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Cardiology 1.1. Chest pain - by Dr. Farjad Ikram


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Introduction to one of the most common symptoms that can represent a wide range of diseases, from benign to life-threatening, covering number of systems including gastrointestinal, cardiovascular, pulmonary, musculoskeletal and psychiatric. Includes a brief explanation of anti-anginal therapy.
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Cardiology 1.1. Chest pain - by Dr. Farjad Ikram

  1. 1. Good Morning! I am Dr. Farjad Ikram House Officer, Cardiology, Shalamar Hospital
  2. 2. Chest Pain
  3. 3. Contents Case Scenario Cardiac causes Pulmonary causes Gastrointestinal causes Other causes
  4. 4. • Mr. Arshad • 60 Years, Male • Weight 86 kg • Height 142 cm • Diabetic for 10 years • Ex-smoker • Family history of IHD Case • Presented in E.R • Chest heaviness (30 min) • Sudden onset • Retrosternal • Radiates to left arm • Aggravates on exertion • Relieved by rest • Associated with sweating
  5. 5. Case (cont.) Physical Examination: • Pulse - 76 b/m, regular • B.P. - 150/90 mmHg • R.R. - 27 b/m • SpO2 - 95% on room air • Temp - 98° F • BSR - 117 mg/dl • S1 + S2 + 0 • Vesicular breathing • Abdomen non-tender • GCS - 15 / 15 • No edema, pallor or jaundice • 12 Lead ECG was carried out
  6. 6. ECG at ER admission
  7. 7. ECG 20 minutes later
  8. 8. Case (cont.) What are your differential diagnoses? • Acute coronary syndrome • Aortic stenosis • R. T. I • Myocarditis • Pericarditis
  9. 9. 1. Introduction Chest pain is one of the most common complaints...
  10. 10. One of the chief complaints in E.R • Chest Pain is the second most common presentation in E.R visits, after abdominal pain. • Can represent range of diseases from benign to life threatening. • It is upto the clinician to exclude the life threatening causes first.
  11. 11. History Taking ✘Site ✘Onset ✘Character ✘Radiation ✘Association ✘Time ✘Exacerbating / relieving factors ✘Severity ✘Risk factors
  12. 12. Typical vs Atypical vs Non-Cardiac Aggravated by exertion or emotional stress Relieved by rest or nitroglycerin Diffuse retrosternal chest pain or discomfort 3 / 3 Typical 2 / 3 Atypical 1 / 3 Noncardiac
  13. 13. Causes of Chest Pain CARDIAC RESPIRATORY GASTROINTESTINAL MISC. Ischemic Heart Disease Bronchospasm Reflux Disease (GERD) Rib Fracture Aortic Stenosis Pulmonary Embolism Acid Peptic Disease Precordial Catch Mitral Valve Prolapse Respiratory Tract Infection Esophageal Motility Disorders Acute Chest Syndrome Pericarditis Pleurisy Esophageal Rupture Costochondritis Myocarditis Pneumothorax Pancreatitis Herpes Zoster Cardiac Tamponade Hemothorax Cholecystitis Anxiety Disorder Aortic Dissection Empyema Biliary Colic Panic Disorder
  14. 14. Triple Rule Out C.T Angiography • TRO-CTA provides a cost-effective evaluation of aorta, coronaries, and pulmonary arteries in patients presenting with acute chest pain. • Rules out three life threatening causes: 1 - Coronary Artery Disease 2 - Pulmonary Embolism 3 - Aortic Dissection +/- Cardiac Tamponade • Can safely eliminate the need of further testing in 75% of the patients.
  15. 15. 2. Cardiovascular causes of Chest Pain
  16. 16. Ischemic Heart Disease • IHD must be excluded in all patients presenting with chest pain. • Especially in middle and old age groups. Initial suspicion is on history. • ECG may be normal in early stages of ACS, so a normal ECG doesn’t exclude ACS. • Angina Pectoris is typical chest pain < 30 min (similar episodes in past) - Seen in stable angina, coronary vasospasm • Acute Coronary Syndrome (ACS) is typical / atypical chest pain > 30 min - Seen in unstable angina (38%), NSTEMI (25%), STEMI (30%)
  17. 17. Ischemic Heart Disease • Unstable Angina (UA) - occurs at rest or with minimal exertion - it is severe and van be of new onset - it can occur with a crescendo pattern (distinctively more severe, prolonged, and frequent than previous episodes) - may or may not be relieved by rest or S/L nitrates - can precede myocardial infarction • Decubitus Angina - Typical chest pain which appears after lying down - Due to increase in venous return and preload - Seen in heart failure and/or severe underlying CAD
  18. 18. Angina Pectoris / ACS Features of chest pain in Angina Pectoris and ACS Site Diffuse, retro-sternal Character Discomfort, tightness, heaviness, squeezing, sinking Radiation Left arm, neck, jaw, shoulders, back, right arm, epigastrium Association Diaphoresis, dyspnea, nausea, vomiting Time course Constant, non-spasmodic, non-pleuritic Exacerbated by Exertion and emotional stress Relieved by Rest, S/L nitroglycerin (stable angina) Not relieved by rest, S/L nitrates (unstable angina, MI) Risk factors Age, Sex, Smoking, Diabetes, Hyperlipidemia, F/H of IHD
  19. 19. Levine Sign
  20. 20. Classification Of Angina Canadian Classification Scale (CCS) of Angina Class I Angina on strenuous, rapid or prolonged exertion No limitation of ordinary activity like walking or climbing stairs Class II Slight limitation of ordinary activities like walking or climbing stairs, in cold, in wind, after meals, or emotional stress Class III Marked limitation of ordinary activities i.e . after walking 1-2 blocks, or climbing 1-2 flight of stairs Class IV Unable to perform any physical activity without discomfort Angina may be present at rest
  21. 21. Ischemia VS Infarction Feature Stable Angina Unstable Angina Myocardial Infarction Onset On exertion On rest or exertion On rest or exertion Relieved by rest Yes No No S/L nitrates Relieves pain May relieve pain Does not relieve Duration < 30 min > 30 min > 30 min ECG Normal or transient changes (ST depression and T wave flattening or inversions) Maybe normal initially transient changes (ST depression and T wave flattening or inversions) Maybe normal initially ST elevation and/or depression (may be transient) T wave inversions (may persist) Q waves (permanent) Cardiac enzymes Within range Within range Raised
  22. 22. Medical Therapy in Angina Objectives: • Prevent episodes of angina Short-acting nitrates 5 min before planned exertion 1st line Anti-anginals - Beta Blockers and /or Calcium Channel Blockers 2nd line Anti-anginals - Long-acting nitrate, Ivabradin, Ranolazine, Nicorandil • Treat episodes of angina During angina – Take a dose of short-acting nitrates If no relief after 5 min, repeat dose and call an ambulance • Secondary prevention of CV disease - Lifestyle modifications - weight reduction, diet control, regular exercise - Anti-Platelet Therapy - Aspirin (+/- Clopidogrel) - Cholesterol lowering therapy - ideally with a statin (alt. is ezetimibe) - Treat hypertension if present - ideally with an ACEI or ARB - Refer to endocrinologist for diabetes management if present
  23. 23. Acute Pericarditis • “Sharp” retrosternal chest pain • Aggravates on movement, inspiration, cough and lying supine • Relieves on leaning forward • Signs: Tachycardia, pericardial friction rub • There maybe history of recent MI (Dressler’s syndrome) • ECG: diffuse ST elevation concave upwards diffuse PR depression • Cardiac enzymes: may be elevated
  24. 24. Acute Pericarditis
  25. 25. Acute Myocarditis ✘“Sharp” retrosternal chest pain ✘Associated symptoms: palpitations, tachypnea ✘Sometimes concomitant with pericarditis, heart failure, arrhythmias ✘May preceded by pro-dromal symptoms like fever, rash, arthritis etc ✘Seen with rheumatic fever, sarcoidosis, SLE or scleroderma ✘Delayed complication = dilated CMP ✘ECG – sinus tachycardia, QT prolongation, diffuse T wave inversions ✘Increased troponin levels due to myocardial inflammation
  26. 26. Aortic Stenosis • Angina mimic – sub-endocardial ischemia due to raised LVEDP • Syncope (LVOT obstruction & hypotension) • Features of heart failure may be present • Ejection Systolic Murmur at aortic area • Causes: aortic sclerosis (aging), RHD, congenital bicuspid AV • ECG – LVH, P. mitrale, possibly conduction blocks like LBBB • Echo – dilated aortic root, thickened / immobile AV, concentric LVH, On the basis of AVPG, AV area can be determined, AS can be graded as: Mild, Moderate, Severe, Very Severe
  27. 27. Aortic Stenosis SEVERITY OF AORTIC STENOSIS
  28. 28. Aortic Stenosis
  29. 29. Hypertrophic CMP • Typical chest pain (angina mimic) due to: increased demand (hypertrophy) reduced blood supply (aberrant coronary flow) • Syncope or pre-syncope (LVOT obstruction in 30% cases, HOCM) • Features of heart failure may be present • Palpitations (if complicated by arrhythmias) • ECG – LVH, P mitrale, possibly PACs, PVCs, SVTs or a. fib Septal hypertrophy – narrow “dagger like” Q waves in lat. & inf. leads Apical hypertrophy - giant inverted T waves in chest leads • Echo is diagnostic – Asymmetrical Septal Hypertrophy (ASH)
  31. 31. Mitral Valve Prolapse • Symptoms: atypical chest pain, panic, palpitations, pre-syncope, SOB • Signs: Mid systolic click with a late systolic murmur Accentuated with standing and Valsalva maneuver • Significant MR can cause heart failure, and a holosystolic murmur • Myxomatous degeneration of MV leaflets that bulge backward into LA • Presents to us in second or third decade of life • ECG – may be normal, sinus tachycardia, LVH, P mitrale • Echo – concentric LVH, dilated LA, MR present classic MVP - thickened mitral leaflets > 5mm - leaflet displacement > 2mm into LA during systole
  32. 32. Mitral Valve Prolapse
  33. 33. Cardiac Tamponade • Symptoms: Atypical pain relieved by leaning forward, SOB, pre-syncope • Signs: Beck’s triad (hypotension, engorged neck veins, muffled heart sounds), pulsus paradoxus, pericardial rub, Ewart’s sign • Fluid/blood in the pericardial sac resulting in the compression of heart • Causes: trauma, heart rupture, aortic dissection, uremia, cancer, TB etc • ECG – low voltage, tachycardia Electrical alternans – consecutive QRS complexes alternate in height, produced by heart swinging to and fro in a large fluid filled pericardium. • Echo is diagnostic. CXR is supportive. Cardiac markers may be elevated.
  34. 34. Cardiac Tamponade
  35. 35. Cardiac Tamponade
  36. 36. Cardiac Tamponade
  37. 37. Aortic Dissection • Symptoms: Sudden onset of severe “tearing” pain in the inter-scapular region of the back, sweating, vomiting and lightheadedness • If ascending aorta is involved - there can be frontal chest pain, and cardiac tamponade can occur (most common cause of death in A.D) • MI can occur if aortic root is involved as coronary arteries arise from it • Abdominal pain and GI bleed due to mesenteric ischemia • Syncope due to cerebral hypo-perfusion, paralysis due to stroke • Tear inside the aorta causes the blood to between the layers of the wall • Etiology: chronic hypertension causing cystic medial degeneration • CXR – normal, wide mediastinum, wide aortic knob, left pleural effusion • CT angiogram is diagnostic. MRI is the gold standard.
  38. 38. Aortic Dissection
  39. 39. Other Cardio-vascular Causes • Arrhythmias • Heart Failure • Hypertensive Heart Disease • Aortitis (syphilis, autoimmune) • Thoracic aortic aneurysm
  40. 40. 3. Respiratory causes of Chest Pain
  41. 41. Pulmonary Embolism • Symptoms: “Sharp” pleuritic chest pain, sudden SOB, hemoptysis • Signs: pyrexia, cyanosis, tachycardia, hypotension, pleural rub • Signs of DVT: calf tenderness, calf pain on dorsiflexion (Homans sign) • Wells and Geneva scores: risk factor stratification of suspected PE • ECG - most commonly normal, sinus tachycardia, RBBB, S1-Q3-T3 (10-15%) • CXR - most commonly normal - elevated hemi-diaphragm, pleural effusions, band atelectasis - Westermark sign (dilated pulmonary artery, olegemia of the lung field) - Hampton’s hump (wedge shaped opacity, signifying lung infarct) • Echo - RV dilation, RV wall hypokinesis (McConnell’s sign), dilated IVC • D-dimer (sensitive but non-specific), Cardiac markers (raised in 16-47% cases) • CT Pulmonary Angiogram (diagnostic), V/Q scan, SPECT • Supportive - Doppler lower limbs (for DVT)
  42. 42. Pulmonary Embolism
  43. 43. Lower R.T.I • Symptoms: dull/sharp localized chest pain, increases with inspiration/cough • Associated: fever, cough +/- sputum, SOB, hemoptysis, weight loss • Signs: pyrexia, coarse crackles, rhonchi, bronchial breathing • Causes: pneumonia, lung abscess, tuberculosis • ECG – can be normal, sinus tachycardia • Cardiac markers – not elevated • F/U – CXR, Montoux test, sputum (gram stain, AFB, C&S)
  44. 44. Other Pulmonary Causes • Tracheitis • Bronchitis • Bronchiolitis • Bronchospasm • Hypersensitivity pneumonitis • Sarcoidosis • Lung malignancy
  45. 45. Pleural Causes • Pleurisy • Pneumothorax • Hemothorax • Pyothorax • Mesothelioma
  46. 46. 4. Gastrointestinal causes of Chest Pain
  47. 47. Gastro-esophageal causes • Gastro-esophageal reflux disease (GERD) • Esophagitis • Acid peptic disease (APD) • Gastritis • Hiatal Hernia • Esophageal motility disorders (EMDs) • Boerhaave’s syndrome • Mediastinitis
  48. 48. Other G.I. causes • Gas bloating • Nutmeg liver • Hepatitis • Liver abscess • Pancreatitis • Cholecystitis • Cholangitis • Biliary colic
  49. 49. 5. Other causes of Chest Pain
  50. 50. Musculoskeletal Causes • Rib fracture / flail chest – Splenic injury? • Costochondritis • Fibromyalgia • Radiculopathy • Disc prolapse • Osteoarthritis • Thoracic outlet syndrome • Pott’s disease (tuberculosis)
  51. 51. Other Causes • Empyema • Herpes Zoster (shingles) • Post Herpetic Neuralgia • Acute chest syndrome (sickle cell disease) • Invasive breast cancer • Pain of unexplained origin (PUO) • Pre-cordial catch syndrome (PCS)
  52. 52. Psychosomatic Causes • Da Costa’s syndrome: physical manifestation of an anxiety disorder • Generalized Anxiety Disorder (GAD) • Panic Disorder • Phobia i.e. agoraphobia • Post-traumatic stress disorder (PTSD) • Clinical depression • Conversion disorder • Hypochondriasis
  53. 53. • Mr. Arshad • 60 Years, Male • Weight 86 kg • Height 142 cm • Diabetic for 10 years • Ex-smoker • Family history of IHD Case • Presented in E.R • Chest heaviness (30 min) • Sudden onset • Retrosternal • Radiates to left arm • Aggravates on exertion • Relieved by rest • Associated with sweating
  54. 54. Case (cont.) Physical Examination: • Pulse - 76 b/m, regular • B.P. - 150/90 mmHg • R.R. - 27 b/m • SpO2 - 95% on room air • Temp - 98° F • BSR - 117 mg/dl • S1 + S2 + 0 • Vesicular breathing • Abdomen non-tender • GCS - 15 / 15 • No edema, pallor or jaundice • 12 Lead ECG was carried out
  55. 55. ECG at ER admission
  56. 56. ECG 20 minutes later
  57. 57. Case (cont.) What are your differential diagnoses? • Acute coronary syndrome • Aortic stenosis • Respiratory tract infection • Myocarditis • Pericarditis PROVISIONAL DIAGNOSIS: Acute Coronary Syndrome
  58. 58. thanks! Any questions?