Approach to chest pain diagnosis

By
RODERICK T. VITO, M.D.
 Overview
• Five percent of total ED visits in a year
• Symptom of several life threatening diseases
• Dissociation between intensity of S/Sx and
seriousness of underlying pathology
• Accurate diagnosis is still a challenge
• Involves the somatic and visceral afferent
fibers
 Somatic vs. Visceral
• Somatic pain : dermis and parietal pleura
• Visceral pain : esophagus, heart, blood vessels,
visceral pleura

• Somatic pain : easily described, precisely located,

sharp sensation
• Visceral pain : difficult to describe, poorly localized,
discomfort, heaviness, aching
• ACUTE CHEST PAIN

– Recent onset, <24 hours

– Located anterior thorax
– Noxious , uncomfortable sensation
– Distressed patient
 Initial approach to chest pain
• Focused in the Life Threatening diseases
• ABC life support
• Secondary Survey :
– History taking: quality , location, radiation,
severity, time, provoking factors, relieving factors,
associated symptoms
– Risk factors
– Physical examination
• Three categories of chest pain
1. Chest wall pain
2. Pleuritc or respiratory chest pain
3. Visceral chest pain
 Chest wall pain
• Somatic pain
• Sharp quality, precisely localized
• Reproducible by direct palpation and or chest
wall movement during stretching or twisting
 Chest wall pain
Costosternal Syndrome
Costochondritis
Fibromyalgia
Slipping rib syndrome
Radicular symptoms
Intercostal nerve syndromes
 Pleuritic pain
• Somatic pain
• Sharp quality
• Worsened by coughing or breathing
 Pleuritic pain
Pulmonary embolism
Pneumonia
Pneumothorax
Pericarditis
pleurisy
 Visceral chest pain
• Poorly localized
• Aching and heaviness
 visceral chest pain
• Typical exertional angina
• Atypical angina
• Unstable angina
• AMI
• Aortic dissection
• Pericarditis
• Esophageal reflux
• Aortic dissection
• Esophageal rupture
• Mitral valve prolapse
• In chest pain diagnosis there is no one fact or
observation make the diagnosis
• Challenge is to select the useful features that
guide further assessment, management and
disposition
• Risk factors
• Age
• Review of medical records
• Therapeutic trials
 Risk factors
• CAD: cigarette smoking, HPN, DM, high
cholesterol, family history
• Aortic dissection : middle age, male, HPN,
marfan syndrome
• Pulmonary embolism: hypercoagulable
diasthesis, malignancy, recent immobilization
or surgery
• Age: below 30 years rare to have coronary
artery disease
• Acute cocaine use prone to have AMI
• Chronic cocaine : atherosclerosis, severe
coronary artery disease
Youth or absence of risk factors does not
completely eliminate any potentially serious
cause of acute chest pain
 Review medical records
• Compare tracing or finding of previous cardiac
studies: EKG, stress testings, catheterization
( coronary angiography)
• Esophageal studies: endoscopy, barium
swallowing studies
• GIT: UTZ, CT scan
• Pulmonary : spirometry
 Therapeutic trials
• Gastrointestinal cocktail: antacids,
antispasmodics and local anesthetic:
esophageal reflux
• Nitroglycerin: myocardial ischemia
• NSAID: chest wall pain
 Ischemic equivalents
• Atypical presentations
• Dyspnea at rest, lightheadedness, jaw or
shoulder pain, body weakness, acute change
in mental status, diaphoresis
• Epigastric pain or upper abdominal discomfort
• Patients with sensory impairment : DM,
advanced age, psychiatric patients
• Women, non-white population
 Differential Diagnosis
• Myocardial ischemia
– Imbalance in myocardial blood supply and
oxygen requirements

• In the ER :
– Acute coronary syndrome: unstable angina
pectoris, STEMI and non-STEMI
– Stable Angina : episodic pain, less than 10 min,
exertional, relieved by rest and or NTG
• Unstable Angina: new onset ( less than 1-2
months)
– More frequent, easily provoked, more severe,
difficult to relieve
– Occur at rest ( more than 20 minutes)
– Associated with dyspnea, diaphoresis, nausea
• Acute Myocardial Infarction ( STEMI or non-
STEMI)
– EKG : ST segment elevation, T wave inversion, new
Left bundle branch block
– Serum Markers : (+) cardiac enzymes :
• Troponin T or I
• Myoglobin
• CPK- MB
 Pulmonary Embolism
• Thrombi from the deep vein of the lower extremities
and pelvis would travel to the lungs
• Signs and symptoms will depend on the size of the
thrombi
• Chest pain , dyspnea, syncope, shock, hypoxia
• Pleuritic chest pain
• Tender chest wall during palpation
• Fever, cough, hemptysis
 Aortic dissection
• Jet of blood induces an intimal tear
• Blood dissects the media due systolic aortic
pressures among uncontrolled hypertensives
• Risk factors : uncontrolled hypertension, coarctation
of the aorta, bicuspid aortic valves, aortic stenosis,
marfans syndrome, etc.
• Midline substernal chest pain: tearing , ripping and
searing; radiating interscapular area
• Pain is as worst at its onset felt above and below the
diaphragm
 pneumothorax
• Due to sudden changes in barometric
pressures: smokers, COPD, pleural bleb
disease
• Sudden, sharp, lancinating pleuritic chest pain
and dyspnea
• Absent lung sounds affected side,
hyperresonance to percussion
• Chest X-ray
 Esophageal rupture
• Boerhaave syndrome: rare
• Mackler triad :Substernal sharp chest pain,
vomiting, subcutaneous emphysema
• Spontaneous esophageal rupture
• Increase in intraabdominal pressure
• Esophagus has no serosal layer( contains
elastic fibers and collagen)
 Gastrointestinal disorders
• Dyspepsia syndromes
1. gastroesophageal reflux – burning and
gnawing in character lower half of the chest
2. esophageal spasm – sudden,tight or
gripping substernal chest pain precipitated by
consumpation of hot or cold liquids or large
food bolus
 Peptic ulcer disease
• Postprandial, dull , boring pain in the
midepigastric area
• Awakened from sleep
• Duodenal ulcer type : relieved after eating
• Gastric ulcer type: aggravated by food
• Differentiated from acute pancreatitis or
biliary tract diseases
 Acute pericarditis
• Inflammation of the pericardium following bacterial,
viral or fungal infection
• Non-specific or idiopathic pericarditis
• Trauma : hemopericardium
• Neoplasms: lung and breast
• Dull or sharp precordial pain radiating to the
trapezius, neck and shoulders
• Aggravated by thoracic motion, cough or respiration
• CP maybe relieved by sitting up and leaning
forward
• Auscultation: “friction rub”
• Pericardial effusion is common
 Pneumonia
• Acute infection of the lung parenchyma including
alveolar spaces and interstitial tissues
• Lobar, segmental, bronchopneumonia, interstitial
• Pleuritic chest pain, dyspnea, fever, sputum
production
• Common bacteria: strep pneumonia, anaerobic
bacteria, Staph aureus, H. influenza, kleb pneumonia,
mycoplasma pneumoniae, chlamydia pneumoniae
 Muskuloskeletal pain
• Localized, sharp pain
• Reproduced by light palpation of a discrete area
• Costochondritis – inflammation of the costal
cartilages and /or their sternal articulations ; sharp
and dull pain increased with respiration
• Differentiated from pulmonary embolism and
myocardial ischemia
 Panic Disorders
• Recurrent, unexpected panic attacks
• Palpitation, diaphoresis, tremor , dyspahagia,
choking, chest pain , nausea, dizziness, fear of
losing control or dying, paresthesia, chills
• Diagnosis of exclusion
 Ancillary Studies

ECG
Chest x-ray
Serum markers
– CK-MB
– Myoglobin
– Troponin I and T
 Empiric Management
• Placed in cardiac monitor
• Oxygen therapy
• IV line initiated
• Vital Signs
• ECG
• Chest x-ray
• MONA ( morphine, oxygen, nitroglycerine and
aspirin)
• Pericardiocenthesis
Thank you.