Chest Pain Flashcards
Broad things to think about in Chest Pain
- Chest Wall and Skin
- Cardiac, Aortic
- Pulmonary
- Gastroenterologic
- Psychogenic
Etiology of CP
- Depends on patient population in question
- Primary Care vs. Emergency Department
- Age of Patient
T/F: Up to 60% of patients with chest pain in primary care setting have non-organic causes.
True
Chest Pain in the Primary Care Setting by organ system
- MSK (Costochondritis) – 36%
- GI – 19%
- Cardiac – 16%
- Psychiatric – 8%
- Pulmonary – 5%
- Unknown/Other – 16%
Cardiac Complaint Breakdown of CP in Primary Care Settings
Chronic Stable Angina – 10%
Unstable Angina/NSTEMI/STEMI – 2%
Other Cardiac Causes – 4%
What could cause Chest Wall Pain?
- MSK
- Nerve Injury
When a chest pain is worse with deep inspiration, cough, or movement, what is this called?
Pleuritic in nature
If there is Chest Wall Pain, what is a common indication?
They can usually pinpoint it to an anatomic location.
Quality of Chest Wall Pain
Usually sharp, but also dull/aching. Often reproducible by pressing
Duration of Chest Wall Pain
Moments to Weeks (…good to know -__-)
Nerve Injury causing Chest Wall Pain that presents with pain preceding the outbreak of vesicles. The pain may persist months after skin lesions disappear.
Herpes Zoster Infection causing Shingles.
Other Nerve Injury causing Chest Wall Pain
- Nerve Root Compression from Cervical Spine Disease
2. Post-radiation Neuralgia (cancer therapy) may not present for years
Other Causes of MSK Pain
- Costochondritis
- Post-CABG
- Rheumatologic Conditions Causing Joint Involvement
- Systemic Diseases
This condition is defined by inflammation between the ribs and costal cartilages and has reproducible pain.
Costochondritis
Rheumatologic Conditions Causing Joint Involvement/MSK Pain:
- Ankylosing Spondylitis
- Psoriatic Arthritis
- Lupus
- Fibromyalgia
Systemic Diseases Causing MSK Pain:
- Sickle Cell Anemia (Acute Chest Syndrome)
- Infection or Osteomyelitis of the Sternum (post-thoracic sx)
Cardiac Causes of Chest Pain
- Coronary Heart Disease
- - Chronic stable angina
- - Unstable angina
- - Variant “Prinzmetal’s” angina
- - non ST-segment elevation myocardial infarction (NSTEMI)
- - ST-segment elevation myocardial infarction (STEMI) - Aortic Dissection
- Valvular Heart Disease
- - Aortic stenosis
- - Mitral stenosis
- - Mitral valve prolapse - Pericardial Heart Disease
- - Pericarditis
- - Pericardial effusion and tamponade - Myocardial Heart Disease (non-coronary)
- - Myocarditis
Classic Symptoms of Coronary Heart Disease
- Chest “heavy”, “pressure”, “elephant”, “squeezing”. Though may be “burning”, “sharp”
- At rest or activity, stress, eating
- Usually 2 – 20 minutes (caveat: active infarction → ongoing)
- May be relieved by rest, nitro (usually < 5 minutes)
- Classically radiates to the jaw, arm, neck, upper abdomen
- Associated symptoms include:
- indigestion
- numbness/tingling in arm/hand
- dyspnea
- nausea
- vomiting
- diaphoresis
- palpitations
- syncope
- presyncope
Non-classic or “Atypical” Presentation of Coronary Heart Dz.
This is a KEY point
People with this:
- Women
- Diabetics
- Elderly
What they present with:
- Fatigue
- Indigestion
- Nausea
- SOB
- Altered mentation
This condition presents with intermittent episodes of chest pain due to coronary spasm, cocaine or tobacco use. Can lead to LETHAL ventricular arrhythmia
Variant (Prinzmetal’s) Angina
Signs of Aortic Dissection
- REMEMBER: high index of suspicion and low threshold for testing!!!
- Classically presents with sudden onset, sharp, stabbing pain
- Men > 60 years old
- “ripping”, “tearing” pain transmitted from chest to the mid-scapular region
- Patients almost always hypertensive, smoking
- Associations: Marfan’s, bicuspid aortic valve, pregnancy, cocaine
Assc Findings in patients with Aortic Dissection
- Acute aortic regurgitation (with CHF)
- Carotid dissection (with neurologic or stroke symptoms)
- Hemothorax
- Shock
- Asymmetric blood pressures
Diagnostic Test of Choice for Aortic Dissection
CT with Contrast
Other Tests for Aortic Dissection
- TEE
- CXR (may show widened mediastinum)
This can cause angina, CHF, and syncope. Physical findings include “pulsus parvus et tardus,” “crescendo-descrescendo” systolic ejection murmur.
Aortic Stenosis
This can cause of chest pain often due to elevated right heart pressures, pulmonary HTN. Can have a loud S1, opening snap, and early diastolic murmur.
Mitral Stenosis
This can cause chest pain commonly assc with “atypical” chest pain. “Mid systolic click”
Mitral Valve Prolapse
This presents with “pleuritic” chest pain. It is usually substernal and improves with sitting up and forward. Usually persistent and not relieved by NTG. Pericardial friction rub may be present. May have pericardial effusion.
Pericarditis (Pericardial Heart Dz)
Cause of Pericarditis
- Post-myocardial infarction/post-cardiac surgery
- Viral (Coxsackie B, Influenza) = MOST COMMON CAUSE (KEY)
- Metastatic Malignancy
- Uremia
- TB
- Systemic Lupus Erythematous
What is Dressler’s Syndrome?
Syndrome 1-2 months following post-myocardial infarction/post-cardiac surgery. It is immunologically mediated.
This is a non-coronary cause of chest pain that is often with co-existent systemic conditions such as fevers, malaise, chills, and muscle tenderness. May be pleuritic or substernal pressure-like. Similar to Angina
Myocarditis
What is the BEST way to differentiate between Myocarditis and Pericarditis?
Myocarditis = Increased Cardiac Enzymes Pericarditis = Cardiac Enzymes Normal
**Because cardiac enzymes are in the muscles!
Characteristics of Myocarditis
- Inflamed Heart Muscle
- Often Post-Viral
- Similar Symptoms with Pericarditis
- Myocarditis not as much physical exam findings (unless there is heart failure)
Characteristics of Pericarditis
- Inflamed Pericardial Lining
- Post-Viral
- Feels better leaning forward
- JVD, distant heart sounds, rub
This is a cause of chest pain common in post-menopausal women. The pain is anginal in quality. It is due to DECREASED coronary flow reserve at microvascular level (versus obstructive dz in larger coronary arteries).
Microvascular Dysfunction (Syndrome X)
This is a cause of chest pain commonly precipitated by emotional or physical stress. Classic anginal symptoms in patients with or without risk factors. It will show positive cardiac enzymes. It could be triggered by a sympathetic storm. Sometimes called Takotsubu CM.
Stress-Induced CM
Commonly after being drunk we see this
Similar Symptoms seen in BOTH GI and Cardiac Disorders:
- “Pressure” worse with exercise or emotions
- Improvement at rest
- Both may improve with NTG
T/F: Heart and Esophagus share vagal innervation
True
If pain is alleviated by NTG, what is NOT the cause?
Ischemic Heart Dz
GI Causes of Chest Pain
- GERD
- Esophageal dysmotility / achalasia
- Pill esophagitis
- - Doxycycline
- - NSAIDs
- - Potassium
- - Iron
- - Bisphosphonates - Referred visceral pain from:
- - Peptic ulcer disease
- - Cholecystitis
- - Pancreatitis
- - Gas in splenic flexure
This is a GI cause of chest pain that is described as a “burning” and may radiate to neck, jaws, arm, and back. May wake patients from sleep in supine position. It may last hours (unlike coronary angina). Clues to identifying this condition may include: acid taste, dyspepsia, and improvements.
GERD
This is a GI cause of chest pain that presents with dysphagia, odynophagia. Consider this condition in people with scleroderma, Chaga’s Dz, and Diabetic Neuropathy.
Esophageal Dysmotility
Tools used to diagnose Esophageal Dysmotility
- Barium Study
- Endoscopy
- Esophageal Manometry
What causes Chaga’s Dz
Trypanosomiasis
This is a GI cause of chest pain that is due to a rupture classically from wretching/vomiting. Also seen in caustic ingestion. Suspect foreign bodies in psychiatric patients, children, sz, prisoners, and alcoholics.
Esophageal rupture, mediastinitis, aspirated foreign bodies.
This is a GI cause of chest pain that is often worse 1-2 hours after meals. Usually epigastric and may radiate into chest. Described as burning or gnawing pain.
Peptic Ulcer Dz
This is a GI cause of chest pain that is assc with hyperglycemia and elevated pancreatic enzymes. Caused by EtOH history and/or gallstones.
Pancreatitis
This is a GI cause of chest pain that is colicky in nature related to meals. Presents with RUQ pain on direct palpation. “Murphy’s Sign”
Cholecystitis or Other Biliary Tract Dz
This is a GI cause of chest pain that is describes as a persistent pain causing writhing, inability to get comfortable.
Kidney STONESSSSS
Pulmonary Causes of Chest Pain
- Pulmonary Vasculature
- - Pulmonary embolism
- - Pulmonary hypertension and cor pulmonale - Parenchymal Lung Disease
- - Pneumonia
- - Malignancy - Pleura and Pleural Space
- - Pneumothorax
- - Pleurisy
- - Pleural Effusion
This Pulmonary Cause of CP is supposed to be considered in EVERY patient with CP and SOB. It is usually pleuritic and may be crushing pain. However, pain is only in about 10% of these cases. It is commonly assc with weakness, nausea, comiting, DYSPNEA, TACHYCARDIA, Hemoptysis (rare), hypoxia, TACHYPNEA, Circulatory collapse with shock, death. They usually have a normal CXR
Pulmonary Embolism
Diagnostic Tests for PE
- EKG most often shows sinus tachycardia and often a new RBBB
- Arterial Blood Gas showing elevated A-a gradient and respiratory alkalosis
- - A-a gradient = PaO2 - FIO2 x (760 - 47) - (PaCO2/0.8)
- - “normal” A-a gradient (estimate): (age/4) + 4 - History is key in identifying risk factors for venous thromboembolic disease
- - malignancy, stasis, recent surgery, trauma, genetic factors
This Pulmonary Cause of CP with symptoms of dyspnea on exertion, fatigue, lethargy, chest pain, syncope. It is assc with chronic disease affecting the lungs such as COPD, Chronic PEs, Collagen Vascular Dz. Often have signs of Right Sided Heart Failure (Elevated of JVP, Palpable Parastenal Lift, Peripheral Edema or Ascites).
Pulmonary HTN
This Pulmonary Cause of CP has a sudden onset, pleuritic CP, and respiratory distress. Could be iatrogenic, traumatic, or sponteanous in nature.
Pneumothorax
T/F: Spontaneous pneumothorax is common in male children.
False, common in young, tall, adult male smokers.
T/F: Spontaneous pneumothorax may also be seen in patients with known COP (Bullous Lung Dz).
True
This Pulmonary Cause of CP is commonly due to a preceding viral infection or pneumonia. It is assc with autoimmune dz like SLE. Can have effusions present.
Pleuritis.
Psychiatric Causes of CP
- Anxiety
- Depression
- Malingering
- Cardiac Neurosis
What to not miss in DDx of CP
- MI
- PE
- Esophageal Rupture
- Pneumothorax
- Aortic Dissection
Review: Hx of CP
Quality
- Squeezing, tightness, pressure, constriction, burning, heartburn, lump in throat, “elephant on my chest”
- Worse with inspiration, cough, position, directly pressing on it
- Sharp, stabbing, ripping, shredding
Review: Hx of CP
Precipitating Factors
- Exertion – think angina, esophageal
- Eating – think upper GI disease; postprandial, GI or cardiac
- Swallowing – likely esophageal
- Position – pleuritic when supine, moving, coughing; think: pneumonia, pneumothorax, pleurisy
Review: Hx of CP
Mitigating Factors
- Antacids – GI
- Nitro – cardiac, GI
- “GI cocktail”
- Leaning forward – pericarditis
Review: Hx of CP
Radiation
- Cholecystitis – R shoulder with concomitant RUQ pain
- Aortic Dissection – interscapular pain
- Neck, jaw, throat, teeth, upper extremity – ischemia (may be GI as well)
Review: Hx of CP
Severity
- Pain intensity does not correlate to severity of ischemia
- Relief with nitro does not ensure that it’s a cardiac cause and…
- Vice versa
Review: Hx of CP
Assc Symptoms
- Diaphoresis more common in MI than esophageal
- Nausea, belching, vomiting, dysphagia may be seen in MI or GI
Review: Hx of CP
Physical Exam Findings
- Tachypnea, tachycardia, vitals
- Hyperventilation
- Carotid arteries, elevated JVP
- Lung exam: hyperresonance, absent breath sounds, trachea, crackles
- Cardiac exam: impulse location, parasternal heave, murmur, friction rub
- Abdomen: check epigastric area, RUQ
- Extremities: bilateral blood pressures in upper & lower ext
Review: Hx of CP
Normal EKG
- Reduces pretest probability of acute MI but not unstable angina
- Dissection, PE classically normal
Review: Hx of CP
Abnormal EKG
- ST elevation, Q-waves is predictive of current/old MI
- Non-specific findings (ST depression, T-inversion)
- May lead to noncardiac diagnoses
Review: Hx of CP
Chest Radiograph
- Rule out pneumothorax, dissection, pneumomediastinum
- Pulmonary infiltrate, mass, adenopathy
- Pulmonary edema suggestive of CHF from acute LV dysfunction from a myocardial infarction
T/F: Most routine tests for chest pain (EKG, CXR, enzymes) are sufficient to exclude this condition!!!
False, they are not.
