CHEST PAIN

Dr. Nighat Majeed Dr. Nighat Majeed Assistant professor medicineAssistant professor medicineMedical unit 11 Medical unit 11 SIMS/SHL LahoreSIMS/SHL Lahore

INTRODUCTION

• In medicine, chest pain is a symptom of a of serious conditions and is considered a medical emergency most of the time.

• The chest pain is non-cardiac in origin this is often a diagnosis of exclusion made after ruling out more serious causes of pain.

Etiology

Cardiopulmonary Acute coronary

syndrome •Unstable angina Pectoris - requiring emergency medical treatment but not primary intervention as in a myocardial infarction.

Cardiopulmonary

• Aortic dissection• Pericarditis• Arrhythmia - atrial fibrillation and a

number of other arrhythmias can cause chest pain

Cardiopulmonary

• Pulmonary embolism. • Pneumonia.• Hemothorax. • Pneumothorax and Tension

pneumothorax.• Sarcoidosis.• Carbon Monoxide poisoning.

Upper gastrointestinal Ailments •Gastro esophageal reflux disease (GERD) and other causes of heartburn. •Hiatus hernia (which may not accompany GERD). • Achalasia, nutcracker esophagus and other neuromuscular disorders of the esophagus. • Functional dyspepsia.

Problems of chest wall • Costochondritis or Tietze's

syndrome. • Spinal nerve problem. • Fibromyalgia is the presence of

chronic widespread pain and a heightened and painful response to gentle touch (tactile allodynia).

• Breast conditions. • Herpes zoster known as shingles.

Problems of chest wall• Thoracic outlet syndrome(cervical rib)

may cause chest pain.• Disorders of shoulder may cause chest

pain.

Psychological

• Panic attack.• Anxiety.• Clinical depression.• Somatization disorder.• Hypochondria.

Others

•Bornholm disease - a viral disease that can mimic many other conditions.

•Precordial catch syndrome - another benign and harmless form of a sharp, localized chest pain often mistaken for heart disease.

Others• Hyperventilation syndrome- chest

pain, tingling sensation of the fingertips and around the mouth.

• Da costa's syndrome- known as soldier's heart, is a syndrome with a set of symptoms that are similar to those of heart disease, though a physical examination does not reveal any physiological abnormalities. the manifestation of an anxiety disorder.

Others

Referred pain from Upper abdomen:

• Pancreatitis.• Cholecystitis.• Peptic ulcer.

Psychological

•Panic attack are sudden, discrete periods of intense anxiety, mounting physiological arousal, fear, stomach problems and discomfort that are associated with a variety of somatic and cognitive symptoms.

Psychological

•Clinical depression is a mental disorder typically characterized by a pervasive low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities.

Psychological

• Hypochondrias is (or hypochondria, sometimes referred to as health phobia) refers to an excessive preoccupation or worry about having a serious illness.

Psychological

• Anxiety is a physiological and psychological state characterized by cognitive, somatic, emotional, and behavioral components.

Psychological

• Somatization disorder (also Briquet's disorder or, in antiquity, hysteria) is a psychiatric diagnosis applied to patients who chronically and persistently complain of varied physical symptoms that have no identifiable physical origin.

Characteristic of ischemic chest pain• Pain of ischemic heart disease is

retrosternal and across the midline(horizontal),pain radiates to left arm along the medial side and the jaw, pain is severe in intensity and constricting in character as if there is a tight band around the chest, associated with sweating, palpitations and breathlessness precipitated with exertion and relieved with s/L nitrates.

Ischemic heart disease

• Angina:• Usually occurs on exertion,releived by rest

or sublingual nitrates.• Of brief duration is less than 30

minutes,often of 2 to 10 min only rarely longer and shorter.

• It is usually moderate in intensity.• Typically reterosternal.• Pain is precipitated with effort, emotional

stress,meals and exposure to cold air,increases with recumbency.

Angina:• Excluded• If it can be localized with one finger.• Consistently lasts for less than 30 sec

or longer than 30 min.• Sticking, jabbing or throbbing pain.• Rest pain with exceptions to unstable

angina and prinzmetal angina. • Consistently severe.

Angina• Angina can coexist with pain of different

origin so history and lab investigations may help.

• Physical examination is normal.• S4, High blood pressure.• Murmur of mitral regurgitation.• Paradoxical splitting of second heart

sound.• Relieve of pain with carotid sinus

massage(Levine sign).

Angina(Investigations)• Resting ECG is normal or shows ST-T

changes during attacks.• Cardiac markers are normal.• Exercise tolerance test.• Thallium-201 or Technicium-99 scan.• Angiography can be done to localize the

lesion.• Normal coronary angiogram syndrome-

X.

Myocardial infarction

• Occurs at rest or on exertion. not relieved by S/L nitroglycerine, lasting for more than 30 minutes.

• Crushing, pressing or aching pain.• Preceeding history of angina.• Lasts from half an hour to several hours

or longer.

Myocardial infarction• Crushing, pressing or aching pain.• Preceeding history of angina.• Lasts from half an hour to several hours or

longer.• Reterosternal or left sided.• Autonomic symptoms.• Painless MI or silent ischemia.• At times presents with dyspeptic

symptoms.

Myocardial infarction• Serial ECG shows ST elevation deep

symmetric T wave inversions and Q waves.• Elevated serum levels of cardiac

markers:CPK, CPK-MB, AST, LDH, Trop-T, Trop-I.

• Thallium-201 or Technicium-99 scan scan shows permanent filling defect or a Hot spot representing infracted myocardium.

• Coronary angiogram shows occlusion of affected artery.

Cardiac marker

Troponine-T• The most sensitive and specific test for

myocardial damage. Because it has increased specificity compared with CK-MB, troponin is a superior marker for myocardial injury.

• It is relatively specific when skeletal muscle damage is not present.

• 12 hours

Cardiac marker• LDH; LDH is not as specific as

troponin, duration is 48 hours.• Aspartate transaminase;(AST,

also called "glutamic oxaloacetic transaminase" (GOT/SGOT) or "aspartate aminotransferase" (ASAT)).

• Myoglobin (Mb) Ischemia-modified albumin (IMA).

Pericarditis Inflammation of pericardium:• Idiopathic.• Viral infection, especially Coxsackie virus.• Bacterial infection, especially

pneumococcus Tuberculosis bacillus. • Fungal. • Immunologic conditions including lupus

erythematosus or rheumatic fever. • Myocardial Infarction (Dressler's syndrome).

Pericarditis• Uremia. • Malignancy ( paraneoplastic

phenomenon). • Side effect of some medications, e.g

isoniazid, cyclosporine, hydralazine. • Radiation induced. • Aortic dissection. • Tetracyclines. • Postpericardiotomy syndrome. • Trauma to the heart.

Pericarditis• Clinical presentation• Chest pain, radiating to the back and

relieved by sitting up forward and worsened by lying down, is the classical presentation. Other symptoms of pericarditis may include dry cough, fever, fatigue, and anxiety. Pericarditis can be misdiagnosed as myocardial infarction

, and vice versa.

Pericarditis• The classic signs.• A friction rub, superficial scratchy sound

best heard at left sternal edge and increase in intensity when diaphragm of stethoscope is pressed upon the chest.

• Diffuse ST-elevation and PR-depression on ECG (all leads).

• Cardiac tamponade (pulsus paradoxus with hypotension).

• congestive heart failure (elevated jugular venous pressure with peripheral edema.

Precordial Catch Syndrome • Also known as Texidor's twinge, is a

common cause of chest pain complaints in children and adolescents. It also occurs less frequently in adults. PCS manifests itself as an intense, sharp pain typically at the left side of the chest. which is worse when taking breaths. This typically lasts 30 seconds to 3 minutes and then is resolved as quickly as it began.

Gastroesophageal reflux disease

• Gastro-oesophageal reflux disease , is defined as chronic symptoms or mucosal damage produced by the abnormal reflux in the esophagus. This can be due to incompetence of the lower esophageal sphincter, transient lower esophageal sphincter relaxation, impaired expulsion of gastric reflux from the esophagus, or a hiatus hernia.

Gastroesophageal reflux disease• The most-common symptoms of GERD

are heartburn, regurgitation, trouble swallowing (dysphagia), and chest pain. Less-common symptoms include pain with swallowing (odynophagia), excessive salivation, and nausea.

Gastroesophageal reflux disease• A detailed historical knowledge is vital

for an accurate diagnosis. • Useful investigations include • barium swallow X-rays.• Esophageal manometry. • 24 hour esophageal impedance-pH

monitoring.• Esophagogastroduodenoscopy (EGD).

Gastroesophageal reflux disease• In general, an EGD is done when the

patient either does not respond well to treatment or has alarm symptoms including dysphagia, anemia, blood in the stool (detected chemically), wheezing, weight loss, or voice changes.

• once-in-a-lifetime endoscopy for patients with longstanding GERD, to evaluate the possible presence of Barrett's esophagus, a precursor lesion for esophageal adenocarcinoma

Aortic dissection• Is a tear in the wall

of the aorta that causes blood to flow between the layers of the wall of the aorta and force the layers apart. Aortic dissection is a medical emergency and can quickly lead to death, even with optimal treatment.

Aortic dissection

Signs and symptoms• About 96% of individuals with aortic

dissection present with severe pain that had a sudden onset It may be described as tearing in nature, or stabbing or sharp in character If the pain is pleuritic in nature, it may suggest acute pericarditis due to hemorrhage into the pericardial sac.

Aortic dissection• The location of pain is associated with

the location of the dissection. Anterior chest pain is associated with dissections involving the ascending aorta, while intrascapular (back) pain is associated with descending aortic dissections.

Aortic dissection• While the pain may be confused with the

pain of a myocardial infarction (heart attack), aortic dissection is usually not associated with the other signs that suggest myocardial infarction, including heart failure, and ECG changes. Also, individuals suffering from an aortic dissection usually do not present with diaphoresis (profuse sweating.

Aortic dissection• Individuals with aortic dissection who do not

present with pain have chronic dissection.• Less common symptoms that may be seen

in the setting of aortic dissection include congestive heart failure (7%).

• syncope (9%).• cerebrovascular accident (3-6%).• Ischemic peripheral neuropathy.• Paraplegia.• cardiac arrest, and sudden death.

Aortic dissection• If the aortic dissection involves the

abdominal aorta, compromise of the branches of the abdominal aorta are possible. In abdominal aortic dissections, compromise of one or both renal arteries occurs in 5-8% of cases, while mesenteric ischemia (ischemia of the large intestines) occurs 3-5% of the time.

Aortic dissection• If the individual had a syncopal

episode, about half the time it is due to hemorrhage into the pericardium leading to pericardial tamponade.

Aortic dissection• Neurologic complications of aortic

dissection (i.e., cerebrovascular accident (CVA) and paralysis) are due to involvement of one or more arteries supplying portions of the central nervous system.

Aortic dissection• More severe cases can include signs

such as pleural rub, cyanosis (blue discoloration, usually of the lips and fingers), collapse, and circulatory instability. About 15% of all cases of sudden death are attributable to PE.

Pulmonary embolism (PE)• It is a blockage of the pulmonary artery

or one of its branches. Symptoms of PE are sudden-onset dyspnea (shortness of breath), tachypnea (rapid breathing), chest pain of a "pleuritic" nature (worsened by breathing), cough, hemoptysis (coughing up blood), and may aid in the diagnosis.

Pulmonary embolism (Diagnostic Approach)

Pulmonary embolism The Wells score:• clinically suspected DVT - 3.0 points. • Alternative diagnosis is less likely than PE -

3.0 points.• Tachycardia - 1.5 points. • Immobilization/surgery in previous four

weeks - 1.5 points. • History of DVT or PE - 1.5 points.• Hemoptysis - 1.0 points. • Malignancy (treatment for within 6 months,

palliative) - 1.0 points

The Wells score:• Score •   High> 6.0•   Moderate2.0 to 6.0•   Low< 2.0

Pulmonary embolism• Symptoms• cough,fever,palpitations,&

dizziness. • Massive PE sudden onset of

syncope.• Dyspnea.• Respirophasic chest pain. 

Pulmonary embolism• Leg pain, swelling, warmth;DVT.

• Hemoptysis/pleuritic chest pain;pulmonary infarction.

• Palpitations.

• Wheezing.

• Anginal pain.

Pulmonary embolism• Signs• Respiratory rate>16.• Heart rate>100/min.• Fourth heart sound (S4).

• Loud P2.• Temperature 37.5 °C- 38.5 °C. • Homans' sign.  

Pulmonary embolism• Respiratory rate>16.• Heart rate>100/min.• Fourth heart sound (S4).

• Loud P2.• Temperature 37.5 °C- 38.5 °C. • Homans' sign.  

Pulmonary embolism• Pleural friction rub.• Third heart sound (S3).

• CyanosisTachypnoea and tacycardia.• Signs of pulmonary HTN,raised JVP,loud

P2,right sided gallop & RV lift.• Hypoxemia,electomechanical

dissociation & sudden cardiac arrest.

Pulmonary embolism (Diagnosis) Chest X-rays are often done on patients

with shortness of breath to help rule-out other causes, such as congestive heart failure and rib fracture.

Chest X-rays in PE are rarely normal. but usually lack signs that suggest the diagnosis of PE (e.g. Westermark sign, Hampton's hump).

Pulmonary embolism (Diagnosis)• ECG(("S1Q3T3"). The most commonly

seen signs in the ECG is sinus tachycardia, right axis deviation and right bundle branch block.

• Echocardiography

Pulmonary embolism (Diagnosis)• Arterial blood gases.• Plasma levels of D-dimer.• Serum troponin I, troponin T, and

plasma beta-natriuretic peptide (BNP) levels are typically higher in patients with PE.

Pulmonary embolism (Diagnosis)• Lung scanning(V/Q scan).• MRI.• Helical CT pulmonary angiography.• Pulmonary angiography.• Venous ultrasonography.• Impedance plethysmography. • Contrast venography.

Pneumothorax pneumothorax, or collapsed lung, is a

potential medical emergency caused by accumulation of air or gas in the pleural cavity. A pneumothorax can occur spontaneously, or as the result of disease or injury.

Pneumothorax (Etiology)

• It most commonly arises:• Spontaneously (most commonly in tall

slim young males and in Marfan syndrome)

• Penetrating chest wound • Barotrauma to the lungs.

Pneumothorax(Etiology)

• Less common causes:• Chronic lung pathologies including

emphysema, asthma. • Acute infections • Chronic infections, such as tuberculosis. • Cancer. • Catamenial pneumothorax (due to

endometriosis in the chest cavity).• lymphangioleiomyomatosis (LAM).

Pneumothorax(symptoms)• Sudden shortness of breath, dry

coughs, cyanosis (turning blue) and pain felt in the chest, back and/or arms are the main symptoms

• "sucking" chest wound. • The flopping sound of the punctured

lung is also occasionally heard. • Subcutaneous emphysema is another

symptom.

Pneumothorax(signs) Untreated, • hypoxia may lead to loss of

consciousness and coma. • Shifting of the mediastinum away from

the site of the injury can obstruct the superior and inferior vena cava resulting in reduced cardiac preload and decreased cardiac output.

• Untreated, a severe pneumothorax can lead to death within several minutes.

Pneumothorax(signs) The absence of audible breath sounds

through a stethoscope can indicate that the lung is not unfolded in the pleural cavity.

This accompanied by (higher pitched sounds than normal) to percussion of the chest wall is suggestive of the diagnosis. The "coin test" may be positive. Two coins when tapped on the affected side, produce a tinkling resonant sound which is audible on auscultation.

Pneumothorax.• If the signs and symptoms are doubtful,

an X-ray of the chest can be performed, but in severe hypoxia, or evidence of tension pneumothorax emergency treatment has to be administered first.

• In a supine chest X-ray the deep sulcus sign is diagnostic, which is characterized by a low lateral costophrenic angle on the affected side.

Analysis

• A careful medical history and physical examination.

• Management of chest pain is often done on specialized units

• . A rapid diagnosis can be life-saving and often has to be made without the help of

• X-rays or blood tests(e.g. aortic dissection).

Analysis• Occasionally, invisible medical signs

will direct the diagnosis towards particular causes.

• Levine's sign is a clenched fist held over the chest to describe ischemic chest pain. An emergency medicine also focus on recent health changes, family history (premature atherosclerosis, cholesterol disorders), tobacco smoking, diabetes and other risk factors.

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Analysis

• Features of the pain suggest of cardiac ischaemia are describing the pain as heaviness; radiation of the pain to neck, jaw or left arm; sweating; nausea; palpitations; the pain coming upon exertion; dizziness; shortness of breath and a "sense of impending doom."

Analysis Reterosternal pain which often radiates

to neck and shoulder,aggravated by change in posture and is relieved by sitting up and bending forward.If pleuropericarditis pain gets worse on deep breathing.

Investigations Blood tests:

• Complete blood count. • Electrolytes and renal function

(creatinine). • Liver enzymes • Creatine kinase. • Troponin I or T.• D-dimer ( suspicion for pulmonary

embolism). • serum amylase to exclude acute

pancreatitis.

Investigations

• X-rays of the chest and/or abdomen.

• An electrocardiogram (ECG).• • V/Q scintigraphy.

• CT pulmonaryangiogram.

Interpretation

• In finding the cause, the history given by the patient is often the most important tool. In angina pectoris, for example, blood tests and other analyses are not sensitive enough. Physician's typical approach is to rule-out the most dangerous causes of chest pain first (e.g., heart attack, pumonary embolism, aneurysm).

Interpretation

• By sequential elimination or confirmation from the most serious to the least serious causes, a diagnosis of the origin of the pain is eventually made. Often, no definite cause will be found, and the focus in these cases is on excluding severe diseases and reassuring the patient.

Interpretation

• If acute coronary syndrome is suspected, many patients are admitted briefly for observation, sequential ECGs, and determination of cardiac enzyme levels over time (CK-MB, troponin or myoglobin). On occasion, later out-patient testing may be necessary to follow-up and make better determinations on causes and therapies.