2. The typical patients’ concern with the first bout of
chest pain is their apprehension of the onset of
cardiac pathology, such as ischemic heart
disease (IHD).
Chest discomfort is among the most common
reasons for which patients present for medical
attention at either an emergency department (ED)
or an outpatient clinic
3. 5 million emergency department visits
2 million hospitalizations annually with cost of
more then 8B dollars
Cardiac etiology is found in less than one third of
patients
2% of patients with acute MI are unrecognized
and discharged from ED
4. Goals
Reognition and management of true ACS
Recognition of other life threatening causes of
chest pain
9. History taking
Ask the patient the following 10 points about chest pain:
1. Onset
2. Site of pain
3. Character (Quality)
4. Duration
5. Radiation
6. Aggravating factor
7. Relieving factor
8. Local tenderness
9. Associated symptoms
10. Severity.
10. History of presenting illness
This will help in determining the etiology of chest pain
Characteristic of chest pain
Site
Cardiac ischemic pain: central and may radiate to neck, jaw,
both upper limbs
Respiratory chest pain: localises to site of pathology, i.e.,
infection or pneumothorax
However in asthma or obstructive airway diseases, central
chest pain or tightness
Musculoskeletal chest pain: localises to site of pathology, or
injury or to posterior chest in region of spine
Peptic ulcer disease and GERD: lower chest and epigastrium
11. Nature
Cardiac ischemic pain: dull, pressure like sensation,
tightness, squeezing type
Respiratory and musculoskeletsal: sharp and pleuritic
Pericarditis: sharp and pleuritic
Nerve root pain: band like shooting pain around the
chest from back to front
Peptic ulcer disease and GERD: sharp and burning
sensation
Aortic dissection: tearing or ripping, knife like
Pulmonary embolism: pleuritic, may manifest as
heaviness with masssive PE
12. Radiation
Cardiac ischemic pain: jaw, neck, arms(often left). Can
extend from mandible uptill umbilicus
aortic dissection peptic ulcer disease and pancreatitis:
radiating to back, shoulders
Nerve root pain: around the chest wall
Pulmonary embolism: often on side of pathology
Pneumothorax: unilateral
Esophageal reflux: substernal, retrosternal
PUD: epigastric
13. Onset, duration and frequency:
When did the pain start?
What were you doing while pain started?
Did it start sudden(vascular) or gradual?
Is it constant or intermittent?
What was the duration of pain?
Stable angina- on exertion, cold, stress, 2-10 min
Unstable angina- at rest,
MI- >30 mins
Pericarditis: hours to days
16. Associated features:
Cardiac ischemic pain: nausea, vomiting, sweating,
pallor, breathlessness, and symptoms of LVD -
orthopnea, PND, ankle edema, reduced excercise
tolerance, symptoms of arrhythmia – palpitations,
dizziness
Respiratory tract infection: cough(productive or non
productive), sputum, fever, hemoptysis
Pulmonary embolism: non productive cough,
hemoptysis, lowgrade fever, calf pain and
swelling(underlying dvt)
Lung malignancy: productive cough, hemoptysis, wt.
loss, loss of appetite
17. Peptic ulcer disease: nausea, vomiting,
hematemesis, melena.
Gerd: acid taste in mouth
Musculoskeletal: back and joint pains
h/o trauma?
18. Past medical history
Cardiovascular risk factors- age, gender, smoking, diabetes,
hypertension, hyperchlesterolemia,
Menopause- are at more risk of ishemia, MI
Thrombotic risk factors- previous history of thromboembolic
disease, malignancy, immobility, recent surgery, OCP use
Peptic ulcer disease
Asthma/ copd – history of asthma/copd
Pneumothorax - recurrence
19. Family history
of ischemic heart disease
Thrombo embolic disease
Medication history
Personal history: addictions- smoking, alcohol.
Social history – work type
20. Examination
Patient’s general appearance is helpful in
establishing an initial impression of the severity of
illness. Patients with acute MI or other acute
cardiopulmonary disorders often appear anxious,
uncomfortable, pale, cyanotic, or diaphoretic.
Patients who are massaging or clutching their
chests may describe their pain with a clenched
fist held against the sternum (Levine’s sign)
21.
22. Vitals: Significant tachycardia and hypotension-acute MI
with cardiogenic shock, massive pulmonary embolism,
pericarditis with tamponade, or tension pneumothorax.
Acute aortic emergencies usually present with severe
hypertension but may be associated with profound
hypotension when there is coronary arterial compromise
or dissection into the pericardium
Sinus tachycardia is an important manifestation of
submassive pulmonary embolism
Tachypnea and hypoxemia point toward a pulmonary
cause.
23. Pulmonary examination(breath sounds): localise
pulmonary cause as pneumonia, pneumothorax
or asthma
LV dysfunction-pulmonary edema
Cardiac examination: s3, s4, murmurs(AS),
complication of MI(mr, vsd).
Pericardial friction rubs- pericarditis.
24. JVP- raised in right heart failure, cardiac
tamponade
Vascular: acute limb ischemia with loss of pulse
and pallor- aortic dissection
25. Per Abdomen examination: Localizing tenderness
on the abdomen help in identifying a
gastrointestinal cause of the presenting symptom
like in peptic ulcer disease, pancreatitis, GERD
Abdominal findings are infrequent with purely
acute cardiopulmonary problems, except in the
case of underlying chronic cardiopulmonary
disease or severe right ventricular dysfunction
leading to hepatic congestion
27. INVESTIGATION-ECG
Crucial role in cardiac ischemia and other causes of chest pain
Cardiac ischemic pain: ST elevation, ST depression, T wave
inversion.
Serial ECGs to see the ischemic changes in Emergency
department.
Changes Localised to the artery involved,
Reciprocal changes in opposite lead,
Can take right sided leads or posterior leads if Right sided MI or
Post Wall MI is suspected
Pericarditis: ST elevation with upward concavity, reciprocal
changes may be seen.
Pulmonary embolism: s1q3t3 pattern
28.
29. CXR
Most useful in pulmonary causes
Pneumonia- consolidation
Pneumothorax- linear shadow of visceral
pleura,(lung margin)
Pulmonary embolism- westermark sign
Chronic pericarditis- pericardial calcification
30. Biochemistry
Creatine kinase MB and cardiac troponin most
specific
Serial monitoring helps to detect
D-dimer – in pulmonary thromboembolism
31. Echocardiography: not necessarily a routine
testing, but done in patients with non specific ST
elevation, ongoing symptoms, hemodynamic
instability- can detect abnormal regional wall
motion
Can detect mechanical complications of MI –
cardiac tamponade, valvular lesions
To look for aortic dissection.
32. CT angiography : to look for coronary arteries, to
look for any pulmonary embolism, aortic
dissection, pericardial effusion.
UGI endoscopy – to look for peptic ulcer disease,
GERD.
