CHEST PAIN

BY

MONA ADEL, MD,FACC

A.PROFESSOR OF CARDIOLOGY TANTA UNIVERSITY CARDIOLOGY CONSULTANT ELITE MEDICAL CENTER

Mona Adel FEB.2010

 Abnormal unpleasant sensation in the chest area. Chest pain accounts for approximately 6 million annual visits to emergency departments (ED) in the United States (US), making chest pain the second most common complaint .

Mona Adel FEB.2010

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Mona Adel FEB.2010

 Patients present with a spectrum of signs and symptoms reflecting the many potential etiologies of chest pain. Diseases of the heart, aorta, lungs, esophagus, stomach, mediastinum, pleura, chest wall and abdominal viscera may all cause chest discomfort.
Mona Adel FEB.2010

Take few minutes to have a good history and examination for the patient

Mona Adel FEB.2010

HISTORY
Age Sex Smoking Alcohol or illicit drugs HTN DM Dyslipidemia Family history Previous conditions or diagnostic procedures
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ANALYSIS OF 7
Onset of pain Provocation Quality of pain Radiation Site of pain Timing Palliation
Mona Adel FEB.2010

Associated symptoms
Diaphoresis, nausea, and vomiting ACS, aortic dissection, pulmonary embolus, acute heart failure, and esophageal spasm.
Shortness of breath frequently accompanies pulmonary causes of chest pain and may be the predominant symptom in pulmonary embolus, pneumothorax, and pneumonia. Cough, syncope, and hemoptysis

Fever infectious causes, pericarditis, myocarditis, PE and Dressler syndrome

Mona Adel FEB.2010

Atypical presentation
Elderly patients Women DM Disturbed consciousness ACS may only complain of symptoms other than chest pain, such as dyspnea, weakness, altered mental status, or syncope
Mona Adel FEB.2010

PHYSICAL EXAMINATION
1- VITALS, UNEQUAL PULSES 2- LOCAL SIGNS 3-TENDERNESS 4- MURMURS 5-PULMONARY SIGNS

Mona Adel FEB.2010

ANCILLARY STUDIES
ECG 1- ACS( STEMI.NSTEMI.UNSTABLE ANGINA) 2-AORTIC DISSECTION 3-PE 4-PNEUMOTHORAX 5-TAMPONADE
Mona Adel FEB.2010

LAB
Cardiac biomarkers D-dimer Complete blood count B-type natriuretic peptide (BNP 100 pg/mL have a 90 % sensitivity for acute heart failure Arterial blood gas
Mona Adel FEB.2010

Chest radiograph
chest radiograph (CXR) is obtained in all chest pain patients with hemodynamic instability or a potentially life-threatening diagnosis. A nondiagnostic CXR is typical in patients with ACS Acute heart failure Aortic dissection Pulmonary embolus Pneumonia and pneumothorax Mediastinal emphysema and pleural effusion
Mona Adel FEB.2010

Other imaging
CT MRI ECHO

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Life-threatening conditions
Acute coronary syndrome Aortic dissection Pulmonary embolism Tension pneumothorax Pericardial tamponade Mediastinitis (eg, Esophageal rupture)

Mona Adel FEB.2010

APPROACH TO DIAGNOSIS

Mona Adel FEB.2010

CASE 1
Mr x is 57 , not HTN, DM , heavy smoker presented with compressing chest pain, retrosternal , referred to the lower jaw started 2 hours before ,it is continuous and increasing in intensity. ABP =150/90 , PULSE 100 , RR=16 , TEMP=37 P ale , sweaty , Heart silent, Lungs are clear What to do ?
Mona Adel FEB.2010

ECG

Mona Adel FEB.2010

What to do ?
1- TH. TH 2-WAIT FOR TROPONIN AND THEN TH.TH 3-WAIT FOR CHEST X-RAY AND GIVE TH.TH 4- TRANSFER TO A HOSPITAL 1 HOUR AWAY FOR PCI

Mona Adel FEB.2010

CASE 2
22 , male patient , not DM , not HTN , smoker Acute chest pain and SOB after chest trauma Distressed , ABP=90/60 , PULSE 120 , Thready Congested neck veins , clear lungs Heart sounds , remote
Mona Adel FEB.2010

What to do
1- ECG and follow up 2- Wait for chest x-ray and TH.TH 3-ECHO and follow up 4-Fluid challenge and immediate echo

Mona Adel FEB.2010

 Vedeo of severe pericardial effusion

Mona Adel FEB.2010

Case 3
34 years old MRs x with acute chest pain Not DM , NOT HTN , PUERPERUM FOR 7 DAYS TALL AND THIN ABP=120/80 , PULSE 100 , UNEQUAL CLEAR LUNGS DIASTOLIC MURMUR INSIDE THE APEX
Mona Adel FEB.2010

WHAT TO DO
IMMEDIATE X-RAY AND FOLLOW UP IMMEDIATE ECHO AND CONSULT CARDIAC SURGERY IMMEDIATE TH.TH INTERCOSTAL TUBE

Mona Adel FEB.2010

 ECHO OF DISSECTION

Mona Adel FEB.2010

CASE 4
MRS X IS 33 , NOT DM , NOT HTN , NOT SMOKER REPEATED ABORTIONS ACUTE SEVERE CHEST PAIN DISTRESSED , ABP=80/60, PULSE 120 , THREADY, CLEAR LUNGS, CONGESTED NECK VEINS HEART FREE
Mona Adel FEB.2010

ECG

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 D.DIMER POSITIVE

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WHAT TO DO
HEPARIN AND FOLLOW UP ICU , ECHO AND TH .TH BLOOD GASES PULMONARY ANGIO AND FOLLOW UP

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Pneumothorax

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OTHERS
CHEST WALL PAIN Musculoskeletal pain Rheumatic diseases Nonrheumatic systemic diseases Skin and sensory nerves GASTROINTESTINAL CAUSES OF CHEST PAIN PULMONARY CAUSES OF CHEST PAIN
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PSYCHOGENIC/PSYCHOSOMATI C CAUSES OF CHEST PAIN

20 percent had panic disorder as the etiology Hyperventilation, which is associated with panic attacks, can also result in nonanginal chest pain and occasionally electrocardiographic changes, particularly nonspecific ST and T wave abnormalities
Munchausen syndrome
Mona Adel FEB.2010

PAIN REFERRED TO THE CHEST

Referred pain may occur when the same spinal cord segments supplying dermatomal areas of the chest wall also innervate the very sensitive parietal pleura or peritoneum. As an example, irritation of the mediastinal pleura or of the central diaphragm due to gallbladder or liver disease may result in neck and shoulder pain, while more peripheral diaphragmatic irritation may result in inferior chest pain A herniated thoracic disc may cause "band-like" anterior chest pain [4].
Mona Adel FEB.2010

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