Chest Pain Flashcards
CHEST PAIN
One of the most common reasons for ER or OPD
consult.
THREE MAIN CATEGORIES OF NON-TRAUMATIC
CHEST DISCOMFORT
1. Myocardial Ischemia (Acute Coronary Syndromes) 2. Cardiopulmonary Causes (Pericardial diseases, aortic emergencies, and pulmonary conditions) 3. Non-cardiopulmonary Causes
GIT, MUSCULOSKELETAL AND CHEST WALL
SYNDROME-
predominates causes of nontraumatic chest pain/ non-cardiopulmonary
causes of chest pain
● However it is imperative to accurately rule out
cardiopulmonary causes for they carry higher
morbidity and mortality than other causes of chest
pain
unrecognized or missed diagnosis of MI
2-6%
Missed diagnosis of MI carries a poor outcome
30-day risk of death
HISTORY
- HISTORY
- PHYSICAL EXAMINATION
- DIAGNOSTIC AND ANCILLARY
PROCEDURES
SOCRATES
Site, Onset, Character, Radiation, Associated symptoms, TIme, Exacerbating/Releiving, Severuty
PLEURITIC
for the Respiratory and
Musculoskeletal, it may Be exacerbated by Movement or Inspiration
CARDIAC
ISCHEMIA
Central
Substernal
Dull
Heavy
Jaw
Neck
Arms
RESPIRATORY
Localized
Central
(Asthma Or COPD)
Sharp
Pleuritic
Localized
MUSCULO
-SKELETAL
Localized to the site of Pathology Sharp Pleuritic Band-like/ Shooting Pain (Nerve Root) Around the Chest Wall (Nerve Root)
PUD/GERD
Lower chest, Epigastric area
Sharp, Burning
Epigastric Area to the Back Pancreatitis
EXERTION
Cardiac Ischemia
DEEP INSPIRATION
Respiratory,
Musculoskeletal,
Pericarditis
MOVEMENT
Musculoskeletal
EATING
PED/GERD
POSITION
Pericarditis, Pancreatitis, GERD
REST
Cardiac Ischemia
SUBLINGUAL
NITRATES
Cardiac Ischemia
Oesophageal Spasm
ANTACID
PUD
GERD
ANALGESICS
Musculoskeletal
Pericarditis
Respiratory
PAST MEDICAL HISTORY
It is important to determine an accurate past
medical history because this can help us elicit risk
factors for certain diseases, particularly risk
factors for cardiovascular diseases.
Cardiovascular risk factors
○ Hypertension
○ Diabetes mellitus
○ Dyslipidemia
Marfan Syndrome
○ Acute Aortic Syndrome
○ Spontaneous Pneumothorax
Thrombotic risk factors
○ Malignancy
○ Thrombophilia
○ Recent surgery
Premature CAD
Coronary artery disease
occurring in women and men younger than 55 and 45, respectively
PHYSICAL EXAMINATION
● Give clues on the clinical stability of the patient.
● You can triage which of this patients complaining
of chest pain should receive an urgent evaluation
● Can provide direct evidence of specific etiologies
of chest pain e.g., unilateral absence of lung
sounds
● Help identify potential precipitants of acute
cardiopulmonary causes of chest pain. e.g.,
uncontrolled hypertension predisposes to Aortic
Dissection or Acute Myocardial Infarction
● Relevant comorbid conditions (e.g., COPD) and
complications of the presenting syndrome (e.g.,
heart failure).
● A normal P.E. would not mean that there is no
cardiac ischemia e.g.
○ In some cases of unstable angina, the
patient still has normal PE.
Cold sweat
sign of heart attack
Patients with acute MI or other acute
cardiopulmonary disorders often appear
anxious,
uncomfortable, pale, cyanotic, or diaphoretic.
Patients who are massaging or clutching their
chests may describe their pain with a clenched
fist held against the sternum
(Levine’s sign
Occasionally, body habitus is helpful
e.g., in patients with Marfan syndrome or the prototypical young, tall, thin man with spontaneous pneumothorax. ○ Patients with Marfan’s syndrome are at risk for Acute Aortic emergencies or spontaneous pneumothorax. So a general survey may reveal findings that may be consistent with Marfan’s syndrome
VITAL SIGNS
○ Acute MI with Cardiogenic Shock
○ Massive Pulmonary Embolism
○ Pericarditis with Tamponade
○ Tension Pneumothorax
ACUTE AORTIC EMERGENCIES
Usually present with severe hypertension but may be associated with profound hypotension when there is coronary arterial compromise or dissection into the pericardium
SINUS TACHYCARDIA
● First manifestation
● Important manifestation of submassive
pulmonary embolism
PULMONARY CAUSE
Tachypnea and hypoxemia point toward a pulmonary cause
FEVER
he presence of low-grade fever is nonspecific
because it may occur with MI and with
thromboembolism in addition to infection
PULMONARY EXAMINATION
May localize a primary pulmonary cause of chest discomfort. ○ Pneumonia ○ Asthma ○ Pneumothorax ○ Left ventricular dysfunction from severe ischemia/infarction as well as acute valvular complications of MI or aortic dissection can lead to pulmonary edema, which is an indicator of high risk
Pulmonary Edema
may be suggested of left
ventricular dysfunction, acute valvular
dysfunction
CARDIAC PE
● JVP (useful in checking for right-sided heart failure)
● The jugular venous pulse is often normal in patients with acute myocardial ischemia but may reveal characteristic patterns with:
○ Pericardial tamponade
○ Acute right ventricular dysfunction
Cardiac auscultation may reveal S3 or S4
reflecting myocardial systolic or diastolic
dysfunction.
Mitral regurgitation or ventricular septal defect
mechanical complications of STEMI.
The murmur of aortic insufficiency
complication of
proximal aortic dissection
Other murmurs may reveal underlying cardiac
disorders contributory to ischemia
e.g., aortic
stenosis or hypertrophic cardiomyopathy
Pericardial friction rubs
Reflect pericardial inflammation;
○ It May be heard in a patient with pericarditis as the cause of chest pain
ABDOMINAL PE
● Localizing tenderness is useful in identifying a gastrointestinal cause of the presenting syndrome ○ However, sometimes the Right Upper Quadrant tenderness is observed in patients with severe right ventricular dysfunction due to hepatic congestion.
Abdominal findings are infrequent with
purely
acute cardiopulmonary problems, except in the
case of underlying chronic cardiopulmonary
disease or severe right ventricular dysfunction
leading to hepatic congestion
VASCULAR PE
Pulse deficits - reflect underlying chronic
atherosclerosis which increases the likelihood of
coronary artery disease.
● Loss of the pulse and pallor - evidence of acute
limb ischemia, particularly in the upper
extremities; can indicate consequences of aortic
dissection
● Unilateral lower extremity swelling-venous
thromboembolism
MUSCULOSKELETAL PE
● Pain arising from the costochondral and
chondrosternal articulations may be associated
with localized swelling, redness, or marked
localized tenderness.
● Although palpation of the chest wall often elicits
pain in patients with various musculoskeletal
conditions, chest wall tenderness does not
exclude myocardial ischemia.
●
Cervical disk disease-
Sensory deficits in the upper extremities
MYOCARDIAL ISCHEMIA
● Myocardial ischemia causing chest discomfort，
termed angina pectoris, is a primary clinical
concern in patients presenting with chest
symptoms.
● Myocardial ischemia is precipitated by an imbalance between myocardial oxygen requirements and myocardial oxygen supply, resulting in insufficient delivery of oxygen to meet the heart’s
Factors that increase myocardial contractility,
heart rate, ventricular wall stress increases the
myocardial oxygen consumption.
When myocardial ischemia is sufficiently severe
and prolonged in duration (as little as 20 min)
irreversible cellular injury occurs, resulting in MI.
The afferent fibers traverse the nerves that connect to the upper five thoracic sympathetic ganglia and upper five distal thoracic roots of the spinal cord
impulses are transmitted
to the thalamus eliciting pain
Within the spinal cord, cardiac sympathetic
afferent impulses may converge with impulses
from somatic thoracic structures, and this
convergence may be the basis for
referred
cardiac pain.
ISCHEMIC HEART DISEASE
Ischemic heart disease is most commonly caused
by atheromatous plaque that obstructs one or
more of the epicardial coronary arteries. Starts
with fatty deposits and the growth of the plaque
obstructs the blood flow. Symptoms are noted
depending on the degree of blockage.
Stable Angina
results from the gradual
atherosclerotic narrowing of the coronary
arteries. It is characterized by ischemic episodes
that are typically precipitated by a superimposed
increase in oxygen demand during physical
exertion and relieved upon resting
Unstable ischemic heart disease
ccurs when
rupture or erosion of one or more atherosclerotic
lesions triggers coronary thrombosis.
● It is classified clinically by the presence or
absence of detectable myocardial injury and the
presence or absence of ST-segment elevation on
the patient’s electrocardiogram (ECG)
Coronary atherothrombosis
is marked by
ischemic symptoms at rest, with minimal activity,
or in an accelerating pattern.
unstable ischemic heart disease is classified as
unstable angina when
there is no detectable
myocardial injury
When acute coronary atherothrombosis occurs,
the intracoronary thrombus may be partially
obstructive, generally leading to myocardial
ischemia in the absence of
ST-segment
elevation
Read Black Table
PERICARDITIS
● Visceral surface and most of the parietal surface
of the pericardium are insensitive to pain.
● What causes the pain of pericarditis is the
associated pleural inflammation
● This pleural inflammation can also explain the
Pleuritic pain that is exacerbated by breathing,
coughing or changes in position noted in
pericarditis.
Neck and Shoulder Referred pain
Overlapping sensory
supply of central diaphragm (phrenic nerve) with
Somatic Sensory Fibers from the 3rd to 5th
cervical segments
Upper abdomen referred to pain
-Involvement of pleural
the surface of the lateral diaphragm will then explain
the pain of pericarditis that is referred at the upper
abdomen
ACUTE AORTIC DISSECTION
● Less common cause of chest discomfort
● Catastrophic Natural History if recognized late
and if untreated
● Involves a tear in the aortic intima -> separation of the media -> creation of a separate lumen (false lumen). If this lumen ruptures it may lead to
catastrophic diseases or death because of bleeding and hypotension also.
ACUTE AORTIC SYNDROME
● Severe, sudden in onset, and sometimes
described as ―”tearing” in quality.
Ascending aorta -
pain in the midline of the
anterior chest.
Descending aortic syndromes
pain in the back
Myocardial Infarction in AAS
compromise of the
aortic Ostia of the coronary arteries
Acute aortic insufficiency
disruption of
the aortic valve
Pericardial tamponade
rupture of the
hematoma into the pericardial space
Pulmonary - Vascular Conditions
● Pleuritic chest pain
○ Pulmonary Embolism
PULMONARY EMBOLISM
● Pleuritic in pattern
● Clinical features depend on size
● Massive pulmonary emboli may cause severe
● substernal pain that may mimic MI.
● Massive or submassive pulmonary embolism may also be associated with syncope, hypotension, and signs of right heart failure.
MECHANISM OF PLEURITIC PAIN
- Involvement of the pleural surface of the lung adjacent to a resultant pulmonary infarction;
- Distention of the pulmonary artery;
- Right ventricular wall stress and/or
subendocardial ischemia related to acute
pulmonary hypertension
Modified Well’s criteria
Study from the table
PE score
>6- High 2.0-6.0- Moderate <2.0- Low PE likely- >4.0 PE unlikely- <= 4.0
If low probability
D-dimer
If moderate to high probability,
we proceed to CT
angiogram
PNEUMOTHORAX
● Abnormal collection of air in the pleural space
between the lung and the chest wall
● Clinical manifestation s:
○ sudden onset of sharp, one-sided chest
1 Spontaneous Pneumo
Rare, Risk includes males, smoking, Marfan’s; sudden onset, Mild Dyspnea
2 pneumo
Underlying disorder, COPD
Tension Pneumo
Emergency, Hemodynamic collapse due to Intrathoracic air, Shifting if trachea to the opp side of the collapsed lung.
GASTROINTESTINAL DISORDERS
● Most common cause of nontraumatic chest
discomfort
● Esophageal disorders may mimic angina in the
character and location of the pain.
Esophageal Spasm
ntense, squeezing,
retrosternal, may be relieved by nitroglycerin or
Ca-blocker (Mimics pain of angina)
Burning
GERD and esophageal dysmotility
Peptic Ulcer
60-90min, burning, Epigastri, Antacis
Cholecystitis
Prolonged, Aching/colicky, Epigastric, RUQ, may follow meal
Costochondritis
vaqriable, Aching, Sternal
ELECTROCARDIOGRAPHY
● Crucial in the evaluation of nontraumatic chest
discomfort.
● Pivotal for identifying patients with ongoing
ischemia as the principal reason for their
presentation, as well as secondary cardiac
complications of other disorders.
● Primary goal: identify patients with ST-segment
elevation diagnostic of MI who are candidates for
immediate interventions to restore flow in the
occluded coronary artery.
Despite the value of the resting ECG, its
sensitivity for ischemia is poor
as low as 20％ in
some studies.
ST SEGMENT AND T WAVE ABNORMALITIES
May occur in a variety of conditions including pulmonary embolism, ventricular hypertrophy, acute and chronic pericarditis, myocarditis,
electrolyte imbalance, metabolic disorders.
● Hyperventilation associated with panic disorder can also lead to nonspecific ST and T wave abnormalities.
PULMONARY EMBOLISM
● Sinus tachycardia is the most common finding
● Can also lead to rightward shift of the ECG axis manifesting as an S wave in lead I with a Q wave and T wave in lead III.
PERICARDITIS
● Diffuses ST segment elevation
● PR segment depression
CHEST RADIOGRAPHY
● Performed routinely when patients present with
acute chest discomfort and selectively when
individuals who are being evaluated as
outpatients have subacute or chronic pain.
● Most useful for identifying pulmonary processes,
such as pneumonia or pneumothorax.
Aortic dissection
widening of
the mediastinum
Pulmonary embolism
Hampton’s hump or
Westermark’s sign
Chronic pericarditis
pericardial calcification
CARDIAC BIOMARKERS
● Detects presence of circulating proteins released
from damaged myocardial
● D/t superior cardiac tissue-specificity compared
with creatine kinase MB, cardiac troponin is the
preferred biomarker for the diagnosis of MI and
repeated in 3–6 hrs.
● Includes D-dimer test to aid in exclusion of
pulmonary embolism.
● Measurement of a B-type natriuretic peptide is
useful when considered in conjunction with the
clinical history and exam for the diagnosis of
heart failure.
● Provides prognostic information among patients
with ACS and those with pulmonary embolism
CARDIAC TROPONIN
● Superior cardiac tissue specificity compared with creatine kinase MB
● Preferred biomarker for diagnosis of MI
● Should be measured in all patients with
suspected ACS at presentation and repeated in 3-6 hours.
● Testing after 6 hours is required only when there is uncertainty regarding the onset of pain or when stuttering symptoms have occurred.
ACUTE MYOCARDIAL INFARCTION
Diagnosis of MI is reserved for acute myocardial injury that is marked by a rising and/or falling pattern with at least one value exceeding the 99th
percentile reference limit and that is caused by ischemia.
INTEGRATIVE DECISION AIDS
● Multiple clinical algorithms
● Used in decision making during the evaluation and disposition of patients with acute non traumatic chest pain
● Used most commonly to identify patients with a low clinical probability of ACS who are candidates
either for early provocative testing for ischemia or for discharge from the ED.
PROVOCATIVE TESTING FOR ISCHEMIA
● Exercise electrocardiography (―Stress testing‖)
Early exercise testing is safe in patients without
high-risk findings
8-12 hours of observation
and can assist in refining their prognostic
assessment.
low-risk patients who underwent
exercise testing in the first 48 hours after
presentation, without evidence of ischemia, had a
2％rate of cardiac events through 6 months,
whereas the rate was 15% among patients with
either clear evidence of ischemia or an equivocal
result.
RESTING MYOCARDIAL PERFUSION SCAN
● Ongoing chest pain is a contraindication to stress testing
● Indicated for persistent pain and non-diagnostic ECG and biomarker data
● Absence of any perfusion abnormality
substantially reduces the likelihood of coronary artery disease
● Management of patients with normal perfusion images can be expedited with earlier discharge and outpatient stress testing, if indicated.
ECHOCARDIOGRAPHY
● Not necessarily routine
● detection of abnormal regional wall motion
provides evidence of dysfunction in patients with
an uncertain diagnosis
ECHOCARDIOGRAM
Diagnostic in patients with mechanical
complications of MI or inpatients with pericardial
tamponade
Transthoracic echocardiography
poorly sensitive for aortic dissection, although an intimal flap may sometimes be detected in the ascending
aorta.
CT ANGIOGRAPHY
Coronary CT angiography is a sensitive
technique for detection of obstructive coronary
disease, particularly in the proximal third of the
major epicardial coronary arteries. CT appears to
enhance the speed to disposition of patients with
a low-intermediate probability for ACS; its major
strength being the negative predictive value of a
finding of no significant disease. In addition,
contrast-enhanced CT can detect focal areas of
myocardial injury in the acute setting as
decreased areas of enhancement
CT angiography can exclude
aortic
dissection, pericardial effusion, and pulmonary
embolism
CARDIAC MRI
● Structural and functional evaluation of the heart and the vasculature of the chest
● Modality for pharmacologic stress perfusion imaging
● Early detection of MI, defining areas of
myocardial necrosis accurately, and can
delineate patterns of myocardial disease that are often useful in discriminating ischemia from nonischemic myocardial injury.
● Cardiac structural evaluation of patients with elevated cardiac troponin levels in the absence of definite coronary artery disease.
● Highly accurate assessment for aortic dissection.
