Chest Pain and Acute Coronary Syndromes

Cardiovascular Unit
Dr Lisa Quinn,
Associate Professor in Medical Education
Overview
What can cause chest pain?
Building a “differential diagnosis”
Features of cardiac (ischaemic) pain vs ‘pleuritic chest pain’

What are cardiac causes for chest pain and how do I recognise them?
Pericarditis
Acute coronary syndromes: pathophysiology, clinical features
Unstable angina vs myocardial infarction (NSTEMI/STEMI)
Stable angina
Chest pain is a common presenting complaint!

Present to GP or hospital

Spectrum of pathology

Life-threatening Non-urgent
Image: http://www.rcemlearning.co.uk/wp-content/uploads/Man-with-chest-pains.jpg
How do I reach a diagnosis?

History Clinical Examination Further investigations

Diagnosis
Brain-dump!
scribble down as many causes of chest pain you can think of in 10 seconds…*

*without looking at the subsequent slides

Causes of chest pain
Skin
Musculoskeletal (bone, muscle & cartilage)
Trachea
Lungs & surrounding pleura
Heart
Gastrointestinal tract- oesophagus
Blood vessels- aorta

Illustrative purposes only: not entirely anatomically accurate

Causes of chest pain
Respiratory
Cardiac
Lungs and pleura
Heart muscle (ischaemia) e.g.
Pericardial sac

Musculoskeletal Gastro-intestinal
Muscle, bone, cartilage… Oesophagus, stomach
Costochondritis e.g. reflux disease (GORD),
Rib facture Vascular peptic ulcer disease
Aorta
e.g. aortic dissection GORD: gastro-oesophageal reflux disease
Important to quickly identify potentially life-threatening causes…
Chest pain relating to the heart muscle
causing or risking cardiac muscle death (infarct)
Acute coronary syndromes

Features of the pain described by the patient provides

key information

Musculoskeletal problem
Non-life threatening: much less concerning
e.g. costochondritis
Some causes of chest pain present with similar pain features…
Respiratory Involvement
Cardiac Lung conditions with pleura involved
of pleura
causes
Heart muscle e.g. pneumonia with pleurisy
inflammation
of pleura
Acute Coronary Syndromes
associated features also likely- that suggest
Stable angina involvement of respiratory system e.g.

Pericardial sac

Pericarditis
Musculoskeletal
Muscle, bone, cartilage…
Costochondritis
Rib facture
 “Cardiac (ischaemic)” vs “Pleuritic” Chest Pain
Pain ‘features’ determined by type of nerve innervation of structure(s) involved by disease

Pain from heart muscle due to ischaemic or infarct Pain from lung pleura, pericardial sac
or musculoskeletal structures of chest wall

Visceral (afferent) nerves Somatic (afferent) nerves

Visceral pain* Somatic pain

Particular features described… Particular features described…

*visceral pain can also come from other ‘viscera’ i.e. deep tissue structures like organs
“Cardiac (ischaemic)” Chest Pain
Pain from heart muscle due to ischaemic or infarct
“Dull”, “pressure” ‘tightness’ ‘heaviness’ in chest
Visceral (afferent) nerves
(carried in sympathetic fibres) Felt centrally (centre of chest)
Poorly localised
Brain perceives “visceral pain” May also describe pain in shoulder and/or neck
Why is cardiac (ischaemic pain) felt in central chest
3. Somatic afferents from skin dermatomes
(T1 –T4/5)  same spinal cord segment

2. Enter spinal cord segments

T1- T4/5
Brain ‘interprets’ signals as
pain arising from skin
Pain perceived as arising from chest
1. Visceral correlating to T1-T4/5
afferents sense tissue damage
(run in sympathetic nerves)
“Pleuritic” Chest Pain
Pain from lung pleura, pericardial sac or
musculoskeletal structures of chest wall
Somatic (afferent) nerves
Brain perceives “somatic pain”
Sharp
Well localised
No radiation
Other features may include
Worsened with position (e.g. pericarditis)
Worsened with inspiration & coughing
(e.g respiratory or MSK cause)
(ischaemic)
A 55 year old woman presents with chest pain. It started a few days ago gradually. It’s been present
continuously but much worse when breathing deeply or if coughs.

The pain is sharp, and she indicates with her fingers to an area to the left of the sternum, which is very
tender to palpation. The pain is not felt anywhere else. She feels otherwise well but is anxious about the
pain.

She has a history of hypertension and is a current smoker. No other prior medical history of note.
Clinical examination is normal including all vital signs
There is area of tenderness over left 4th intercostal cartilage

Is this pleuritic or typical cardiac-sounding chest pain?

What is the likely involved ‘system’ e.g. MSK, resp, cardiac?
Possible diagnoses within each…how well does the ‘story’ match your ‘illness scripts’
What is the most likely diagnosis?
For extra notes…
Overview
What can cause chest pain?
Building a differential diagnosis
Key features cardiac (ischemic) pain vs pleuritic pain
Overview

What are the cardiac causes for chest pain and how do I recognise them?
Pericarditis
Stable angina
Acute coronary syndromes: pathophysiology, clinical features
Unstable angina vs myocardial infarction (NSTEMI/STEMI)
Cardiac Causes for Chest Pain…

Pericardium (innervated by somatic afferents)

can become inflamed
-pericarditis

Cardiac muscle (innervated by visceral afferents [run with sympathetic nerves into spinal cord])
can become ischaemic or infarcted
-stable angina
-acute coronary syndromes
Pericarditis…inflammation of the pericardium
Pericarditis…inflammation of the pericardium

Male > Female May be normal ECG

Typically viral in aetiology
Viral prodrome
‘Pleuritic’ pain worsened by being
supine; eased with sitting up or forward
Tachycardia Blood tests
Pericardial rub (on auscultation of Other investigations may include (to help rule
heart) out other causes or complications)
e.g. chest x-ray, echocardiogram
 Widespread
saddle-shaped
ST elevation
Acute Coronary Syndrome & Stable Angina
Acute Coronary Syndrome is used to describe a spectrum of
conditions…
These include
A. Stable angina
B. Unstable angina
C. Myocardial infarction
D. ST-elevation myocardial infarction
E. Non- ST-elevation myocardial infarction
attempt without looking on next slide
An acute coronary syndrome can often be first clinical manifestation of underlying
cardiovascular disease…
 Ischaemic heart disease
(cardiovascular disease)

Insufficient blood supply to heart muscle due to atherosclerotic disease of coronary

arteries

Stable angina Unstable angina NSTEMI STEMI

A spectrum of acute myocardial ischaemia and/or infarction

Pathophysiology of Ischaemic Heart Disease

Atherosclerosis*
Stable (chronic) occlusion

Image from- 5minuteconsult.com

* refer to Pathological Processes Module-Session

Pathophysiology of Ischaemic Heart Disease

Risk factors for atherosclerosis = risk factors for acute coronary syndrome

Modifiable vs non-modifiable

* refer to Pathological Processes Module-Session

Pathophysiology of Ischaemic Heart Disease…
Stable (chronic) occlusion Stable angina

Plaque rupture (acute)

Thrombus formation
Sudden increased occlusion Acute Coronary Syndrome

Severity of occlusion determines… UA, NSTEMI…or STEMI

* refer to Pathological Processes Module

Pathophysiology of Acute Coronary Syndromes…

Image from- 5minuteconsult.com

* refer to Pathological Processes Module

Acute Coronary Syndromes
Spectrum of acute myocardial ischaemic events caused by

Atheromatous plaque rupture with thrombus formation

Causing acute increased occlusion in coronary artery (in already partially occluded
lumen)

Leading to ischaemia and potentially infarction (myocardial tissue necrosis)

 How do we differentiate between…

All will present with cardiac (ischaemic)-sounding chest pain

Why is it important to differentiate between them?

 Stable angina Unstable angina
“Cardiac”-sounding chest pain
Relieved by rest; comes on with exertion
No associated autonomic features e.g. sweating, nausea
History IHD risk factors

Examination

ECG- normal/no acute changes* ECG- ST seg depression or normal

Investigations Blood tests (cardiac enzymes)- Blood tests (cardiac enzymes)-

Not required…but if taken
Troponin Troponin
 NSTEMI / STEMI

History

Examination
ECG
NSTEMI: ST seg depress/ T wave inversion STEMI: ST segment elevation
Investigations Blood tests (cardiac enzymes)
Troponin
Which of the following causes of chest pain are associated with
a rise in troponin?
A. Stable angina
B. Unstable angina
C. ST-elevation myocardial infarction
D. Non- ST-elevation myocardial infarction
The following changes are noted in several leads of a patient’s ECG. The patient
is describing cardiac chest pain at rest. You are awaiting blood tests.
What is the diagnosis?

A. Stable angina
B. Unstable angina
C. NSTEMI
D. STEMI
The following changes are noted in several leads of a patient’s ECG. The patient
is describing cardiac sounding chest pain at rest.
What is the diagnosis?

A. Stable angina
B. Unstable angina
C. NSTEMI
D. STEMI
There is an evolution of ECG changes in STEMIs…

Hyperacute T waves ST elevation T wave inversion ST normalises ST & T normal

ST elevation Q wave begins Q wave deepens T wave inverted Q wave persists =
Pathological Q waves

Pathophysiology of Heart Disease: Lily

A 69 year old man presents with chest pain. It started 30 minutes ago, quite suddenly while sitting
eating breakfast.

The pain is dull and heavy, and he clutches the front of his chest. He looks pale and sweaty and also
reports feeling an ache in his jaw.

He has a past medical history of hypertension and is a current smoker..

Is this pleuritic or cardiac (ischaemic)-sounding chest pain?

What would be your initial working diagnosis?
What investigation(s) would you order first?
How will this help you further refine your working diagnosis?
What will need to happen next…?
Summary
Chest pain has a wide differential diagnosis that can be non-cardiac or cardiac in origin

Descriptive features of the chest pain can be very helpful in identifying cardiac causes for pain
Cardiac (ischaemic) chest pain vs “pleuritic” chest pain

Important to identify potentially life threatening causes such as acute coronary syndromes quickly, so urgent treatment can be
started

Ischaemic heart disease includes stable angina and acute coronary syndromes
Stable angina is characterised by cardiac sounding pain only on exertion and relieved by rest
Pain settles relatively quickly (<10-15 minutes) during an episode
Summary
Acute coronary syndromes (ACS) includes unstable angina, NSTEMI and STEMI
spectrum of coronary artery disease of increasing severity of coronary artery occlusion
secondary to an acute plaque rupture which causes platelet aggregation and thrombus formation

Cause cardiac sounding chest pain at rest, duration >15 mins, more severe pain, associated autonomic features
e.g. sweating, pallor, nausea

ECG and blood tests (troponin) are critical tests if suspect ACS
Summary
ECG identifies changes consistent with
ischaemia (ST depression, T wave changes)  unstable angina or NSTEMI
infarct (ST elevation..but note evolution of changes time) STEMI

Troponin rise seen in STEMI and NSTEMI (presence of myocyte death) but not in unstable angina or stable
angina