Approach to Chest Pain Flashcards
60 year oldman presents to ED complaining of pain in the chest
What structures can cause pain in the chest?
Heart
Pericardium
Lungs
Pleura
Aorta
Oesophagua
Chest wall
Spine
Skin
Diaphragm (may cause shoulder tip pain)
Abdominal organs
60 year oldman presents to ED complaining of pain in the chest
What are the possible mechanisms of pain in the chest?
60 year old man presents to ED complaining of pain in the chest
DDx?
Cardiac: ACS, pericarditis
Vascular: dissecting aortic aneurysm
Respiratory: PE, pneumonia, pleurisy, pneumothorax
Oesophageal: oesophagitis, oesophageal spasm
Musculoskeletal: muscle injury or spasm, costochondral joint inflammation
Skin: Herpes Zoster (shingles)
How is myocardial ischaemic pain described?
“Angina pectoris” = pain in the chest
Central chest pressure, tightness, squeezing, ache or discomfort with intensity increasing over a few minutes (may be mistaken for indigestion)
Radiation to shoulders, arms, neck, jaw
Worse with exertion
May be relieved by rest or GTN
Associated with sweating, nausea, dyspnoea
Distinguish between the patterns of pain seen in stable angina, and unstable angina and myocardial infarction, in terms of the underlying pathology
Stable angina: chronic atherosclerotic narrowing, pain when myocardial oxygen demand > supply
Unstable angina and MI: ruptured atherosclerotic plaque and thrombus, acute narrowing or occlusion of coronary artery, pain due to acute disruption of myocardial oxygen supply
List 3 features of pain which make myocardial ischaemic more likely
Radiates to shoulders
Worse on exertion
Associated dyspnoea
List 8 features of pain which make myocardial ischaemia 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 legs
When might an ACS present atypically?
More common in women
May be “silent” ischaemia or infarction more commonly in diabetics due to neuropathy
What PHx is important to ask about directly when considering the possibility of ischaemic chest pain in a patient?
Hx of previous coronary disease: angina, infarction, bypass surgery, coronary intervention
Hx of coronary RFs: high cholesterol, smoking, HTN, DM
Describe the clinical features of pericardial pain
Central or L-sided
Sharp, stabbing
Worse on movement and breathing
Describe the clinical features of pleuritic pain
Pain worse on inspiration, coughing
Sharp, stabbing
Localised
May be worse on sitting up or leaning forward
Not related to exertion
Describe the clinical features of oesophageal pain
Usually “burning” but may be dull ache
Worse after meals, on lying down
Relieved by antacid
Oesophageal spasm may be relieved by GTN
Describe the clinical features of pain due to dissecting aortic aneurysm
Severe chest pain
Radiation to back
Describe the key things to look for on examination of a patient with acute chest pain
General appearance: sweating, cyanosed, any skin rash (e.g. shingles), any tenderness over location of pain, vitals
Cardiac exam: HS, murmurs, pericardial rub
Respiratory exam: focal signs, pleural rub
Abdominal exam: tenderness
What specific features O/E would be expected in a patient with dissecting aortic aneurysm?
BP different in each arm
Early diastolic murmur of AR
What specific features O/E would be expected in a patient with pericarditis?
Pericardial rub
What specific features O/E would be expected in a patient with pleurisy?
Pleural rub
What changes are seen on ECG in AMI?
ST elevation: earliest change, resolves earliest, most specific
ST depression: recipricol to ST elevation or as only change
T wave inversion: after several hurs
Q waves: may develop early and remain permanently
Charlie, 65 year old male truck driver, presents with 2/24 Hx of chest pain which is central and radiates to the L arm; describes it as a “tightness more than pain” and feel nauseated
Had minor chest pain for 10 mins last night
PHx: HTN (treated), smoker 20/day
FHx: father died aged 64 from AMI
O/E: HR 84, BP 110/80, temp 37.0, sweat, normal cardiorespiratory examination
Likely Dx?
Ix?
Cardiac ischaemia: angina or MI
Ix: ECG, CXR, cardiac enzymes
Charlie, 65 year old male truck driver, presents with 2/24 Hx of chest pain which is central and radiates to the L arm; describes it as a “tightness more than pain” and feel nauseated
Had minor chest pain for 10 mins last night
PHx: HTN (treated), smoker 20/day
FHx: father died aged 64 from AMI
O/E: HR 84, BP 110/80, temp 37.0, sweat, normal cardiorespiratory examination
Interpret the results of his ECG
ST elevation in leads V1-V4
Charlie, 65 year old male truck driver, presents with 2/24 Hx of chest pain which is central and radiates to the L arm; describes it as a “tightness more than pain” and feel nauseated
Had minor chest pain for 10 mins last night
PHx: HTN (treated), smoker 20/day
FHx: father died aged 64 from AMI
O/E: HR 84, BP 110/80, temp 37.0, sweat, normal cardiorespiratory examination
Cardiac enzymes at admission are normal - why might this be?
Usually take ~6 hours to increase, so they are of no help with initial Dx and Mx (as reperfusion needs to be within 6 hours to be most effective!)
High sensitivity troponin (hs-Tn) may be positive earlier
Charlie, 65 year old male truck driver, presents with 2/24 Hx of chest pain which is central and radiates to the L arm; describes it as a “tightness more than pain” and feel nauseated
Had minor chest pain for 10 mins last night
PHx: HTN (treated), smoker 20/day
FHx: father died aged 64 from AMI
O/E: HR 84, BP 110/80, temp 37.0, sweat, normal cardiorespiratory examination
ECG changes included ST elevation
Dx: STEMI
Mx?
Monitor ECG
Defibrillator close by
Reperfusion by thrombolysis or PCI (preferable)
