Approach - Chest pain Flashcards
name the (10) structures that cause chest pain
- Heart
- Pericardium
- Lungs
- Pleura
- Aorta
- Oesophagus
- Chest Wall
- Spine
- Skin
- Abdominal Organs
outline the initial evaluation of a patient with chest pain, including relevant history, examination findings and
investigations
•Early diagnosis of myocardial infarction (& other conditions) enables early treatment •History •Examination •Investigations –ECG –Cardiac Enzymes –CXR
discuss the clinical features of cardiac conditions that cause chest pain
- “Angina Pectoris” = Pain in the chest
- Central chest pressure, tightness, squeezing
- Intensity increases over a few minutes
- Radiation to shoulders, arms, neck, jaw
- Worse with exertion
- May be relieved by rest
- May be relieved by Glyceryl Tri Nitrate (GTN)
- Associated sweating, nausea, dyspnoea
- Often not described as a “pain” but as: Pressure, Discomfort, Ache, Tightness
- May be mistaken by patient (and doctor) for indigestion
discuss the ECG findings in acute myocardial infarction at an introductory level. When do they occur?
- ST elevation
- ST depression
- T wave inversion
- Q waves
•ST elevation
–Earliest change. Resolves earliest
–Most specific for AMI
•ST depression
–Reciprocal to ST elevation (ie in “opposite leads”)
–Or as only change
•T wave inversion
–After several hours
•Q waves
–May develop early & remain permanently
What are the nerves involved in chest pain?
- cardiac muscle ischaemia
- pericardial inflammation
- pleural inflammation
•Cardiac muscle ischaemia
–Sympathetic Afferent Nerves -> T1-T5
–Vagal Afferent Nerves -> Medulla
•Pericardial inflammation
–Branch of phrenic nerve
•Pleural inflammation
–Thoracic nerves
–NO lung pain fibres
Others include: •Aortic dissection •Oesophageal irritation by acid •Muscle/Bone/Joint Pain •Skin inflammation
What are (3) causes of cardiac chest pain?
–Acute Myocardial Infarction
–Unstable Angina
–Pericarditis
What are (1) cause of vascular chest pain?
–Dissecting Aortic Aneurysm
What are (4) causes of respiratory chest pain?
–Pulmonary Embolus
–Pneumonia
–Pleurisy
–Pneumothorax
What are (2) causes of oesophageal chest pain?
–Oesophagitis
–Oesophageal spasm
What are (2) causes of musculoskeletal chest pain?
–Muscle injury, spasm
–Costochondral joint inflammation
What are (1) cause of skin chest pain?
–Herpes Zoster (Shingles)
What are the (3) patterns of ischaemic chest pain? Compare & contrast
•Stable Angina
–Pain comes on with exercise, cold, stress
–Relieved by rest
–No recent change
•Unstable Angina
–New onset pain or pain at rest
–Pain at lower levels of exercise
•Myocardial Infarction
–Pain at rest
Compare the pathology b/w stable angina and unstable angina/MI
- Stable Angina:
–Chronic atherosclerotic coronary artery narrowing
–Pain when myocardial oxygen demand > supply - Unstable Angina & Myocardial Infarction:
–Ruptured atherosclerotic plaque + thrombus
–Acute narrowing or occlusion of coronary artery
–Pain due to acute reduction of myocardial oxygen supply
Which features of pain make myocardial ischaemia more or less likely?
More likely
–Radiates to shoulders
–Worse on exercise
–Associated dyspnoea
Less likely –Stabbing, sharp –Pleuritic –Worse on changing position –Very localised –Reproduced by palpation or movement –Very brief (seconds) –Very prolonged (constant for days) –Radiates to the legs
Describe pericardial pain
- character
- site
- worse with..
- Due to pericardial inflammation: pericarditis
- Central or Left side
- Sharp, stabbing
- Worse on movement
- Worse on breathing
Describe pleuritic pain
- character
- site
- worse with..
- exertional?
Pleuritic Pain = Pain worse on inspiration
–Sharp, stabbing –Localised –Worse on inspiration, coughing –May be worse on sitting up or leaning forward –Not related to exertion
Describe oesophageal pain
- character
- site
- worse with..
- relieved with..
- Usually “Burning” but may be dull ache
- Worse after meals
- Worse on lying down
- Relieved by antacid
- Oesophageal spasm may be relieved by GTN
Describe pain from dissecting aortic aneurysm
- character
- site
- Severe chest pain
* Radiation to the back
Examination in the Evaluation of Chest Pain: what should you look for in general inspection?
- General appearance: sweaty, cyanosed?
- Skin – rash eg shingles
- Tenderness over location of pain
- Pulse, BP, Resp Rate, Temp
Examination in the Evaluation of Chest Pain: what should you look for in chest & abdomen?
- Cardiac Exam: Heart sounds, Murmurs, Pericardial Rub
- Respiratory Exam: Focal signs, Pleural Rub
- Abdominal Exam: Tenderness
Examination in the Evaluation of Chest Pain: what should you look for specific diagnoses?
- e.g. dissecting aortic aneurysm
- pericarditis
- pleurisy
•Dissecting Aortic Aneurysm
–BP different in each arm
–Early diastolic murmur of Aortic Regurgitation
•Pericarditis
–Pericardial rub
•Pleurisy
–Pleural rub
Dx & Mx of STEMI
•Diagnosis
–Diagnostic ECG changes: ST elevation
–“STEMI”: ST Elevation Myocardial Infarct
Possibly detection of rise of cardiac markers
•Management
–Monitor ECG, Defibrillator close by
–Reperfusion by thrombolysis or coronary intervention
Comment on the use of cardiac enzymes in treating AMI
E.g. Creatine Kinase, Troponin
They may be normal on admission
–Usually take ~6 hours to increase
–NO help with initial diagnosis & management
–Reperfusion needs to be within 6 hours
High Sensitivity Troponin (hs-Tn) may be positive earlier
Dx & Mx of NSTEMI
•Diagnosis –Not definite AMI –No specific features of other causes –May be AMI or Unstable Angina e.g. ST depression in V5, V6 (suggestive of cardiac ischaemia) with normal cardiac enzymes at initial set on arrival. Normal exam but with clinical Hx typical of AMI
•Management
–Observe, repeat ECG & enzymes
–May do further tests for ischaemia later. E.g. stress testing or angiography
Is tenderness in favour or against ischaemia?
Against ischaemia.
How do you (3) manage a nonspecific chest pain that has a low suspicion index of myocardial ischaemia?
–Reassure – but tell to return if pain continues
–Refer for outpatient stress testing
–Send to hospital emergency department
