Approach to Chest Pain Flashcards
What are the causes of chest pain?
Cardiac/ Vascular
- AMI
- Pericarditis
- Myocarditis
- Aortic Dissection
- Tamponade
- Stable angina
- heart failure
Pulmonary
- Pulmonary embolism
- Pneumothorax
- Pneumonia/pleurisy
- Pulmonary hypertension
- Malignancy
- Sarcoidosis
Gastrointestinal
- Esophageal Reflux
- Biliary colic
- Gastritis/PUD
- Esophageal rupture/ Boerhaave syndrome
- Liver abscess
- Pancreatitis
- Subdiaphragmatic abscess
- Malignancy
- Cholecystitis
- Hiatus hernia
Mediastinum
- Lymphoma
- Thymoma
MSK
- Rib fracture
- Cervical/thoracic spondylosis
- Costochondritis
- Myositis
- Herpes zoster
Breast
- Fibroadenoma
- Mastitis
Others
- Herpes zoster
- Panic attack/disorder
What are the Big 6 causes of acute chest pain (must not miss, life threatening!)
- Acute Coronary Syndrome (ACS) – STEMI, NSTEMI, unstable angina
- Pulmonary Embolism (PE)
- Tension pneumothorax
- Aortic dissection
- Cardiac Tamponade
- Oesophageal rupture / Boerhaave Syndrome
What are the clinical features favoring peptic- oesophageal pain?
- Precipitating factors: meals, posture
- Relieving factors: antacids
- Radiation: epigastrium
- Associated symptom: heartburn, regurgitation, dysphagia
What are the clinical features favoring biliary pain?
- Precipitating factors: fatty food
- Radiation: tip of right shoulder
- Associated symptoms: flatulence, dypsepsia
What are the clinical features favoring cardiac pain?
- Precipitating factors: consistently with exercise
- Relieving factors: rest, nitrates
- Radiation: left arm and jaw
- Associated symptoms: dypsnea, diaphoresis
What are the clinical features of acute coronary syndrome?
- Character: Diffuse, crushing central pain
- Time: >10 mins, at rest
- Radiation: Radiating to arm, neck, jaw
- Associated symptoms: Diaphoresis, N&V
- Risk factors: age >60, previous hx, vascular
What are the clinical features favoring aortic dissection? What are the relevant investigations?
- Character: sharp, tearing, stabbing interscapular pain which radiates to the back
- Timing: maximal pain within seconds, improves w time
- asymmetrical pulses
- Marfan’s syndrome
- widened mediastinum (CXR)
- Risk factors: trauma, age, CTDz (Marfan’s etc), HTN
- associated features: syncope, stroke
Other supporting features (minor)
- B/G hypertension
- aortic surgery, trauma
- pregnancy
physical findings
- unequal pulses & BP (>20 mmHg)
- aortic regurgitation
Complications:
- If tears towards heart: new AR murmur, Chest Pain
- If tear occludes origin of carotids – Syncope, TIA
- If tear occludes origin of subclavian – RR Delay, Unequal Pulse, unequal BP (>20mmHg)
- if dissects downwards = inferiorly migratory pain; +/- abdo pain (mesenteric ischaemia
Investigations:
- IF STABLE: CT aortogram
- IF NOT STABLE: Bedside US for widened aortic root >3cm
What are the clinical features favoring pulmonary embolism?
- central, pleuritic pain
- dyspnea, hypoxaemia, tachycardia, ↓SPO2
- risk factors: malignancy, recent surgery, immobility, DVT, travel, bedrest, OCP, HRT, pregnancy, DVT
- Constant with no relieving factors
- Associated features: cough, calf swelling
- Physical findings: tachypnea, tachycardia, loud P2
- syncope, signs of shock
- ECG changes (sinus tachycardia most common), S1Q3T3
- Signs of R heart strain (RBBB, Right Axis Deviation, P Pulmonale
Investigations: CT pulmonary angiogram, Doppler US of lower limbs (for DVT); US for R heart strain
What are the clinical features favoring esophageal rupture? What are the relevant investigations?
- retrosternal, excruciating pain
- radiating to abdomen
- constant with no relieving factors
- arises after vomiting or oesophageal instrumentation
- associated features: odynophagia, alcoholism
Investigations
- contrast barium swallow / CT surgical review
- CXR (if > 1 hr): may show subcutaneous emphysema or pneumomediastinum
What are the clinical features favoring pericarditis? What are the relevant investigations?
- sharp central pain radiating to trapezius ridge
- Positional: Worse when supine; relieved when leaning forward
- pericardial friction rub
- associated features: fevere=, recent viral illness (e.g. rash, arthralgia)
- ECG changes (upward sloping ST elevation in most leads + PR depression in most leads; Reciprocal ST↓ & PR↑ in aVR & V1)
Investigations: Echocardiogram US – detect effusion/tamponade
What are the differentials of pleuritic pain? What are the relevant investigations?
Pleural etiology (infectious)
- infectious exacerbations of non infectious etiologies
- Pneumonia: Associated with cough, sputum, dyspnea, fever
- Bronchiectasis: productive cough, fever, other risk factors a/w bronchiectasis (post infectious etc)
- Tuberculosis: chronic cough >2 weeks; LOW, LOA, Fever, Night Sweats, Fatigue
Pleural etiology (non infectious)
- Malignancy: LOW, LOA
- Pulmonary embolism
- Asthma: Hx / FHx of Atopy, wheezing
- COPD: smoking Hx, wheezing
- Interstitial Lung Disease : dry non-productive cough w/ risk factors for ILD
Fracture
Parenchyma Vascular etiology
- Pneumothorax: associated with dypsnea, decreased breath sounds, hyper resonance, decreased chest expansion
- Pleural effusion: Associated with decreased breath sounds, dull percussion, hypo resonance
- Pneumothorax
What is the clinical presentation of cardiac tamponade?
Hypotension: as a result of decreased venous return, due to constant compressive forces on the heart + the leftward bulging interventricular septum
Elevated JVP: almost always elevated in cardiac tamponade and may be associated with venous distension in the forehead and scalp
- The decreased venous return can lead to backlog of blood into the venous circulation causing elevated JVP
- This is similar to fluid overload in CCF where there is also Hypotension and ↑JVP
Sinus tachycardia – to maintain CO
Pulsus Paradoxus – defined as an abnormally large decrease in systolic blood pressure (>10 mmHg) on inspiration
- consequence of ventricular interdependence
- The limitation on outward expansion of the right ventricle as blood flows in during inspiration, along with relative underfilling of the left ventricle during inspiration, results in bulging of the interventricular septum into the left ventricle. Both the bulging of the interventricular septum and the reduction in left ventricular filling contribute to a large decrease in stroke volume.
- However, not all patients with cardiac tamponade have pulsus paradoxus.
Pericardial rub (in the c of inflammatory pericarditis)
Must be distinguished from: AMI, PE, and an aortic dissection
- AMI: associated with characteristic ECG of infarction, no pulsus paradoxus
- Aortic Dissection: Should not cause an increase in JVP, no pulsus paradoxus
- PE: Dyspnoea, hypotension, and even elevated jugular venous pressures, but not pulsus paradoxus
What is the clinical presentation of perforated PUD?
- site of pain: xiphisternal
- character: gnawing
- radiation: abdomen
- constant with no relieving factors
- associated with nausea, fever, vomiting
PE: abdominal guarding, rebound tenderness
What is the routine acute workup for chest pain?
Cardiac Enzymes: help rule out HF as a result of Chest Pain
• Do Troponin I; Troponin T; CK-MB
• 2 sets 6 hours apart (1 set normal =/= no MI)
• CKMB only detectable after 4-6hours
• Troponin normalizes in 1-2 weeks; CKMB in 2-3 days (hence indicative of acute)
Chest X Ray: Look at • Lung Fields - Pleural Effusion secondary to HF - Pneumothorax - Consolidation - PE classically has a normal XCR - Atelectasis – secondary to severe PE • Cardiac: For cardiomegaly • Mediastinum - widened mediastinum or aortic knob (aortic dissection) - Pneumomediastinum (esophageal rupture)
Blood Test – routine stuff • FBC – WCC elevated in infective cause (myocarditis and pericarditis, mediastinitis, and pneumonia) • UECr • ABG • Lactate
What is the management of acute pulmonary oedema?
Management:
- IV furosemide (Lasix) for definitive treatment
- IV GTN (Nitroglycerin) for acute relief
- Remove drip
- Strict I/O, Fluid restriction
- Insert IDC
What is the management of STEMI?
- Morphine
- Oxygen therapy
- Aspirin 300mg STAT
- Nitroglycerin (converted to NO)
- Ticagrelor 180mg (platelet aggregation inhib)
- urgent PCI: percutaneous coronary intervention
What is the management of PE?
- Patients with symptoms suggestive of PE and right ventricular heart dysfunction or hemodynamic instability high risk emergent thrombolysis or embolectomy. For all other patients with suspected PE, we look to the score.
- Several scoring systems exist to characterize patient risk for PE, including the Wells score, the Charlotte criteria, the revised Geneva score, and the PERC rule
- The PERC rule identifies patients at sufficiently low risk for PE that even D-dimer testing may be unnecessary
- For patients at low-clinical risk it is generally reasonable to withhold anticoagulant therapy while a D-dimer test is performed. In patients at low risk, PE can be ruled out with a negative D-dimer test, provided the test is of high sensitivity.
- Patients at low risk but whose D-dimer test is positive and those at higher risk require further testing.
What is the management of aortic dissection?
Mainly BP and HR control
- beta blockers (eg, esmolol)
- sodium nitroprusside (or nitroglycerin)
Beta blockers should be started first to prevent potential rebound tachycardia associated with the vasodilatory effects of sodium nitroprusside
What is the management of mediastinitis?
- Broad spectrum antibiotics are given early in suspected mediastinitis
- Surgical Debridement and repair
