESOPHAGITISPUDBILIARY DISEASE

AUTONOMICDISTURBANCES

MIMI

CHEST PAIN CHEST PAIN ANXIETYANXIETYFEAR OF IMPENDING DEATHFEAR OF IMPENDING DEATHBREATHLESSNESSBREATHLESSNESSVOMITINGVOMITINGCOLLAPSECOLLAPSESYNCOPESYNCOPESILENTSILENT

SEVERELASTS LONGER THAN ANGINAL PAINTIGHTNESSHEAVINESSCONSTRICTION IN NECK

SYMPTOMS

MYOCARDIAL INFARCTIONMYOCARDIAL INFARCTIONSIGNSSIGNS

SIGNS OF SYMPATHETIC ACTIVATIONSIGNS OF SYMPATHETIC ACTIVATIONPALLORPALLOR

SWEATINGSWEATING

TACHYCARDIATACHYCARDIA

SIGNS OF VAGAL STIMULATIONSIGNS OF VAGAL STIMULATIONVOMITINGVOMITING

BRADYCARDIABRADYCARDIA

MYOCARDIAL INFARCTIONMYOCARDIAL INFARCTIONSIGNSSIGNS

SIGNS OF IMPAIRED MYOCARDIAL FUNCTIONSIGNS OF IMPAIRED MYOCARDIAL FUNCTIONHYPOTENSIONHYPOTENSIONOLIGURIAOLIGURIACOLD PERIPHERIESCOLD PERIPHERIESNARROW PULSE PRESSURENARROW PULSE PRESSURERAISED JVPRAISED JVPS3S3QUIET S1QUIET S1DIFFUSE APICAL IMPULSEDIFFUSE APICAL IMPULSELUNG CREPTSLUNG CREPTS SIGNS OF TISSUE DAMAGE-------FEVERSIGNS OF TISSUE DAMAGE-------FEVER SIGNS OF COMPLICATIONS----MR,,,,,,,PERICARDITISSIGNS OF COMPLICATIONS----MR,,,,,,,PERICARDITIS

MIMIINVESTIGATIONSINVESTIGATIONS

ECG HELPFUL ECG HELPFUL DIFFICULT INTERPRETATION IN PREVIOUS MI DIFFICULT INTERPRETATION IN PREVIOUS MI

PATIENTS AND OLD BBBPATIENTS AND OLD BBB RARELY NORMAL ECGRARELY NORMAL ECG IN 1/3 OF MI CASES INITIAL CHANGES MAY NOT BE IN 1/3 OF MI CASES INITIAL CHANGES MAY NOT BE

DIAGNOSTICDIAGNOSTIC EARLIEST CHANGE ST ELEVATIONEARLIEST CHANGE ST ELEVATION LATER R WAVE SIZE DIMINUTIONLATER R WAVE SIZE DIMINUTION Q WAVES IN TRANSMURAL MIQ WAVES IN TRANSMURAL MI T WAVE INVERSIONT WAVE INVERSION CHEK AREA OF INFARCTIONCHEK AREA OF INFARCTION

MIMIINVESTIGATIONSINVESTIGATIONS

PLASMA BIOCHEMICAL MARKERS PLASMA BIOCHEMICAL MARKERSCK-MBCK-MBTROPONIN T & ITROPONIN T & I

MIMIINVESTIGATIONSINVESTIGATIONS

FBC FBC LEUCOCYTOSIS ON 1LEUCOCYTOSIS ON 1STST. DAY. DAY

ESRESR RAISED RAISED

CRPCRP ELEVATED ELEVATED

CXR CXR PUMONARY EDEMA,,,CARDIOMEGALYPUMONARY EDEMA,,,CARDIOMEGALY ECHOECHO

Clinical Spectrum of Acute Coronary Clinical Spectrum of Acute Coronary SyndromesSyndromes

Evidence of necrosis None Positive Positive

ECG earlyST-segment depression

and/orT-wave inversion

ST-segment elevation

ECG late No Q No Q Q develops

Stable Stable anginaangina

UnstableUnstableanginaangina

Non-STE MINon-STE MI STE MISTE MI

Antman EM. In: Braunwald E, ed. Heart Disease: A Textbook in Cardiovascular Medicine, 5th ed. Philadelphia, Pa: WB Saunders; 1997.

ST-segment depression

and/or T-wave inversion

Acute Coronary SyndromesAcute Coronary Syndromes

Similar pathophysiologySimilar pathophysiology

Similar presentation and Similar presentation and early management rulesearly management rules

STEMI requires evaluation STEMI requires evaluation for acute reperfusion for acute reperfusion interventionintervention

Unstable AnginaUnstable Angina

Non-ST-Segment Non-ST-Segment Elevation MI Elevation MI (NSTEMI)(NSTEMI)

ST-Segment ST-Segment Elevation MI Elevation MI (STEMI)(STEMI)

Diagnosis of Acute MIDiagnosis of Acute MI STEMI / NSTEMI STEMI / NSTEMI

At least 2 of the At least 2 of the followingfollowing

Ischemic symptomsIschemic symptomsDiagnostic ECG Diagnostic ECG

changeschangesSerum cardiac Serum cardiac

marker elevationsmarker elevations

Diagnosis of Unstable AnginaDiagnosis of Unstable Angina

Patients with typical angina - An episode of angina Patients with typical angina - An episode of angina Increased in severity or durationIncreased in severity or durationHas onset at rest or at a low level of exertionHas onset at rest or at a low level of exertionUnrelieved by the amount of nitroglycerin or rest that Unrelieved by the amount of nitroglycerin or rest that

had previously relieved the painhad previously relieved the pain

Patients not known to have typical anginaPatients not known to have typical anginaFirst episode with usual activity or at rest within the First episode with usual activity or at rest within the

previous two weeksprevious two weeksProlonged pain at restProlonged pain at rest

ACS Clinical PresentationACS Clinical Presentation Substernal chest pain or pressure (>20-30 Substernal chest pain or pressure (>20-30

min)min) Localization or radiation to arms, back, Localization or radiation to arms, back,

throat, jawthroat, jaw Accompanying featuresAccompanying features

DyspneaDyspneaNausea/vomitingNausea/vomitingDiaphoresisDiaphoresisWeaknessWeakness

Atypical: syncope, CVA, DKAAtypical: syncope, CVA, DKA

Unstable Unstable AnginaAngina STEMISTEMI NSTEMINSTEMI

Non occlusive thrombus

Non specific ECG

Normal cardiac enzymes

Occluding thrombus sufficient to cause tissue damage & mild myocardial necrosis

ST depression +/- T wave inversion on ECG

Elevated cardiac enzymes

Complete thrombus occlusion

ST elevations on ECG or new LBBB

Elevated cardiac enzymes

More severe symptoms

ECG assessmentECG assessment

ST Elevation or new LBBBST Elevation or new LBBBSTEMISTEMI

Non-specific ECGNon-specific ECGUnstable AnginaUnstable Angina

ST Depression or dynamicST Depression or dynamicT wave inversionsT wave inversions

NSTEMINSTEMI

Normal or non-diagnostic EKGNormal or non-diagnostic EKG

ST Depression or Dynamic T wave ST Depression or Dynamic T wave InversionsInversions

ST-Segment Elevation MIST-Segment Elevation MI

New LBBBNew LBBB

QRS > 0.12 secL Axis deviationProminent R wave V1-V3Prominent S wave 1, aVL, V5-V6 with t-wave inversion

Cardiac markersCardiac markers Troponin ( T, I)Troponin ( T, I)

Very specific and more Very specific and more sensitive than CKsensitive than CK

Rises 4-8 hours after Rises 4-8 hours after injuryinjury

May remain elevated May remain elevated for up to two weeksfor up to two weeks

Can provide Can provide prognostic informationprognostic information

Troponin T may be Troponin T may be elevated with renal dz, elevated with renal dz, poly/dermatomyositispoly/dermatomyositis

CK-MB isoenzymeCK-MB isoenzyme

Rises 4-6 hours after Rises 4-6 hours after injury and peaks at 24 injury and peaks at 24 hourshours

Remains elevated 36-48 Remains elevated 36-48 hourshours

Positive if CK/MB > 5% Positive if CK/MB > 5% of total CK and 2 times of total CK and 2 times normalnormal

Elevation can be Elevation can be predictive of mortalitypredictive of mortality

False positives with False positives with exercise, trauma, muscle exercise, trauma, muscle dz, DM, PEdz, DM, PE

AORTIC DISSECTIONAORTIC DISSECTION

A BREACH IN INTEGRITY OF AORTIC A BREACH IN INTEGRITY OF AORTIC WALLWALL

ARTERIAL BLOOD BURSTS INTO ARTERIAL BLOOD BURSTS INTO MEDIA OF AORTAMEDIA OF AORTA

MEDIA SPLITS IN TWO LAYERS.MEDIA SPLITS IN TWO LAYERS.FALSE LUMEN ALONGSIDE A TRUE FALSE LUMEN ALONGSIDE A TRUE

LUMEN.LUMEN.DOUBLE-BARRELLED OR BILUMINAL DOUBLE-BARRELLED OR BILUMINAL

AORTA. AORTA.

AORTIC DISSECTIONAORTIC DISSECTIONPREDISPOSING FACTORSPREDISPOSING FACTORS

HTNHTN AORTIC ATHEROSCLEROSISAORTIC ATHEROSCLEROSIS NON-SPECIFIC AORTIC ANEURYSMNON-SPECIFIC AORTIC ANEURYSM AORTIC COARCTATIONAORTIC COARCTATION COLLAGEN DISORDERS MARFANS SYND,,,E D COLLAGEN DISORDERS MARFANS SYND,,,E D

SYNDROMESYNDROME FIBROMUSCULAR DYSPLASIAFIBROMUSCULAR DYSPLASIA PREVIOUS AORTIC SURGERY CABG AV PREVIOUS AORTIC SURGERY CABG AV

REPLACEMENT REPLACEMENT PREGNANCY(3PREGNANCY(3RDRD, TRIMESTER), TRIMESTER) TRAUMATRAUMA IATROGENICIATROGENIC

AORTIC DISSECTIONAORTIC DISSECTIONCLINICAL FEATURESCLINICAL FEATURES

TEARING PAINTEARING PAIN ABRUPT ONSTABRUPT ONST COLLAPSECOLLAPSE MARFAN`S SYNDROMEMARFAN`S SYNDROME PT APPEARS TO BE IN SHOCKPT APPEARS TO BE IN SHOCK BP---NORMAL OR RAISEDBP---NORMAL OR RAISED AC AR MAY DEVELOPAC AR MAY DEVELOP ASYMMETRY OF PULSESASYMMETRY OF PULSES MIMI PARAPLEGIA(SPINAL)PARAPLEGIA(SPINAL) ACUTE ACUTE

ABDOMEN(MESENTERIC ABDOMEN(MESENTERIC CAELIAC)CAELIAC)

RENAL FAILURERENAL FAILURE ACUTE LIMB ISCHEMIA(LEGS)ACUTE LIMB ISCHEMIA(LEGS)

TENSION PNEUMOTHORAXTENSION PNEUMOTHORAX

PNEUMOTHORAXPNEUMOTHORAX

PRESENCE OF AIR IN PLEURAL SPACEPRESENCE OF AIR IN PLEURAL SPACESPONTANEOUSSPONTANEOUS

PRIMARYPRIMARYSECONDARYSECONDARY

TRAUMATICTRAUMATICIATROGENICIATROGENIC

NON-IATROGENICNON-IATROGENIC

PNEUMOTHORAXPNEUMOTHORAXCLINICAL FEATURESCLINICAL FEATURES

SUDDEN-ONSET UNILAT. CHEST PAINSUDDEN-ONSET UNILAT. CHEST PAIN BREATHLESSNESSBREATHLESSNESS ASYMPTOMATIC (NOT TENSION PNEUMOTHORAX)ASYMPTOMATIC (NOT TENSION PNEUMOTHORAX) DEC OR ABSENT BREATH SOUNDS DEC OR ABSENT BREATH SOUNDS (IF PNEUMOTHORAX (IF PNEUMOTHORAX

MORE THAN15%).MORE THAN15%).

RESONANT ON PERCUSSIONRESONANT ON PERCUSSION MEDIASTINAL DISPLACEMENT TO OPPOSITE SIDEMEDIASTINAL DISPLACEMENT TO OPPOSITE SIDE TACHYCARDIATACHYCARDIA HYPOTENSIONHYPOTENSION CYANOSISCYANOSIS TRACHEAL DISPLACEMENTTRACHEAL DISPLACEMENT

TENSION PNEUMOTHORAXTENSION PNEUMOTHORAXDIAGNOSISDIAGNOSIS

CLINICALCLINICALCXRCXR

PULMONARY EMBOLISMPULMONARY EMBOLISM

RISK FACTORS FOR THROMBOEMBOLISMRISK FACTORS FOR THROMBOEMBOLISM CLINICAL FEATURES DEPEND ON SIZE CLINICAL FEATURES DEPEND ON SIZE FAINTNESS OR COLLAPSEFAINTNESS OR COLLAPSE CENTRAL CHEST PAINCENTRAL CHEST PAIN APPREHENSIONAPPREHENSION SEVERE DYSPNOEASEVERE DYSPNOEA PLEURITIC PAINPLEURITIC PAIN HAEMOPTYSISHAEMOPTYSIS

PULMONARY EMBOLISMPULMONARY EMBOLISMSIGNSSIGNS

MAJOR CIRCULATORY COLLAPSEMAJOR CIRCULATORY COLLAPSETACHYCARDIATACHYCARDIAHYPOTENSIONHYPOTENSIONINC JVPINC JVPRT.VENTRICULAR GALLOP RHYTHMRT.VENTRICULAR GALLOP RHYTHMSPLIT P2SPLIT P2SEVERE CYANOSISSEVERE CYANOSISDEC URINARY OUTPUT.DEC URINARY OUTPUT.

PULMONARY EMBOLISMPULMONARY EMBOLISMINVESTIGATIONSINVESTIGATIONS

CXRCXRUSUALLY NORMALUSUALLY NORMALPULM;OPACITIESPULM;OPACITIESWEDGE-SHAPED OPACITYWEDGE-SHAPED OPACITYHORIZONTAL LINEAR OPACITIESHORIZONTAL LINEAR OPACITIESPLEURL EFFUSIONPLEURL EFFUSIONOLIGAEMIC LUNG FIELDSOLIGAEMIC LUNG FIELDSENLARGED PULMONARY ARTERYENLARGED PULMONARY ARTERYELEVATED DIAPHRAGM ELEVATED DIAPHRAGM

PULMONARY EMBOLISMPULMONARY EMBOLISMINVESTIGATIONSINVESTIGATIONS

ECGECGS1S1Q3Q3T3T3RBBBRBBBSINUS TACHYSINUS TACHYRV HYPERTROPHYRV HYPERTROPHY

PULMONARY EMBOLISMPULMONARY EMBOLISMINVESTIGATIONSINVESTIGATIONS

ABGs ABGsMAY BE NORMALMAY BE NORMAL

OROR

DEC;PaO2DEC;PaO2DEC;PaCO2DEC;PaCO2METABOLIC ACIDOSISMETABOLIC ACIDOSIS

PULM; EMBOLISMPULM; EMBOLISMINVESTIGATIONSINVESTIGATIONS

D-DIMERD-DIMERVENTILATION-PERFUSION SCANNINGVENTILATION-PERFUSION SCANNINGCT PULMONARY ANGIOGRAPHYCT PULMONARY ANGIOGRAPHYMRIMRICOLLOR DOPPLERCOLLOR DOPPLERECHOECHO

PLEURISYPLEURISY

ANY DISEASE PROCESS INVOLVING ANY DISEASE PROCESS INVOLVING PLEURA AND CAUSING PLEURITIC PLEURA AND CAUSING PLEURITIC PAINPAIN

COMMON FEATURE OF PULMONARY COMMON FEATURE OF PULMONARY INFECTION AND INFARCTIONINFECTION AND INFARCTION

MAY OCCUR IN MALIGNANCYMAY OCCUR IN MALIGNANCY

PLEURISYPLEURISY

PLEURAL PAINPLEURAL PAIN RIB MOVEMENT RIB MOVEMENT

RESTRICTEDRESTRICTED PLEURAL RUBPLEURAL RUB H/O RESP ILLNESSH/O RESP ILLNESS CXRCXR

TBTB

CONNECTIVE TISSUE DISORDERS CAUSING CONNECTIVE TISSUE DISORDERS CAUSING CHEST PAINCHEST PAIN

RHEUMATOID ARTHRITISRHEUMATOID ARTHRITISSLESLESSSSDMSDMSPMSPMSRHEUMATIC FEVERRHEUMATIC FEVER

CHEST MALIGNANCIESCHEST MALIGNANCIES

RUPTURED OESOPHAGUSRUPTURED OESOPHAGUSCAUSESCAUSES

MOST COMMON IATROGENIC (ENDOSCOPIC MOST COMMON IATROGENIC (ENDOSCOPIC PERFORATION)PERFORATION)

MALINANCYMALINANCY CORROSIVE STRICTURES PERFORATIONCORROSIVE STRICTURES PERFORATION POST RADIOTHERY STRICTURESPOST RADIOTHERY STRICTURES PERFORATED PEPTIC ULCERPERFORATED PEPTIC ULCER SPONTANEOUS OESOPHAGEAL SPONTANEOUS OESOPHAGEAL

PERFORATION (BOERHAAVE SYNDROME)PERFORATION (BOERHAAVE SYNDROME)

RUPTURED OESOPHAGUSRUPTURED OESOPHAGUSCLINICAL FEATURESCLINICAL FEATURES

SEVERE CHEST PAINSEVERE CHEST PAINSHOCKSHOCKSUB-CUTANEOUS EMPHYSEMASUB-CUTANEOUS EMPHYSEMAPLEURAL EFFUSIONPLEURAL EFFUSIONPNEUMOTHORAXPNEUMOTHORAXPNEUMOMEDIASTINUMPNEUMOMEDIASTINUM

OESOPHAGEAL PAINOESOPHAGEAL PAIN

CAN MIMIC ANGINAL PAINCAN MIMIC ANGINAL PAINMAY GET PRECIPITATED BY MAY GET PRECIPITATED BY

EXERCISEEXERCISEMAY BE RELIEVED BY NITRATESMAY BE RELIEVED BY NITRATESRELATION WITH SUPINE RELATION WITH SUPINE

POSITION,EATING,DRINKINGPOSITION,EATING,DRINKING H/O REFLUXH/O REFLUXCAN RADIATE TO BACKCAN RADIATE TO BACK

MYOCARDITISMYOCARDITISPERICARDITISPERICARDITIS

PAINPAIN ---- ----RETROSTERNAL OR IN THE SHOULDERRETROSTERNAL OR IN THE SHOULDER

INTENSITY--- INTENSITY--- VARIESVARIES IN WITH MOVEMENT AND IN WITH MOVEMENT AND PHASE OF RESPIRATIONPHASE OF RESPIRATION

SHARPSHARP --- ---PAIN MAY CATCH THE PATIENT DURING PAIN MAY CATCH THE PATIENT DURING COUGHING OR INSPIRATIONCOUGHING OR INSPIRATION

H/O PRODROMALH/O PRODROMAL VIRAL ILLNESSVIRAL ILLNESS DYSPNEADYSPNEA PERICARDIAL FRICTION RUBPERICARDIAL FRICTION RUB FEVERFEVER LEUCOCYTOSISLEUCOCYTOSIS

ACUTE MYOCARDITISACUTE MYOCARDITIS

INFECTIOUSINFECTIOUS

TOXIN/ DRUG INDUCEDTOXIN/ DRUG INDUCED

IMMUNOLOGIC CAUSESIMMUNOLOGIC CAUSES

VIRALBACTRICKETTSIALSPIROCHETALFUNGALPARASITIC

INFECTIOUS ACUTE MYOCARDITISINFECTIOUS ACUTE MYOCARDITIS

OFTEN FOLLOWS URTIOFTEN FOLLOWS URTI CHEST PAINCHEST PAIN S/O HEART FAILURES/O HEART FAILURE ECG SHOW ECG SHOW

NON-SPECIFIC NON-SPECIFIC ST-T CHANGES ST-T CHANGES CONDUCTION CONDUCTION DISTURBANCES DISTURBANCES VENTRICULAR VENTRICULAR ECTOPYECTOPY

CXR CARDIOMEGALYCXR CARDIOMEGALY

PERICARDITISPERICARDITIS INFLAMMATORY INFLAMMATORY

VIRAL VIRAL TUBERCULAR TUBERCULAR BORRELIA BURGDORFERI(LYME DISEASE)BORRELIA BURGDORFERI(LYME DISEASE)

UREMIC PERICARDITISUREMIC PERICARDITIS NEOPLASTICNEOPLASTIC POST MI OR POST CARDIOTOMY DRESSLER`S POST MI OR POST CARDIOTOMY DRESSLER`S

SYNDROMESYNDROME RADIATIONRADIATION SLESLE RARA DRUG-INDUCEDDRUG-INDUCED MYXEDEMAMYXEDEMA

PERICARDITISPERICARDITISSYMPTOMSSYMPTOMS

PAINPAIN ---- ----RETROSTERNAL OR IN THE SHOULDERRETROSTERNAL OR IN THE SHOULDER

INTENSITY--- INTENSITY--- VARIESVARIES IN WITH MOVEMENT AND IN WITH MOVEMENT AND PHASE OF RESPIRATIONPHASE OF RESPIRATION

SHARPSHARP --- ---PAIN MAY CATCH THE PATIENT DURING PAIN MAY CATCH THE PATIENT DURING COUGHING OR INSPIRATIONCOUGHING OR INSPIRATION

H/O PRODROMALH/O PRODROMAL VIRAL ILLNESSVIRAL ILLNESS DYSPNEADYSPNEA PERICARDIAL FRICTION RUBPERICARDIAL FRICTION RUB FEVERFEVER LEUCOCYTOSISLEUCOCYTOSIS

PERICARDITISPERICARDITIS

ECG

PERICARDITISPERICARDITIS

CXR IN CXR IN PERICARDITISPERICARDITIS

SHOWS FLUID SHOWS FLUID COLLECTIONCOLLECTION

MAY BE DRYMAY BE DRY ECHO ADVISEDECHO ADVISED

MITRAL VALVE PROLAPSEMITRAL VALVE PROLAPSE

MITRAL VALVE PROLAPSEMITRAL VALVE PROLAPSE SHARP LEFT SIDED CHEST PAINSHARP LEFT SIDED CHEST PAIN DYSPNEADYSPNEA FATIGUEFATIGUE PALPITATIONPALPITATION FEMALESFEMALES THINTHIN CHEST WALL DEFORMITIESCHEST WALL DEFORMITIES MID-SYSTOLIC CLICKSMID-SYSTOLIC CLICKS ECHOECHO CARDIAC CATHCARDIAC CATH

MUSCULOSKELETAL CHEST MUSCULOSKELETAL CHEST PAINPAIN

VARY WITH VARY WITH POSTUREPOSTURE

VARY WITH VARY WITH POSITIONPOSITION

LOCAL LOCAL TENDERNESSTENDERNESS

ARTHRITISARTHRITIS COSTOCONDRITISCOSTOCONDRITIS INTERCOSTAL INTERCOSTAL

MUSCLE INJURYMUSCLE INJURY COXSACKIE VIRAL COXSACKIE VIRAL

INFECTIONINFECTION MINOR SOFT MINOR SOFT

TISSUE INJURIESTISSUE INJURIES

OSTEOARTHRITISOSTEOARTHRITIS

Localized DIS.Localized DIS. KNEE OR HIP KNEE OR HIP

INVOLVEMEMENT IS INVOLVEMEMENT IS COMMONCOMMON

PAIN ON PAIN ON MOVEMENTMOVEMENT

CREPITUSCREPITUS WORSE AT END OF WORSE AT END OF

DAYDAY TENDER JT.TENDER JT.

TEITZE`S SYNDROMETEITZE`S SYNDROMEIDIOPATHIC COSTOCONDRITISIDIOPATHIC COSTOCONDRITIS

LOCALIZED PAIN/TENDERNESS AT LOCALIZED PAIN/TENDERNESS AT COSTOCONDRAL JUNCTIONCOSTOCONDRAL JUNCTION

ENHANCED BY ENHANCED BY EMOTION,COUGHING,SNEEZINGEMOTION,COUGHING,SNEEZING

2nd.RIB MOST AFFECTED2nd.RIB MOST AFFECTED

PROLAPSED DISCPROLAPSED DISC

HERPES ZOSTER HERPES ZOSTER

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