Chest pain evaluation dr md toufiqur rahman dm fcps facc frcp fesc faha fscai fapsic

2. Dr. Md.Toufiqur Rahman
MBBS, FCPS, MD, FACC, FESC, FRCP, FSCAI,
FAPSC, FAPSIC, FAHA
Associate Professor of Cardiology
National Institute of Cardiovascular Diseases
Sher-e-Bangla Nagar, Dhaka-1207
drtoufiq19711@yahoo.com

3. Objectives
 Establish a differential diagnosis for chest pain
 Know what clues to obtain on history to rule-in or out MI,
PE, pneumothorax and aortic dissection
 Identify risk factors for MI
 Know how to do a focused physical exam, identifying
features that would distinguish between MI, PE,
pneumothorax and aortic dissection.
 Identify investigations required in diagnosing MI
 Outline management strategy in MI

4. Etiologies
 Myocardial ischemia or infarction
 Pulmonary embolus
 Pneumothorax
 Pericarditis
 Tamponade
 Pneumonia
 Aortic dissection
 Gastritis, peptic ulcer disease
 Musculo-skeletal
 Shingles

5. Case Scenario----1
 A 65 years old hypertensive, smoker, diabetic and
dyslipidemic gentleman from Mymensingh district
presented with central chest tightness on exertion for last 1
months. His pulse was 104 b/min, BP-150/95 mm Hg,
HbA1c-8.2%. His ECG was normal . What should be his
next investigation? What was the probable cause of his
chest tightness?
a. Esophageal spasm
b. Chronic stable angina
c. acute coronary syndrome
d. acute pericarditis

6. Case Scenario----2
 A 55 years old hypertensive, smoker, diabetic and
dyslipidemic gentleman from Dhanmondi presented with
central chest tightness with excessive sweating for last 30
minutes not relieved by taking sublingual nitrates. His
pulse was 104 b/min, BP-150/95 mm Hg, HbA1c-8.2%. His
ECG showed ST segment elevation in V1-V5 . What was the
probable cause of his chest tightness?
a. Esophageal spasm
b. Chronic stable angina
c. acute coronary syndrome(STEMI)
d. acute pericarditis

7. Case Scenario----3
 A 55 years old hypertensive, smoker, diabetic and dyslipidemic
gentleman from Tejgaon presented with central chest tightness
with excessive sweating for last 30 minutes not relieved by
taking sublingual nitrates. His pulse was 104 b/min, BP-150/95
mm Hg, HbA1c-8.2%. His ECG showed ST segment depression
in V1-V5 . His Troponin I level is 30 ng/L. What was the
probable cause of his chest tightness?
a. Esophageal spasm
b. Chronic stable angina
c. acute coronary syndrome(NSTEMI)
d. acute pericarditis

8. Case Scenario----4
 A 52 years old hypertensive, smoker, diabetic and dyslipidemic
gentleman from Bashaboo presented with central chest
tightness with excessive sweating for last 20 minutes not
relieved by taking sublingual nitrates. His pulse was 110 b/min,
BP-140/95 mm Hg, HbA1c-9.2%. His ECG showed T inversion
in V1-V4 . His Troponin I level is normal. What was the
probable cause of his chest tightness?
a. Esophageal spasm
b. Chronic stable angina
c. acute coronary syndrome(Unstable angina)
d. acute pericarditis

9. Case Scenario----5
 A 32 years old smoker gentleman from Naogaon
presented with central chest pain for last 5 days with fever.
His pulse was 120 b/min, BP-140/95 mm Hg. His ECG
showed ST segment elevation in lead V1-V6 and lead 2, 3
and aVF . What was the probable cause of his chest pain ?
a. Esophageal spasm
b. Chronic stable angina
c. acute coronary syndrome
d. acute pericarditis

10. Case Scenario----6
 A 42 years old smoker gentleman from Rajshahi
presented with central chest pain for last 35 days increased
at night lying flat relieved by taking antacid syrup. His
pulse was 80 b/min, BP-130/85 mm Hg. His ECG showed
normal. What was the probable cause of his chest pain?
a. Reflux esophagitis
b. Chronic stable angina
c. acute coronary syndrome
d. acute pericarditis

11. Case Scenario----7
 A 22 years old lady from Khulna district presented with
central chest pain with palpitations for last 5 months.
Her pulse was 110 b/min, BP-120/80 mm Hg. Her ECG
showed normal , Echocardiography showed normal study,
ETT done previously for 2 times were negative. What was
the probable cause of his chest pain?
a. Reflux esophagitis
b. Chronic stable angina
c. acute coronary syndrome
d. Generalized Anxiety Disorder

12. Case Scenario----8
 A 25 years old lady from Kustia district presented with
central chest heaviness with palpitations with low grade
fever for last 2 months. Her pulse was 110 b/min, BP-
110/70 mm Hg. Her ECG showed low voltage ,
Echocardiography showed echo free space in pericardium.
What was the probable cause of his chest pain?
a. Reflux esophagitis
b. Chronic stable angina
c. Pericardial Effussion
d. Generalized Anxiety Disorder

13. Case Scenario----9
 A 25 years old lady from Kustia district presented with
central chest heaviness with palpitations with low grade
fever for last 2 months. Her pulse was 110 b/min, BP-
110/70 mm Hg. Her ECG showed low voltage ,
Echocardiography showed echo free space in pericardium.
What was the probable cause of his chest pain?
a. Reflux esophagitis
b. Chronic stable angina
c. Pericardial Effussion
d. Generalized Anxiety Disorder

14. Case Scenario----10
 A 19 years old smoker gentleman from Panchagor
presented with central chest pain for last 5 days with fever
and shortness of breath. His pulse was 120 b/min, BP-
110/75 mm Hg. His ECG showed T inversion in lead V1-
V6 . His echocardiography showed global hypokinesia with
EF-40%, Troponin I positive. What was the probable cause
of his chest pain ?
a. Myocarditis
b. Chronic stable angina
c. acute coronary syndrome
d. acute pericarditis

15. Case Scenario----11
 A 27 years old gentleman from Chuadanga district
presented with occasional chest pain with palpitations
for last 2 years. His pulse was 110 b/min, BP-110/70 mm
Hg. His ECG showed normal , Echocardiography showed
echo mitral valvular disease. What was the probable cause
of his chest pain?
a. Mitral valve prolapse
b. Chronic stable angina
c. Pericardial Effusion
d. Generalized Anxiety Disorder

16. Case Scenario----12
 A 21 years old gentleman from Sathkhira district
presented with occasional central chest pain with
palpitations for last 3 years. He was diagnosed as a case
of Marfans Syndrome. His pulse was 112 b/min, BP-110/70
mm Hg. His ECG showed normal , Echocardiography
showed echo aortic root dilataion. What was the probable
cause of his chest pain?
a. Mitral valve prolapse
b. Chronic stable angina
c. Pericardial Effusion
d. Aortic Aneurysm

17. Case Scenario----13
 A 50 years old hypertensive, smoker, diabetic and dyslipidemic
gentleman from Jatrabari presented with severe tearing central
chest pain with excessive sweating for last 30 minutes not
relieved by taking sublingual nitrates. His pulse was 104 b/min,
no pulse in lower limbs BP-150/95 mm Hg, HbA1c-8.2%. His
ECG showed left ventricular hypertrophy . What was the
probable cause of his chest tightness?
a. Esophageal spasm
b. aortic dissection
c. acute coronary syndrome(STEMI)
d. acute pericarditis

18. Case Scenario----14
 A 70 years old hypertensive, smoker, diabetic and
dyslipidemic gentleman from Jessore presented with
central chest pain with burning sensation in mouth while
taking food. His pulse was 86 b/min, BP-140/95 mm Hg,
HbA1c-8.2%. Oral examination showed oral thrush. His
ECG showed left ventricular hypertrophy . What was the
probable cause of his chest tightness?
a. Esophagitis ( Fungal infection)
b. aortic dissection
c. acute coronary syndrome(STEMI)
d. acute pericarditis

19. 26 Old army officer had flu last week,felt chest pain while driving his car,pain
increased by deep breath,he has no history of DM or HTN,nonsmoker,lipid profile LDL
2.0 MMMOL/L

20. A 26 year old woman presented 1 week post
delivery of her first baby. She has sharp L sided
chest pain and she is short of breath.

21.  Pulmonary Embolism
 Why ?
 Young female
 Pegnancy hypercoagulable state
 Occurrence one week post partum

23. 65 year old man(H/O DM,HTN) presented with a 1 hour history
of severe central crushing chest pain. He is sweaty, clammy and
has vomited twice .
 Anterior (extensive) Myocardial infarction.
Why ?
Male 65 years.
H/O DM+HTN( remember INTERHEART study)
Crushing chest pain.
Associated sweaty,clammy,vomiting.

24. 70 years old male with long history of untreated HTN,
nonsmoker came complaining of chest pain migrated to
interscapular region & became severe(tearing), SBP 200,ECG
mild inferior changes
 Most likely diagnosis is
 ? AMI
 ?PE
 ?Esophagear Rupture
 ?Aortic Dissection

25. 26 yr old thin man with sudden onset of severe L
sided sharp chest pain , tachypnoeic.

26. Myocardial ischemia or infarction
 Pressure-type of chest pain
 Generally involves central to left-sided pain with radiation
to jaw or arms
 Exacerbated by activity, relieved with rest
 Relieved with nitro spray
 Associated with nausea, diaphoresis, syncope, shortness of
breath
 Enquire about cardiac risk factors: age, sex, smoking
history, diabetes, hypertension, hyperlipidemia, previous
myocardial infarction and family history

27. Myocardial ischemia or infarction
 ↓BP indicates cardiogenic shock
 ↑JVP, pulsatile liver and peripheral edema seen in right-
sided heart failure
 Oxygen desaturation, crackles, S3 seen in left-sided heart
failure
 New murmurs: mitral regurgitation murmur in papillary
muscle dysfunction

28. Work-up
 EKG (should be knee-jerk reflex in chest pain scenario!)
 CXR to look for signs of congestive heart failure
 Cardiac enzymes: CK (will begin to rise 6 hours after
infarct and remain elevated for 24-48 hours), troponin (will
begin to rise 12 hours after infarct and remain elevated for 2
weeks). Need to follow serially if first set negative.

31. Management Strategy for NSTEMI
Initial therapy
 Morphine for pain
 Oxygen if hypoxic
 Nitro spray/drip for pain
 Aspirin

32. Management Strategy for
NSTEMI/NST Chest Pain
 Establish risk level using the TIMI scoring system:
 Low risk: May be discharged after symptom control
 Moderate risk: Admit for further evaluation; add beta
blockers , Ace inhibitors . Follow cardiac enzyme levels.
If Mi ruled out, Exercise or Adenosine stress test before
discharge
 High Risk: Admit for cardiac catheterization

33. Management Strategy for STEMI
 Morphine, oxygen, nitro, aspirin
 Beta blockers, Ace inhibitors
 Early invasive strategy with either thrombolytic therapy
or percutaneous coronary intervention (preferred)

34. Pulmonary Embolism
 Sudden-onset sharp chest pain
 Exacerbated by inspiratory effort
 Can be associated with hemoptysis, sycope, dyspnea, calf
swelling/pain from DVT
 Risk factors: immobilization, fracture of a limb, post-
operative complications, hypercoagulable states
(underlying carcinoma, high-dose exogenous estrogen
administration, pregnancy, inherited deficiencies of
antithrombin III, activated protein C, S, lupus
anticoagulant, prior history of DVT/PE [Virchow’s triad]

35. Pulmonary Embolism
 Anxious patient, sense of impending doom
 Tachycardia, tachypnea, hypoxia
 EKG: sinus tachycardia most common, S1Q3invertedT3
with large embolus (classic, but rare!), look for right-axis
deviation
 V/Q scan very sensitive but not specific
 Spiral CT with contrast show large, central emboli
 Pulmonary angiogram is gold standard but carries risk
 Consider Doppler U/S of legs

36. Pneumothorax
 Can be asymptomatic or present with acute pleuritic
chest pain and dyspnea
 Primary pneumothorax predominantly in healthy
young tall males
 Due to trauma (MVA accidents – associated with rib
fractures, iatrogenic – during line placement,
thoracentesis)
 Increased alveolar pressure from asthma or
barotraumas (BiPAP, ventilator-associated)
 Rupture of bleb in COPD patients

37. Pneumothorax
 Decreased expansion of chest
 Decreased breath sounds and
 Decreased tactile/vocal fremitus on side of
pneumothorax
 Hyperresonant percussion note
 Usually easily confirmed by CXR

38. Aortic Dissection
 Abrupt onset
 The pain usually is described as ripping or tearing
 Tearing or ripping pain that is felt in the intrascapular area
 New diastolic murmur, asymmetrical pulses, and
asymmetrical blood pressure measurements
 Risk factors: HTN, Marfan syndrome, coarctation of aorta..
 Widened mediastinum on a portable anteroposterior (AP)
radiograph
 TEE considered diagnostic test of choice

39. Key Points
 Not every chest pain is MI, however every chest pain should be
considered as ischemic until proven otherwise
 A good history and physical exam may help with the diagnosis
 EKG is the best single diagnostic test to help rule out MI
 Use the TIMI scoring system to help for the diagnosis and prognosis of
MI

40. Chest Pain Definitions
 Acute Chest Pain:
 Acute - sudden or recent onset (usually within minutes
to hours), presenting typically <24 hrs
 Chest - thorax midaxillary to midaxillary line, xiphoid
to suprasternum notch
 Pain – noxious uncomfortable sensation
 Ache or discomfort

41. Initial Approach
 Triage
 Chest pain
 Significant abnormal pulse
 Abnormal blood pressure
 Dyspnea
 These pts need IV, O2, Monitor, ECG

42. Initial Approach
 Evaluation:
 Airway
 Breathing
 Circulation
 Vital Signs
 Focused exam
 Cardiac, pulmonary, vascular

43. Initial Approach
 History:
 Character of pain
 Presence of associated symptoms
 Cardiopulmonary history
 Pain intensity, 0-10 pain

44. Initial Approach
 Secondary exam:
 History
 Quality, radiation/migration, severity, onset, duration,
frequency, progression and provoking or relieving factors of
pain
 Risk factors
 Physical exam
 Review old records/ekg’s

45. Categorizing Chest Pain
1. Chest Wall Pain
• Sharp, Precisely localized
• Reproducible: Palpation, movement
2. Pleuritic or Respiratory CP
• Somatic pain, Sharp
• Worse with breathing/coughing
3. Visceral CP
• Poorly localized, aching, heaviness

46. Causes OF chest pain
1. Chest wall
 Costosternal synd
 Costochrondritis
 Precordial catch synd
 Slipping Rib Synd
 Xiphodynia
 Radicular Synd
 Intercostal Nerve
 Fibromyalgia
2. Pleuritic
 Pulmonary Embolism
 Pneumonia
 Spontaneous pneumo
 Pericarditis
 Pleurisy

47. Causes of chest pain
3. Visceral Pain:
 Typical Exertional
Angina
 Atypical Angina
 Unstable Angina
 Acute Myocardial
Infarction (AMI)
 Aortic Dissection
 Pericarditis
 Esophageal Reflux or
spasm
 Esophageal Rupture
 Mitral Valve Prolapse

48. Thank
you all