SQN LDRDR AAMIR HUSSAINMEDICAL SPECIALIST/ASSISTANT PROFPAF HOSPITAL /FAZIA MEDICAL COLLEGE

CHEST PAINAN APPROACH

OBJECTIVES•AT THE END OF THIS LECTURE, THE FIRST YEAR STUDENTS WILL BE ABLE TO•UNDERSTAND THE CAUSES OF CHEST PAIN•REALIZE THE LIFE THREATENING CAUSES OF CHEST PAIN•UNDERSTAND THE IMPORTANCE OF HISTORY TAKING•ORDER THE COMMON INVESTIGATIONS•LEARN COMMON ECG CHANGES•PROVIDE INITIAL MANAGEMENT

CHEST PAIN•ACUTE CHEST PAIN ACCOUNTS 7 MILLIONS EMERGENCY VISITS ANNUALLY•APPROXIMATELY 20 % OF PATIENTS ACTUALLY HAVE ACS•ALMOST 65 % THOSE ADMITTED OR DETAINED ,ARE TURNED OUT TO BE NON CARDIAC •ACS IS THE NUMBER ONE CAUSE OF DEATH WORLDWIDE, ACCOUNTS FOR 12% OF DEATHS•NEARLY 3% ACS ARE MISSED AND DISCHARGED FROM EMERGENCY

CHEST PAIN:ORIGIN•HEART• AORTA

•LUNG• PLEURA

•ESOPHAGUS• STOMACH

•MEDIASTINUM•MUSCULOSKELETAL•NERVE ROOTS/NERVES• PSYCHOGENIC

LIFE-THREATENING CAUSES OF CHEST PAIN•ACUTE CORONARY SYNDROME•AORTIC DISSECTION•PULMONARY EMBOLISM• TENSION PNEUMOTHORAX•PERICARDIAL TAMPONADE•MEDIASTINITIS(EG ESOPHAGEAL RUPTURE)

FINAL DIAGNOSIS PERCENTAGE OF EPISODES

MUSCULOSKELETAL PAIN 30%

GASTROINTESTINAL(GERD) 25%

ANGINA 10%MYOCARDIAL INFARCTION 3%

PSYCHOGENIC/PANIC 20%RESPIRATORY DISEASE 5%NO DIAGNOSIS 7%

CAUSES OF CHEST PAIN IN THE PRIMARY CARE (OPD)SETTING

DIAGNOSIS IS BASED ON•1. GOOD HISTORY •2. PHYSICAL EXAMINATION•GENERAL•SYSTEMIC

•3. INVESTIGATIONS• INITIAL• ECG• CARDIAC ENZYMES / TROP T OR I• CXR

•SECOND LINEEXERCISE TOLERANCE TEST & ECHOCARDIOGRAPHY, THALLIUM VIABILITY SCAN & CORONARY ANGIOGRAPHY.MRI AND CT SCAN CHEST

CHARACTERISTICS OF PAIN…. SOCRATES.•1. SITE/POSITION•2.ONSET•3.CHARCTER/QUALITY•4.RADIATION•5.ASSOCIATED SYMPTOMS•6.TIMING•7.EXACERBATING AND RELIEVING FACTORS•8.SEVERITY

CHARACTERISTICS CARDIAC NON CARDIAC

LOCATION CENTRAL,DIFFUSE PERIPHERAL,LOCALIZED

RADIATION JAW,NECK,SHOULDER,ARM

NO RADIATION

CHARACTER TIGHT,SQUEEZING,CHOKING

SHARP,STABBING,CATCHING

PRECIPITATION BY EXERTION,EMOTION SPONTANEOUS,PROVOKED BY COUGH,POSTURE,PALPATION,

RELIEVING FACTORS REST,NITRATES NOT

ASSOCIATED FEATURES BREATHLESSNESS RESP,GASTR,LOCO,PSYCHO

CHEST PAIN

MUSCULOSKELETAL•RAPID ONSET•CONSTANT•INCREASES WITH DEEP BREATHING AND CHANGE IN POSTURE•REPRODUCED/TENDER BY PALPATION•HISTORY OF RECENT EXERCISE/EXERTION•VITALS ARE STABLE•ANXIETY/ATTENTION DEMANDING/MOTIVES

PSYCHOLOGICAL•PANICS•GAD•FEMALE •INTENSE FEAR•SUDDENT ONSET, PEAKED IN MINUTES, DISAPPEARED IN HOURS•ASSOCIATED WITH SHAKING, TACHYPNOEA, TACHYCARDIA•RECURRENT WITHOUT STIMULUS

GASTROINTESTINAL•BURNING•PROLONGED•SUBSTERNAL/EPIGASTRIC•REGURGITATION OF LIQUIDS OR FOOD•INCREASED BY CHOCOLATE,COFFEE•OVERWEIGHT•AFTER LARGE MEAL•LYING AFTER MEAL

CHEST PAIN SITE AND RADIATION

NOT CHARACTERISTIC OF ANGINA

•SHARP OR KNIFE LIKE PAIN BROUGHT ON BY RESPIRATORY MOVEMENTS OR COUGH•PAIN LOCALIZED BY TIP OF ONE FINGER OVER LEFT

CHEST•PAIN REPRODUCED WITH MOVEMENT OR PALPATION

OF CHEST WALL •CONSTANT PAIN THAT PERSISTS FOR MANY

HOURS/DAYS•VERY BRIEF EPISODES OF PAIN THAT LASTS FOR

SECONDS•PAIN IN THE MIDDLE OR LOWER ABDOMEN•PAIN THAT RADIATES TO LOWER LIMBS

RED FLAGS•ABNORMAL VITAL SIGNS•SIGNS OF HYPOPERFUSION•SHORTNESS OF BREATH•HYPOXEMIA ON PULSE OXIMETRY•ASYMMETRIC PULSES OR BREATH SOUNDS•NEW HEART MURMURS•DISTENDED JVP

PITFALLS TO AVOID•THE ECG WAS NORMAL•THE TROP T WAS NORMAL•THE CHEST XRAY WAS NORMAL•LBBB WAS OLD•YOUNG PATIENTS CAN NOT HAVE MI•SHORTNESS OF BREATH/ANGINAL EQUIVALENT

HISTORY AND EXAMINATION ARE MORE IMPORTANT THAN……

Chest pain scenario•A 60-YEAR-OLD BUSINESSMAN COMPLAINS OF CENTRAL CRUSHING CHEST PAIN RADIATING TO BOTH ARMS AFTER RUNNING TO CATCH A BUS.• THE PAIN WAS RELIEVED BY REST AND HIS ECG RECORDING 1 HOUR LATER WAS UNREMARKABLE……..•WHAT IS THE LIKELY DIAGNOSIS……

CHEST PAIN SCENARIO•A 23-YEAR-OLD FEMALE PRESENTS WITH LOCALIZED LEFT-SIDED CHEST PAIN THAT IS EXACERBATED BY COUGHING. •THE AREA IS TENDER TO LIGHT PRESSURE. PAIN IS RELIEVED BY ASPIRIN. THE ECG RECORDING IS UNREMARKABLE……WHAT IS THE LIKELY DIAGNOSIS…….

CHEST PAIN SCENARIO •A 22 YEAR-OLD-MALE PRESENTS TO EMERGENCY

DEPARTMENT WITH SEVERE CENTRAL CHEST PAIN.HE HAS HAD A RECENT FLU LIKE ILLNESS.•THE PAIN IS DESCRIBED AS HEAVY AND STABBING. IT IS

MADE WORSE WHEN LYING DOWN AND RELEIVED BY SITTING FORWARD.•ON EXAMINATION,PULSE IS 90 BPM,BP 120/80 mm

Hg, JVP IS RAISED 2 CM ABOVE STERNAL ANGLE . HEART SOUNDS ARE OBSCURED BY PROMINET RUBBING SOUND. •CHEST IS CLEAR.OTHER SYSTEMS ARE NORMAL.•WHAT IS THE LIKELY DIAGNOSIS…….

CHEST PAIN SCENARIO•A 68-YEAR-OLD FEMALE PRESENTS WITH CENTRAL

TEARING CHEST PAIN THAT RADIATES TO HER BACK FOR 2 HOURS. SHE DESCRIBES PAIN SEVERITY AS 10/10.. SHE IS OBESE AND SMOKES 20 PACK-YEAR. SHE HAS A HISTORY OF POORLY CONTROLLED HYPERTENSION. SHE IS PALE AND SWEATY. BLOOD PRESSURE IS 210/100 mm Hg IN RT ARM AND 190/80 IN LT ARM,PULSE IS 106 bpm.•ON EXAMINATION,SHE WAS UNCOMFORTABLE .•A LOUD DIASTOLIC MURMUR OF AORTIC

REGURGITATION WAS AUDIBLE.CARDIAC BIOMARKERS NEGATIVEWHAT IS LIKELY DIAGNOSIS……

CHEST PAIN SCENARIO•A 55-YEAR-OLD MAN HAS JUST ARRIVED IN EMERGENCY DEPARTMENT COMPLAINING OF 20 MINUTES OF CENTRAL CRUSHING CHEST PAIN. IT RADIATES TO INFERIOR ASPECT OF LEFT ARM….HE IS ANXIOUS, NAUSEATED AND SWEATY...HE IS SMOKER AND A KNOWN CASE OF HYPERTENSION AND DIABETES MELLITUS FOR 10 YEARS.•HIS PULSE 98 bpm, AND BP 160/90 mm Hg.•REST OF THE EXAMINATION IS UNREMARKABLE.•WHAT IS THE LIKELY DIAGNOSIS……SEE THREE SLIDES OF ECG

12 LEAD ECG

RIGHT LEADS

EASY TO MISS,,…….PLEASE SEE IT CAREFULLY

CHEST PAIN SCENARIOA 40-YEAR-OLD FEMALE HAS PRESENTED TO THE EMERGENCY DEPARTMENT WITH CHEST PAIN AND SHORTNESS OF BREATH FOR 12 HOURS. THE PAIN IS LOCATED AROUND THE RIGHT SIDE OF HER CHEST AND IS MADE WORSE ON DEEP INSPIRATION. SYMPTOMS HAD COME ON SUDDENLY AT REST. SHE DENIES ANY SYMPTOMS OF COUGH OR FEVER. HER HISTORY IS SIGNIFICANT FOR TWO MISCARRIAGES AND A DVT IN HER LEFT LEG.ON EXAMINATION,BP 100/60mm Hg, PULSE 120 bpm, RR 32 BPM,OXYGEN SAT 88% AT ROOM AIR. ECG SHOWS……

CHEST PAIN SCENARIO•A 28-YEAR-OLD YOUNG MALE PRESENTS TO

EMERGENCY DEPARTMENT WITH SUDDEN ONSET OF RIGHT SIDED CHEST PAIN.THE PAIN STARTED AS SHARP BUT NOW DULL BUT INCREASES WITH INSPIRATION. •HE HAS COUGH AND SHORTNESS OF BREATH WHICH

HE RELATES WITH HIS SMOKING.•ON EXAMINATION,PULSE 102 bpm, BP 120/80 mm Hg,

RR 26 bpm. OXYGEN SATURATION IS 97% AT ROOM AIR.•CHEST AUSCULTATION DEMONSTRATED DECREASED

AIR ENTRY ON RIGHT SIDE .•ECG IS REPORTED AS NORMAL..•WHAT IS THE NEXT INVESTIGATION…….

ACS INITIAL TREATMENT AND SECONDARY PREVENTION

ACS TREATMENT PROTOCOL•OXYGEN•MORPHINE/NALBINE+MAXOLON•NITROGLYCERINE(SPRAY/SL)•ASPIRINE/CLOPIDOGREL/TICAGRELOR•METOPROLOL/CONCOR•HEPARIN(IV/SC) OR FONDAPARINUX•CLOSE MONITORING WITH ECG/TROP/CK-MB•THROMBOLYSIS VS PCI •GP IIB/IIIA•MEDICATIONS(BETA BLOCKERS/ACE/STATINS)

SECONDARY PREVENTION

•ANTI PLATELET…..ASPIRIN•ANTIPLATELET…..CLOPIDOGREL•BETA-BLOCKER….BISOPROLOL•ACE INHIBITORS…RAMIPRIL•STATINS……………ATORVASTATIN•GOOD BYE TO SEDENTARY LIFE STYLE.

NON CARDIAC

•PROTON PUMP INHIBITOR•ANTIDEPRESSANT•COGNITIVE BEHAVIORAL THERAPY

LIFE THREATENING CAUSES

FOR PULMONARY EMBOLISM•STABILIZATION•THROMBOLYTICS•ANTICOAGULANT• INJECTABLE•ORAL

PNEUMOTHORAX

•STABILIZATION•REST•NEEDLE DECOMPRESSION•CHEST TUBE INSERTION•PLEURODESIS

AORTIC DISSECTION•STABILIZATION•MORPHINE •IMMEDIATE REDUCTION IN BP•SURGICAL /MEDICAL•NO THROMBOLYTIC•NO ANTI-PLATELET•NO ANTICOAGULANT

CHEST PAIN FOR DAYS F0LLOWED BY THESE RASH

THANK YOU