Chest Pain / Discomfort

Dr (Brig) YD Singh
MBBS, MD, FIACM, DIT

Prof & Head Unit of Medicine

FOM, AIMST University, Malaysia
 Chest pain (CP)

• Common challenge in OPD / Emergency.

• Wide D/D ; wide spectrum of outcomes.

• Failure to recognize potentially serious

conditions=> serious complications,death.

• Overly conservative Mx : unnecessary

admissions, tests, procedures & anxiety
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 Major Causes of Chest Pain

Neuromuscular

GI

SPECTRUM OF IHD

Uustable AMI
Chronic Angina
Stable
Angina

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 D/D of patients admitted to hospital with chest pain ruled
not myocardial infarction
Diagnosis Percent
GERD 42
IHD 31
Chest wall 28
syndromes
Pericarditis 4
Pleuritis/Pneumonia 2
Pulmonary embolism 2
Lung cancer 1.5
Aortic aneurysm 1
Aortic stenosis 1
Herpes Zoster 1
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 Approach to the patient with
chest pain

• Two goals
– Diagnosis
– Assess the safety of the immediate
management plan

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Approach to the patient with chest pain
Key Issues

• Focus 1st on identifying patients who require

aggressive interventions to diagnose or
Mx potentially life threatening conditions

• If not, then
– assess the safety of
• DTH
• admission to a non CCU
• immediate ETT.
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 Approach to the patient with
chest pain 1st of 4 questions
• Could the CD be due to an acute,
potentially life threatening condition that
warrants imm hospitalization & aggressive
evaluation?
– ACS
– Aortic dissection
– PE
– Spontaneous/ tension pneumothorax

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 Approach to the patient with
chest pain nd
2 of 4 questions

• If not, could the CD be due to a chronic

condition likely to lead to serious
complications?

– Chronic stable angina

– Aortic stenosis
– Pulmonary hypertension

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 Approach to the patient with
chest pain rd
3 of 4 questions
• If not, could the CD be due to an acute
condition that warrants specific Rx?

– Pericarditis
– Pneumonia/pleurisy
– Herpes zoster

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 Approach to the patient with
chest pain th
4 of 4 questions

• If not, could the CD be due to another

treatable condition?
• Cervical disk
• Eso reflux disease
• Eso spasm • Arthritis of the
• PUD shoulder or spine
• GB disease • Costochondritis
• Other GI condition • Other MSK
disorders
October 14, 2021 • Anxiety state
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 Approach to the patient with
chest pain
Evaluation

• First assess the respiratory & hemodynamic

status :-

• If not stable, then stabilize => diagnostic

evaluation

• If stable => diagnostic evaluation

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 Approach to the patient with
chest pain Understand pain
• Episodic/persistent
• Character
• Severity
• Onset
• Duration
• Location
• Radiation
• Associations
• Aggravating & relieving factors
• Typical clinical features / syndromic approach
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 Approach to the patient with
chest pain Understand pain
• Episodic
• vs
• Non Episodic
• vs
• First Episode / new symptom

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 Understand pain : Character

• Myocardial ischemic pain : angina pectoris

• Visceral discomfort
• Nature :
– Heaviness
– Pressure
– Squeezing
– Burning
– Aching
– Sharp
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Clinical Classification of Chest Pain
(WHO)
• Typical angina (definite)

– (1) Substernal chest discomfort with a characteristic quality and

duration that is
– (2) provoked by exertion or emotional stress and
– (3) relieved by rest or NTG

• Atypical angina (probable)

– Meets 2 of the above characteristics

• Noncardiac chest pain

– Meets 1 or none of the above characteristics

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 Understand pain : Character
• Pericarditis : sharp
• Aortic dissection : tearing / ripping / knifelike
• Pulm Hypertension : pressure
• Pulmonary Embolism : pleuritic
• Esophageal spasm : pressure, tightness, burning
• Peptic Ulcer : burning
• Gall Bladder Disease : burning, pressure
• Neuromuscular: variable
• Herpes zoster : sharp, burning
• Emotional : variable

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 Understand pain : Location

Myocardial Ischemic Pain

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 Levine Sign (AMI)

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 Body language & myocardial
ischemic pain
• If either of 3 gestures => 77% chance that the pain is
due to cardiac ischemia.

• If patients do not use these signs there is an even

chance (50%) that their pain is non-ischemic.

• These signs are not discriminatory, but a positive

response lends support to a diagnosis of cardiac
ischemia.

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 Understand pain : Location

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 Understand pain : Location

• Supradiaphragmatic GI : Substernal
• Subdiaphragmatic GI : mainly abd/epigastric
• Major PE : Substernal
• Other PE / Pulmonary infarct : lateralised,
peripheral
• Pneumonia / pleurisy : lateralised, localised
• Well localized : MSK, emotional
• Interscapular : aortic dissection, myocardial
• Lt shoulder : Pericarditis
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 Understand pain : Radiation

• Wide radiation : myocardial ischemic pain

• Aortic dissection : interscapular
• GB Disease : RUQ, rt shoulder, substernal
• Herpes zoster : dermatomal

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 Understand pain : Onset

• Chr Stable Angina = gradually with

exertion
• UA + AMI : at rest, not related to exertion
• Aortic Dissection : sudden, reach peak
intensity almost immediately
• Pulm Embolism : Abrupt onset
• Spontaneous pneumothorax : Sudden
onset
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 Understand pain : Duration

• Myocardial ischemic pain : Episodic

– CSA : 2-10 min (Chr Stable Angina = CSA)
– UA : 10-20 min
– AMI : often > 30 min, variable
• Aortic Dissection : unrelenting
• Pulmonary embolism : minute to a few hours
• Pericarditis : hours to a few days
• Esophageal spasm : 2-30 min
• Esophageal reflux : 10-60 min
• PUD, GBD, pancreatitis : prolonged
• MSK disease, Herpes zoster : variable
• Emotional & Psychiatric : Variable, often fleeting
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 Understand pain : Precipitants

• Stable Angina : exertion, cold wind, heavy meal, emotion

• GI conditions : alcohol, aspirin, some foods, lying down,

early morning, empty stomach (>2 hr PP), an hour after
a large/fatty meal, vomiting/retching

• Neuromuscular: sport, trauma, respiratory movements,

localized pressure

• Emotional & Psychiatric : situational factors

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 Understand pain : Reproducibility

• Reproducibility of chest pain is used in

– Diagnosing ischemic cardiac pain &
stratifying it’s associated risk
– Diagnosing musculoskeletal pain

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 Understand pain : Relief

• Rest & Nitrates : Myocardial ischemic pain,

Esophageal spasm

• Antacids, PPI, some foods : GE reflux, PUD

• Sitting up : GE reflux, pancreatitis

• Emotional : situational

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 Understand pain : Typical Clinical Features

• Chr Stable Angina :

– episodic, exertional,S4 gallop or MR during pain, relief with
NTG, rest
• UA :
– similar to CSA but precipitated with lower levels of exertion
• AMI :
– Ongoing, unrelieved with NTG
– Sympathetic / vagal activation, emotional aspects (profound
anxiety / fear of death)
– E/O mechanical / hemodynamic / electrical complications
• Aortic Stenosis :
– Similar to CSA
– Late
October
peaking, radiating
14, 2021
Systolic Murmur
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• Aortic dissection :
– Tearing
– HTN, Connective Tissue Disorders
– murmur of AR, pericardial rub, tamponade,
loss of peripheral pulses
– Pregnant ladies
– RV MI
– Point of Care CXR : prominence/dilatation of
aorta, mediastinal widening
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 Dyspnea > Chest Pain Understand pain : Typical C F
Dyspnea > Orthopnea

• Pulmonary Embolism : • Point of Care Echo :

– dyspnea, – IVC collapse
pressure/burning central
chest discomfort – PA dilatation
– tachypnea, tachycardia, – RV dilatation
hypotension(refractory
– RA dilatation
hypotension may
develop in 1-2 days), – IAS bulging to Lt
clear lung fields – Mc Connel’s sign
– Point of Care CXR :
pulmonary oligemia, – TR, annular
Palla’s sign,

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 Hampton’s Hump
(For Pulm Embolism)

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 Hampton’s Hump
(For Pulm Embolism)
Westermark’s Sign
(Relative oligaemia
distal to Pulm infarction

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Dyspnea may not be marked Understand pain : Typical C F

• Pericarditis :
– Central chest pain, Relief with sitting up & leaning
forward
– Pericardial rub
• Eso reflux : Post Prandial recumbency worsens
• Eso spasm : closely mimicks angina
• PUD : several hours, relief with food
• GBD : several hours, may follow meal
• NMSK : movement, reproduced by localized
pressure
• Herpes zoster : vesicular rash, dermatomal
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 Essential to document the likelihood of the Chest Pain being coronary in origin

Feature High likelihood : any of the Intermediate likelihood : Low likelihood :

following : absence of high absence of high &
likelihood features & intermediate
presence of any of the likelihood features
following : but may have :
History Chest or left arm pain or Chest or left arm pain or Probable ischemic
discomfort as chief symptom discomfort as chief symptoms in
reproducing prior documented symptom absence of any of
angina Age >70 years the intermediate
likelihood
Male sex
characteristics
Diabetes mellitus
Exam Transient MR, hypotension Extracardiac vascular Chest discomfort
diaphoresis, pulm edema/rales disease reproduced by
palpation
ECG New, or presumably new, Fixed Q waves T flattening or inv
transient ST deviation (≥0.05 Abnormal ST/T not docu in leads with
mV) or T inversion (≥0.2 mV) to be new dominant R
with symptoms Normal ECG
Cardia Elevated cardiac TnI, TnT, or Normal Normal
c CK-MB
marker
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s
 Non acute Chest Discomfort
• Diagnose & assess likelihood of complications

• OPD

• IHD : stress tests : diagnose & stratify

• GI : endoscopy / radiology / Rx trial

• Emotional & psychiatric : RCT indicate benefit from

cognitive therapy & group interventions

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