Approach To Patient With Chset Pain

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'APPROACH TO PATIENT WITH CHSET PAIN

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Approach To Patient With Chset Pain

  1. 1. Approach to a patient with chest pain presenting in primary care setting DR Ihab Suliman MBBS,MRCP,Diplomate certification Board of Nuclear Cardiology(USA)
  2. 2. Chest Pain <ul><li>Common presentation. </li></ul><ul><li>Trivial to life-threatening causes. </li></ul><ul><li>Key to diagnosis is history NOT INVESTIGATIONS. </li></ul><ul><li>Negative baseline investigations DO NOT ruleout serious conditions </li></ul>
  3. 3. Life-threatening Causes of Chest Pain <ul><li>Myocardial infarction(ACS). </li></ul><ul><li>Thoracic aortic dissection. </li></ul><ul><li>Pulmonary embolus. </li></ul><ul><li>Tension pneumothorax. </li></ul><ul><li>Oesophageal rupture. </li></ul>
  4. 4. Investigations <ul><li>ECG most important But history is more important. </li></ul><ul><li>20% of patients having an MI will have a normal ECG initally. </li></ul><ul><li>Negative cardiac enzymes in A&E are not helpful. </li></ul><ul><li>CXR useful to rule out other causes like pneumonia. </li></ul>
  5. 5. 26 yr old thin man with sudden onset of severe L sided sharp chest pain ,tachypnoeic.
  6. 6. <ul><li>Right Pneumothorax </li></ul>
  7. 7. 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 .
  8. 8. 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 . <ul><li>Anterior (extensive) Myocardial infarction. </li></ul><ul><li>Why ? </li></ul><ul><li>Male 65 years. </li></ul><ul><li>H/O DM+HTN( remember INTERHEART study) </li></ul><ul><li>Crushing chest pain. </li></ul><ul><li>Associated sweaty,clammy,vomiting. </li></ul>
  9. 9. 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 <ul><li>Most likely diagnosis is </li></ul><ul><li>? AMI </li></ul><ul><li>?PE </li></ul><ul><li>?Esophagear Rupture </li></ul><ul><li>?Aortic Dissection </li></ul>
  10. 11. <ul><li>Aortic Dissection </li></ul><ul><li>Severe, sharp, “tearing” posterior chest pain or back pain (occurs in 74-90% of pts) </li></ul><ul><li>Pain may be associated with syncope, CVA, MI, or CHF </li></ul><ul><ul><li>Painless dissection relatively uncommon 15% </li></ul></ul><ul><li>Chest pain is more common with Type A dissections </li></ul><ul><li>Back or abdominal pain is more common with Type B dissections </li></ul>
  11. 12. <ul><li>Physical Examination </li></ul><ul><li>Pulse deficit </li></ul><ul><ul><li>Weak or absent carotid, brachial, or femoral pulses </li></ul></ul><ul><ul><li>these patients have a higher rate of mortality </li></ul></ul><ul><li>Acute Aortic Insufficiency </li></ul><ul><ul><li>Diastolic decrescendo murmur </li></ul></ul><ul><ul><li>Best heard along the right sternal border </li></ul></ul>
  12. 13. TEE of Aortic Dissection & CT aorta
  13. 14. 40 years old male finished cardiac evaluation last week for insurance (every thing is normal) .ate a heavy meal with friends (celebrating).followed by severe vomiting then chest pain.vomitus contains streaks of fresh blood. <ul><li>Likely diagnosis </li></ul><ul><li>?ACS </li></ul><ul><li>?PE </li></ul><ul><li>?Aortic Dissection </li></ul><ul><li>Esophageal submucosal tear(mallory weiss syndrome). </li></ul>
  14. 15. 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.
  15. 16. <ul><li>Pulmonary Embolism </li></ul><ul><li>Why ? </li></ul><ul><li>Young female </li></ul><ul><li>Pegnancy hypercoagulable state </li></ul><ul><li>Occurrence one week post partum </li></ul>
  16. 17. 50 years old female with chronic renal failure,chest pain & dizziness she is hypertensive on lisinopril
  17. 18. <ul><li>Hyperkalemia,tall tented T-wave & bradycardia. </li></ul><ul><li>Why ? </li></ul><ul><li>Chronic renal failure </li></ul><ul><li>Patient on lisinopril </li></ul>
  18. 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
  19. 20. <ul><li>Acute Pericarditis </li></ul>
  20. 21. 26 Old army officer had flu last week,felt chest pain while driving his car,pain increased by deep breath,ECG after 5 days .
  21. 22. <ul><li>Resolved Pericardtis. </li></ul>
  22. 25. <ul><li>Diagnostic limitations </li></ul><ul><li>History: </li></ul><ul><li>25% have ‘atypical’ histories </li></ul><ul><li>ECG: </li></ul><ul><li>55% of pts with AMI have a normal 1 ST 12-lead ECG </li></ul><ul><li>Convential Cardiac Markers : </li></ul><ul><li>Normal for the first 3- 4 hours </li></ul>
  23. 26. <ul><li>Take home points </li></ul><ul><li>History 90% </li></ul><ul><li>ECG: if ST elevated act fast </li></ul><ul><li>Risk factor reduction </li></ul><ul><li>Never ignore chest pain </li></ul>

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