CASE presentation of chest pain types, causes, investigations, management. cardiac vs non cardiac pain. life threatening chest pain. MI, ACS, PNEUMOTHORAX, PE, GERD, AORTIC DISSECTION.

1. Chest Pain
Muqtasid
Ayesha Khan
Final year MBBS
Facilitated by: Dr. Afrasiab Altaf

2. Objectives
 Describe various etiologies for chest pain
 Typical vs Atypical chest pain
 Review approach to chest pain
 Focus on life threatening causes of chest pain
 Management of chest pain
 Review patient cases
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3. Overview
 Chest pain accounts for 6 million annual visits to the Emergency
Departments in the United States
 Chest pain is the second most common Emergency Department
complaint after abdominal pain.
 Wide range of etiologies
 Cardiac, pulmonary, gastrointestinal, musculoskeletal
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4. Causes of chest pain that
can kill

5. Chest pain that can kill
 Acute Coronary Syndrome
 Pulmonary Embolism
 Aortic Dissection
 Esophageal Rupture
 Pneumothorax
 Pneumonia
 Various others:
 Pulmonary HTN
 Myocarditis
 Tamponade
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6. Other causes of chest pain
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7. Do you know the types of
chest pain?

8. Types of chest pain
• Characterized as discomfort/pressure rather than pain
• Time duration >2 mins
• Provoked by activity/exercise
• Radiation (i.e. arms, jaw)
• Does not change with respiration/position
• Associated with diaphoresis/nausea
• Relieved by rest/nitroglycerin
Typical
• Pain that can be localized with one finger
• Constant pain lasting for days
• Fleeting pains lasting for a few seconds
• Pain reproduced by movement/palpation
Atypical
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9. Approach to a patient with chest pain
 History
 Examination
 Stabilization
 Investigations
 Diagnosis
 Management
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10. What are the key parts of HOPI in
chest pain patient?
What can you get out of patient in 4
minutes?
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11. History matters
 Location: Central, left, or right
 Timing: Gradual or sudden onset
 Duration: since onset
 Character: crushing, stabbing, tearing, squeezing, sharp
 Associated symptoms: SOB, sweating, nausea
 Aggravating factors: What makes it worse or better?
 Quality: Visceral vs somatic
 Radiation: Back, neck, arm
 Severity: Scale of 1-10
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12. Rest of the history
 Past medical and surgical: cardiovascular disease, pulmonary disease
 Medication: Nitroglycerin, ASA etc.
 Allergies: Always important!
 Social: Smoker, Alcoholic, Cocaine,
 Family: Sudden Death, Early MI, DVT, Pulmonary embolism
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13. Key points in physical
examination
what can you examine in 2 minutes?
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14. Physical examination
 General Appearance
 Vital Signs
 Heart (Muffled, Regular, Fast,)
 Lungs (Equal, Wet, Tympanitic,)
 Neck (JVD)
 Abdomen (Distention)
 Lower Extremities (Edema, calf tenderness,)
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15. This man is brought to ED through
ambulance
What do you do next?
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16. Approach in emergency department
First 60 seconds
 How does the patient look?
 What are the patient’s vital signs?
 Ambulance story?
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17. Next 5 minutes
What are 2 bedside tests to consider?
What is an important and cheap medication you
should consider?
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18. Next 5 minutes
 Brief History
 Brief Physical
 ABCs, IV line, O2, monitor vitals, pulse oximetry
 What are 2 bedside tests that can be done to help stratify the
patient?
 ECG
 Portable CXR
 What is an important and cheap medication you should consider?
 ASA (More on this later)
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19. Next 10 minutes
 Patient already stabilized, initial data gathered, and
initial orders submitted
 Secondary survey: More detailed history and physical
exam
 Address patient’s pain
 Goal now is to categorize patient
1) Chest wall pain- Musculoskeletal
2) Pleuritic chest pain- Respiratory
3) Visceral chest pain- Cardiac
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20. Case presentation

21. Case 1
 64 year old man presents with 5 hours of chest pain and chest pressure
associated with SOB, nausea and diaphoresis. Gradual onset while
shoveling the snow. Pain radiated towards left jaw. Improved with rest.
 Past medical history: HTN, DM
 General: Nontoxic appearing, apprehensive, mildly diaphoretic
 Vitals: 37.5ºC, RR16, HR 100, BP 160/95
 CVS: RRR, Normal S1, S2, no M/R/G
 Respiratory: CTAB, easy respirations
 Abdomen: Soft, NTND
 Extremities: No calf tenderness or swelling, no edema, strong distal pulses
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22. Diagnosis?
What to do next?
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23. Case 1 Acute Coronary Syndrome
ECG:
 This will differentiate what you must do now.
(Specific but not sensitive)
ST elevation in 2 contiguous leads: STEMI
New LBBB
Ischemia/strain: ST depressions, new T wave inversions, Q
waves
Nonspecific: T wave flattening/inversions or Q waves
without old EKG
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24. Case 1 ACS
 CXR
 To look for failure and evaluate for other cause of chest pain
 Cardiac Enzymes
Marker Elevation Peak Duratio
CK-MB 3-12 h 18-24 h 2 days
Troponin-I 3-12 h 18 h 5-10 d
Troponin-T 3-12 h 12 h 5-14 d
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25. What else can you do for this
ACS patient?
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26. Treatment of ACS
 ABCs, IV line, O2, monitor vitals, pulse oximetry
 Morphine sulphate 5–10 mg or diamorphine 2.5–5 mg
 Aspirin 300mg plus clopedogril 600mg within 12 hours
 Aspirin continued-75–300 mg daily
 Heparin-fondaparinux 2.5 mg daily-8 days
 Sublingual glyceryl trinitrate (300–500 μg)or isosorbide dinitrate 1–2 mg/hour
 Atenolol 5–10 mg or metoprolol 5–15 mg given over 5 mins
 Fibrinolysis with streptokinase or Alteplase(tpA)
 Primary percutaneous coronary intervention (PCI)
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27. Case 2
 30 years old male had an open reduction internal fixation of ankle
fracture 2 weeks ago, now presented with sudden onset of chest
pain.
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28. Pulmonary Embolism
Signs and symptoms?
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29. Pulmonary embolism
Symptoms
SOB or dyspnea- Present in 90%
Chest pain (pleuritic)- 66% of patients with PE
Cough
Sudden onset
Signs
Tachycardia > 100 beats per minute
Tachypnea > 20 breaths per minute
Hypoxia < 95% on RA (no other cause)
Lower extremity swelling
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30. Pulmonary Embolus Risk Factors
 Hypercoaguability
 Malignancy, pregnancy, estrogen use, factor V Leiden, protein C/S
deficiency
 Venous stasis
 Bedrest > 48 hours, recent hospitalization, long distance travel
 Venous injury
 Recent trauma or surgery
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31. Pulmonary embolism: diagnosis
 CT pulmonary angiography (first line diagnostic test)
 Electrocardiography
Rule out MI, pericarditis and other causes
 Arterial blood gases
reduced PaO2, normal or low PaCO2
 D-dimer
 Ventilation–perfusion scanning
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32. Treatment of PE
 Oxygen, keep O2 saturation above 90%
 IV fluid to maintain blood pressure
 Heparin (Will limit propagation but does not dissolve clot)
Unfractionated: 80 u/kg bolus, 18 h/kg/hr
Fractionated (Lovenox): 1 mg/kg SC BID
 Fibrinolytics
Alteplase 50–100 mg infused over 2–6 hrs, (bolus in severe shock)
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33. Case 3
 35 years old male with sudden
ripping pain radiating to back.
Diagnosis?
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34. Aortic dissection
Blood violates aortic
intimal and adventitial
layers
False lumen is created
Dissection may extend
proximally, distally, or
in both directions
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35. Classification; aortic dissection35

36. Etiology; Aortic Dissection
 Bimodal distribution
 Young: Connective tissue (Marfan) or pregnancy
 Older: Most commonly > 50 (mean age 63)
 Risk factors
 Male: 66% of patients
 Hypertension: 72% of patients
 Connective tissue disease
30% of Marfan’s patients get dissections
 Cocaine Use
 Syphilis
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37. Clinical presentation
 Difficult clinical diagnosis
 85% have chest or back pain
 “Ripping” or “tearing” pain in 50%
 Neurologic symptoms(paraplegia) in 20%
 Hematuria
 Asymmetric pulses(brachial, carotid, femoral)
 Occlusion of aortic branches may cause
 MI (coronary)
 stroke (carotid)
 mesenteric infarction with an acute abdomen (coeliac and superior
mesenteric),
 renal failure (renal)
 acute limb (usually leg) ischaemia.
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38. How do you confirm the
diagnosis of this disease?
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39. Aortic dissection; diagnosis
 CXR-
 Widened mediastinum, abnormal aortic knob, pleural effusions
 Chest CT-
 Very sensitive and specific
 Quickly obtained
 Must think about kidney + contrast
 Angiography-
 Gold standard
 Most reliable anatomy of dissection
 Transoesophageal echocardiography
 Bedside U/S – evaluate aorta and look at heart to rule out tampanode.
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40. Ct chest (aortic dissection) Angiography (aortic dissection)
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41. Management
 2 large bore IV’s, monitor vitals, Type and crossmatch blood, ECG
 Ascending dissections will need aortic replacement surgery (type
A dissection)
 If dissection is only descending, management is medical
 Blood pressure control
 Maintain systolic BP at120-130 mmHg
 Beta blockers are first line (Labetalol and Esmolol)
 Can add vasodilators i.e. nitroprusside
 Percutaneous endoluminal repair
 Stent graft implantation
 Admission to ICU
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42. Case 4
 18 year old healthy male was lifting weights when he had sudden onset of
sharp Chest Pain + Shortness Of Breath.
 HR 122, RR 34, BP 70/P, Sat 88%
 Decreased breath sounds on left side
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43. What is your diagnosis?
Pneumothorax!
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44. Diagnosis; pneumothorax
Chest XRay
Free air appears black
Collapse of lung may occur
Mediastinum shifted to
other side
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45. Management
 Primary spontaneous pneumothorax
 If small
 Observe: resolves in 10 days
 Small chest tube with one way valve may help
 If larger
 100% O2 supply
 Analgesics
 Needle aspiration followed by chest tube placement
 Secondary spontaneous pneumothorax
 Chest tube drainage
 Surgical intervention to prevent recurrence
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46. Tension pneumothorax
 Medical emergency
 Chest decompression with a large bore needle
 Placement of chest tube
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47. Chest decompression
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48. Placement of chest tube48

49. Case 5
40 years old man presented with chest pain since 3 weeks with heart burn specially
after meals. He has difficulty in swallowing with sour taste in mouth.
On examination he is anemic and has lost weight.
Diagnosis?
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50. Gastroesophageal reflux disease
 SIGNS AND SYMPTOMS
 Heartburn (30-60min after meal)
 Spontaneous reflux of sour or bitter gastric contents into the mouth.
 Noncardiac chest pain
 Chronic cough
 Alarming features
 Troublesome dysphagia
 Odynophagia,
 Weight loss
 Iron deficiency anemia
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51. Investigations
 Upper endoscopy
 Barium esophagography
 Esophageal pH or combined esophageal pH-impedance
 testing
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52. Management
 Life style modification
 Eating smaller meals and elimination of acidic foods
 Weight loss and smoking cessation
 Avoid lying down within 3 hours after meals
 Initial therapy
 PPIs; omeprazole or rabeprazole, 20 mg taken 30min before breakfast-4-6
weeks
 Long term therapy
 PPIs therapy can be discontinued after 8–12 weeks
 H2-receptor antagonists (cimetidine 200 mg) may be used to control
symptoms
 Surgical fundoplication
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53. Summary
 Chest pain is a very common complaint but has a broad differential
 Always try to rule out the life-threatening causes of chest pain
 It is important to remember that troponin elevation DOES NOT
always mean ACS
 Use the history, physical exam, labs, EKG and imaging to commit to
a diagnosis
 Whenever you are stuck, ask for help. Your seniors are here to help
you!
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54. Thank you!
Questions?