Enquire about chest pain• Site of origin of pain• Duration• Radiation• Character of the pain & severity• Pattern of onset• Aggravating factor relieving factor• Associated features
Site of origin of painAngina - Pain is characteristics central & retrosternal diffuse - because of the derivation of nerve supply to the heart & mediasinumPleural or lung d/s musculo skeletal and Anxiety - Peripheral localised
Radiationischaemic pain - radiate to neck, jaw & upper & even lower arms - sometime only at the site of radiation or in the backNon Cardiac chest pain - other or no radiation
CharacterIshaemic cardiac Pain• typically dull, constricting choking or heavy & is usually described as squeezing, crushing, burning or aching .• The sensation can be described as breathlessness or like indigestion
• patient typicaly use characteristic hand gesture (eg. open hand or clenched fist) when describing ischaemic pain.Non cardiac pain - sharp , stabbing , pricking or knife-like
Aggravating FactorAngina - Exertion - Emotion, excitement - Cold weather - Exercise after meal.Pleural, pericardial pain - breathing coughing or movementMusculoskeletal pain - Specific movement (bending, stretching, turning)
Relieving FactorAngina - Rest - Glyceryl trinitrate - warm up before exerciseNon cardiac pain - Not relieved by rest - Slow or no response to nitrate
Pattern of onsetMI - typically take several minutes or even longer to develop.Angina -build up gradually in proportion to the intensity of exertionAortic dissection, PE, Pneumothorax -very sudden onset
Associated featuresMI, PE, Aortic dissection - Accompanied by autonomic disturbance including sweating, nausea and vomitingMI,Angina - Breathlessness due to pulmonary congestion arising from transient ischaemic left ventricular dysfunctionNon cardiac pain - Respiratory , GI, locomotor or psychological
Severity Of Angina• Canadian Cardiovascular Society: functional classification of stable anginaGrade 1 - Ordinary physical activity such as walking and climbing stairs, does not cause angina. Angina with strenous or rapid or prolonged exertion at work or recreation
Grade 2 - Slight limitation of ordinary activity. Walking or climbing stairs rapidly, walking uphill, walking or stair climbing after meals in cold ,in wind, or when under emotional stress, or only during the few hours after awakening.
Grade 3 - Marked limitation of ordinary physical activity . Walking one to two blocks on the level and climbing less than one flight in normal condition.
• Grade 4 – Inability to carry on any physical activity without discomfort anginal syndrome may be present at rest.
Questions –To assess the severity of angina• How far can you walk on the flat before experiencing discomfort ?• Do you get discomfort climbing stairs or hills ?• Do you experience discomfort gardening, making the bed or during other household chores?
• Does sexual intercourse produce discomfort ?• Is the discomfort influenced by meals ?• Is it influenced by cold weather ?
Types of cardiac painType Cause CharacteristicAngina Coronary stenosis (rarely Precipitated by aortic stenosis hypertrophic exertion, eased by rest cardiomyopathy ) Characteristic distributionMyocardial Coronary occlusion Similar sites toinfarct angina ,more severe ,persists at rest.Pericarditic pain Pericarditis Sharp, raw or stabbing Varies with movement or breathingAortic pain Dissection of the aorta Severe ,sudden onset , radiates to the back
Differential diagnosisPsycological aspects of chest pain• very common• considered if there are features of anxiety or neurosis• lacks a predictable relationship with exercise
Psycological aspects of chestpain• Psychological and organic features can be coexist• responsible for the death of close friend or relative• Anxiety may amplify the effects of organic disease (create a confusing picture)
Musculosketal Chest Pain• Common problem• Very variable in site and intensity• Pain may vary with posture or movement of the upper body• Sometimes accompanied by local tenderness over a rib or costal cartilage
Musculosketal Chest Pain• Numerous causes of chest wall pain - arthritis - Costochondritis - intercostal muscle injury - coxsackie viral infection (epidemic myalgia or Bornholm disease)• Many minor soft tissue injury are related to everyday activities such as
Differential diagnosis:angina vs oesophageal painAngina Oesophageal pain• Usually precipitated • Canbe worsened by by exertion exertion, but often present at other times • Not rapidly relieved• Rapidly relieved by by rest rest • Retrosternal or• Restrosternal and epigastric, sometimes radiates to arm and radiates to arm or jaw back
Differential diagnosis:angina vsoesophageal painAngina Oesophageal pain• seldom wakes • Often wakes patient patient from sleep from sleep• No relation to • Sometimes related heartburn (but to heartbum patients often have wind)• Rapidly relieved by • Often relieved by nitrates nitrates• Typical duration • Variable duration 2-10 minutes
Differential diagnosis:angina vs myocardial infarctionAngina Myocardial infarctionSite: retrosternal, radiates As for anginato arm, epigastrium, neckPrecipitated by exercise or Often no obviousemotion precipitantRelieved by rest, nitrates Not relieved by rest, nitrates
Differential diagnosis:angina vs myocardial infarctionAngina Myocardial infarction• Mild/moderate • Usually severe (may be severity silent)• Anxiety absent or • Severe mild• No increased sympathetic • Increased sympathetic activity activation• No nausea or vomiting • Nausea and vomiting are
Characteristics of percarditic painSite • -Retrosternal, may radiate to left shoulder or backProdrome • -May be preceded by a viral illnessOnset • -No obvious initial recipitating factor; tends to fluctuate in intensity
Characteristics of percarditic painNature • May be stabbing or raw-like sandpaper. Often described as sharp,rarely as tight or heavyMade worse by • Changes in posture, respirationHelped by • Analgesics, especiallyAccompanied by NSAIDs • Pericardial rub
Characteristics of pain caused bydissection of aortic aneurysm Site • Often first felt between shoulder blades, and/or retrosternally Onset • Usually sudden Nature • Very severe pain, often described as tearing in nature
Characteristics of pain caused by dissection of aortic aneurysmRelieved by • Tends to persist. Patients often restless with painAccompanied by • Hypertension, asymmetric pulses, unexpected bradycardia, early diastolic murmur. syncope, focal neurological symptoms and signs