approach to chest pain

1. 1
Approach to
CHEST PAIN
DR.Bilal Natiq Nuaman,MD
CABM,FICMS,DIM,MBChB
2017

2. Chest pain—broadly defined as any discomfort in the
anterior thorax occurring above the epigastrium and
below the mandible—can be one of the most
challenging problem managed by the physicians.
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. CAUSES OF CHEST PAIN
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5. Any adult male (more than 30 years), or
postmenopausal female, complaining of
retrosternal pain should be suspected to be
having myocardial ischemia, until proved
otherwise.
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8. 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.
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16. Ischemic Vs
Non Ischemic
Chest Pain
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18. • Chest pain due to ischemic heart disease (IHD) may manifest as:
Angina pectoris :2-10 min., relieved by rest , not associated with
vomiting
Myocardial infarction :>30 min., not relieved by rest , associated
with vomiting

19. Characteristics of cardiac pain
• Onset. The pain of MI typically takes several minutes
or even longer to develop; similarly, angina builds up
gradually in proportion to the intensity of exertion.
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22. • Associated features. The pain of MI, massive
pulmonary embolism or aortic dissection is often
accompanied by autonomic disturbance, including
sweating, nausea and vomiting.
Breathlessness, due to pulmonary congestion arising
from transient ischemic left ventricular dysfunction, is
often a prominent and occasionally the dominant
feature of MI or angina (angina equivalent).
Breathlessness may also accompany any of the
respiratory causes of chest pain and can be associated
with cough, wheeze or other respiratory symptoms.

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24. Major adverse cardiac events (MACE) 29

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26. DIFFERENTIAL DIAGNOSIS
• Acute, sudden and severe chest pain described as tearing that
is maximal at onset and radiates to interscapular area raises
the possibility of aortic dissection.
Important diagnostic feature is the inequality in the pulses, e.g.
carotid, radial and femoral, and a blood pressure differential of
greater than 20 mm Hg
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27. • Severe chest pain, retrosternal, accompanied by dyspnea,
cough, and hemoptysis developing in a patient who has been
immobilized or bedridden is suggestive of pulmonary embolism
• Chest discomfort due to pericarditis is typically retrosternal,
aggravated by coughing, deep respiration, or change in
position; worse in supine, and relieved in sitting upright and
leaning forward
• The pain of esophageal spasm is commonly an intense,
squeezing discomfort that is retrosternal in location and, like
angina, may be relieved by nitroglycerin
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28. • Pain in a dermatomal distribution can also be caused by herpes
zoster
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29. PULMONARY50%
EXCLUDE75%
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95% CAUSES
• Stable angina NON ischemic chest pain
ECG CXR
DIAGNOSTIC CAUSES
TREADMILL TEST ECHO
DIAGNOSTIC VALVE LESION
CORONARY ABDOMINAL U S
ANGIOGRAPHY , OGD
DIAGNOSTIC ABDOMINAL

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31. THANK YOU
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