Chest pain

CHEST PAIN

MARYAM JAMILAH BINTI ABDUL HAMID

082013100002

IMS BANGALORE

Learning Outcome

• Definition

• Type of chest pain

• Etiology

• Characteristic of cardiac chest pain

• Ischaemic cardiac pain vs non-cardiac chest pain

• Differential diagnosis

Chest PainDefinition:

A general term for any dull, aching pain in thethorax. It can be cardiac or non-cardiac related.

Etiology

Cardiac

• Myocardial ischemia & trauma

• Angina pectoris

• Acute Coronary Syndromes

Non-Cardiac•Aortic stenosis•Aortic dissection•Pericarditis•Pulmonary embolism•Pulmonary hypertension•Pneumonia/pleuritis•Spontaneous hypertension•Esophageal reflux•Esophageal spasm•Peptic ulcer•Gallbladder disease•Musculoskeletal disease•Herpes zoster•Emotional & psychiatric conditions

Types Of Chest Pain

Pleuritic

SharpBurning

PressureTightnessHeaviness

Burning

Tearing/ripping

BurningPressure

Angina, unstable angina, acute MI

Pericarditis

Aortic dissection

Gallbladder disease

Pul. Embolism, Pneumonia,

Pleuritis, Spontaneous hypertension

Esophageal reflux, peptic ulcer, herpes

zoster

PressureTightnessBurning

VariableAching

Emotional & psychiatric conditions

Esophageal spasm

Musculoskeletal disease

Evaluate a chest pain1. Could the chest discomfort be due to an acute, potentially life-threatening

condition that warrants immediate hospitalization and aggressive evaluation?

-Acute ischemic heart disease -Pulmonary embolism

-Aortic dissection -Spontaneous pneumothorax

2. If not, could the discomfort be due to a chronic condition likely to lead to serious complication?

-Stable angina -Aortic stenosis -Pulmonary hypertension

3. If not, could the discomfort be due to an acute condition that warrants specific treatment?

-Pericarditis -Pneumonia/pleuritis -Herpes zoster

4. If not, could the discomfort be due to another treatable chronic condition?

-Oesophagel reflux, oesophageal spasm, peptic ulcer disease, other GI condition, cervical disc disease, arthritis of the shoulder or spine, costochondritis, other musculoskeletal disorders, anxiety state

Initial Evaluation of Suspected Cardiac Pain

Importance of initial evaluation:-

• Crucial process

• Determine the:-

– Nature and extent of any underlying heart disease

– Risk of serious adverse event

– Management

Characteristics Of Ischaemic Cardiac Pain

• Characteristic of pain

• Site

• Radiation

• Provocation

• Onset

• Associated features

Character

• Dull, constricting, choking or heavy

• Squeezing, crushing, burning or aching

• Breathlessness

• Discomfort > pain

Site

• Centre of the chest

• Derivation of the nerve supply to the heart & mediastinum (sensory sympathetic cardiac nerves; T1-T5, mostly dorsal root ganglion Lt.)

Radiation

• Radiate to neck, jaw & upper or even lower arms

• Occasionally, at the sites of radiation or in the back

Provocation

• Angina pain: during exertion and promptly relieved by rest (<5 minutes), pain may exacerbated by emotion but occur more readily by exertion; large meal, cold wind

• Crescendo/Unstable angina: similar pain can be precipitated by minimal exertion or at rest

• Decubitus angina: increase venous return/preload by lying down can provoke pain in vulnerable patients

Onset

• Myocardial infarction (MI): Pain of MI takes several minutes or longer to develop

• Angina: Pain builds up gradually in proportion to the intensity of exertion

• Aortic dissection, massive pulmonary embolism or pneumothorax : Pain is very sudden or instantaneous

• Musculoskeletal or psychological: Pain occur after exertion

Associated features

• Autonomic disturbance; sweating, nausea, vomiting

• Breathlessness: pulmonary congestion from transient ischaemic Lt. ventricular dysfunction

CHARACTERISTICISCHAEMIC CARDIAC

CHEST PAINNON-CARDIAC CHEST PAIN

LOCATION Central, diffuse Peripheral, localised

RADIATIONJaw/neck/shoulder/arm(occasionally back)

Other or no radiation

CHARACTER Tight, squeezing, choking Sharp, stabbing, catching

PRECIPITATION Exertion and/or emotionSpontaneous, provoked by posture,respiration or palpitation

RELIEVING FACTORRest, quick response to nitrates

Not relieved by rest, slow or no response to nitrates

ASSOCIATED FEATURES BreathlessnessRespiratory, gastrointestinal, locomotoror psychological

Differential Diagnosis ofChest Pain

• Anxiety/emotion

• Cardiac

• Aortic

• Oesophageal

• Lungs/pleura

• Musculoskeletal

• Neurological

Anxiety

• Common cause for atypical chest pain

• Lack of relationship with exercise

• Receiving bad news

Cardiac

• Myocardial ishaemia (angina), MI, myocarditis, pericarditis, mitral valve prolapse

• Myocarditis & pericarditis: – Pain felt retrosternally, to the Lt. of the sternum, or in

the Lt./Rt. Shoulder

– Intensity varies with movement and phase of respiration. ‘sharp’ and may ‘catch’ during inspiration, coughing or lying flat.

– Occasionally, history of prodromal viral illness

Aortic

• Aortic dissection, aortic aneurysm

• Aortic dissection:

– Pain is severe, sharp and tearing

– Penetrating through to the back

– Abrupt in onset

– Pain follows path of the dissection

Aortic aneurysm

Aortic dissection

Oesophageal

• Oesophagitis, oesophageal spasm,

Mallory-Weiss syndrome

• Pressure, tightness, burning

• Retrosternal

• Mimic angina very closely– Sometimes precipitated by exercise

– Sometimes relieved by nitrates

• Elicit history of chest pain to supine posture or eating, drinking or oesophageal reflux

• Radiates to the back

Lungs/Pleura

• Bronchospasm, pulmonary infarct, pneumonia, tracheitis, pneumothorax, pulmonary embolism, malignancy, tuberculosis

• Bronchospasm:– Reversible airways obstruction (e.g. asthma):

exertional chest tightness that is relieved by rest. Difficult to distinguish from ischaemic chest tightness

• Pneumonia, pleuritis and pulmonary embolism:– Pleuritic pain (sharp pain when breathing)

Musculoskeletal

• Osteoarthritis, rib fracture/injury, costochondritis(Tietze’s syndrome), intercostal muscle injury, epidemic myalgia (Bornholm disease-by coxsackievirus)

• Aching

• Very variable in site and intensity

• Vary with posture and movement of upper body

• Can be accompanied by local tenderness over a rib or costal cartilage

• Injuries related to everyday activities or viral infection

Neurological

• Prolapsed intervertebral disc

• Herpes zoster (Sharp or burning)

• Thoracic outlet syndrome

Stable Angina VS Acute Coronary Syndrome

STABLE ANGINA ACUTE CORONARY SYNDROMES(unstable angina, STEMI, NSTEMI)

•Effort-related chest or

‘choking in the chest’

•Relationship to physical

exertion (and occasionally

emotion) of the chest pain

•The duration of symptoms

should be noted because

patients with recent-onset

angina are at greater risk

•Urgent evaluation

•Prolonged, severe

cardiac chest pain


•Physical examination: often normal but may reveal evidence of risk factors (egxanthoma indicate hyperlipidaemia),

Lt. ventricular dysfunction (dyskinetic, apex beat, gallop

rhythm), other manifestations of arterial disease (eg bruits, signs of peripheral vascular

disease) and unrelated conditions that may exacerbate angina (eganaemia, thyroid disease)

•Physical examination: signs of important comorbidity, such as peripheral or cerebrovascular disease, autonomic disturbance (pallor or sweating) andcomplications (arrhythmia or heart failure)


•Coronary artery disease, aortic valve disease and hypertrophic cardiomyopathy•Angina+murmur=echocardiography•A full blood count, fasting blood glucose, lipids, TFT, 12-lead ECG, exercise testing•CT Coronary angiography

•Signs of haemodynamiccompromise (hypotension, pulmonary oedema)•ECG changes: ST segment elevation or depression)•Biochemical markers: elevatedtroponin I or T (short-term)•A 12-lead ECG•New ECG changes oran elevated plasma troponinconcentration confirm thediagnosis of an acute coronary syndrome. exercise test or CT coronary angiogram todiagnose underlying coronary artery disease.

Types Of Chest Pain

Pleuritic

SharpBurning

PressureTightnessHeaviness

Burning

Tearing/ripping

BurningPressure

Angina, unstable angina, acute MI

Pericarditis

Aortic dissection

Gallbladder disease

Pul. Embolism, Pneumonia,

Pleuritis, Spontaneous hypertension

Esophageal reflux, peptic ulcer, herpes

zoster

PressureTightnessBurning

VariableAching


Esophageal spasm


Condition Duration Quality LocationAssociated

features

Angina 2 min <t< 10 min Pressure, tightness, heaviness, burning

Retrosternal, often with radiation to or isolated discomfort in neck, jaw, sholders, or arms- freq. left

Precipitated by exertion, exposure to cold,psychologic stressS4 gallop or mitral regurgitation murmur during pain

Unstable angina

10-20 min Similar to angina but >severe

Similar to angina Similar to angina but occurs with low levels of exertion or even at rest

Acute MI Variable; often >30 min

Similar to angina but>severe

Similar to angina Unrelieved with nitroglycerinMay be associated with heart failure or arrhythmia

Typical Clinical Features of Major Causes of Acute Chest Discomfort

Condition Duration Quality Location Associated features

Aortic stenosis

Recurrent episodes

Same as angina Same as angina Late-peakingsystolic murmur radiating to carotid arteries

Pericarditis Hours-days; may be episodic

Sharp Retrosternal or toward cardiac apex; may radiate to Lt. shoulder

May be relieved by sitting up and leaning forwardPericardial friction rub

Aortic dissection

Abrupt onsetof unrelenting pain

Tearing or rippingsensation; knifelike

Anterior chest offten radiating to back,betweenshoulder blades

Hypertensionand/or underlying connective tissue disorder,e.g., Marfan syndrome

Pulmonary embolism

Abrupt onset;several min-few hours

Pleuritic Often lateral, on the side of the embolism

Dyspnea, tachypnea,tachycardia and hypotension

Pulmonaryhypertension

Variable Pressure Substernal Dyspnea,signs of increased venous pressure includingedema & jv distension


features

Pneumonia/pleuritis

Variable Pleuritic Unilateral,oftenlocalized

Dyspnea, cough, fever, rales, occasional rub

Spontaneous hypertension

Sudden onset;several hours

Pleuritic Lateral to side of pneumothorax

Dyspnea,decreased breath sounds on side of pneumothorax

Esophageal reflux

10-60 min Burning Substernal, epigastric

Worsened by postprandial recumbencyRelieved by antacids

Esophageal spasm

2-30 min Pressure,tightness, burning

Retrosternal Can closely mimic angina

Peptic ulcer Prolonged Burning Epigastric, substernal

Relieved with food or antacids


features

Gallbladderdisease

Prolonged Burning,pressure

Epigastric, Rt. Upper quadrant, substernal

May follow meal


Variable Aching Variable Aggravated by movementMay be reproduced by localized pressure one examination

Herpes zoster Variable Sharp or burning

Dermatomaldistribution

Vesicular rash in area of discomfort


Variable;may be fleeting

Variable Variable; may be retrosternal

Situational factors may precipitate symptomsAnxiety or depression often detectable with careful history

Conclusion

Topics which are covered:-

• Define chest pain

• Types of chest pain

• Characteristic of cardiac chest pain

• Ischaemic cardiac pain vs non-cardiac chest pain

• Differential diagnosis

References

• Davidson’s Principles & Practice of Medicine 23rd Edition

• Harrison’s Internal Medicine 18th Edition

• Hutchinson’s Clinical Method 22nd Edition

Chest pain

Education

Transcript of Chest pain