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1. CAUSES &
APPROACH
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2. OVERVIEW
• Magnitude of Problem
• Causes
• Cardiopulmonary Causes
- Cardiac
- Vascular
- Pulmonary
• Non Cardiopulmonary Causes
- Gastrointestinal
- Neuromuscular
- Others
• Approach
• Investigations
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3. Epidemiology
• After injuries, chest pain is the second most common reason for adults to present
to the ER In US.
• >6.5 million visits to ER and 4 million visits to OPD
• The lifetime prevalence of chest pain in the United States is 20% to 40% .
• Of all ED patients with chest pain, only 5.1% will have ACS.
• CAD affects >18.2 million adults in the US and remains the leading cause of
death for men and women, accounting for >365,000 deaths annually.
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4. MAGNITUDE OF PROBLEM
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• Only 15-20 % of patients presenting with chest pain actually have
Acute Coronary Syndrome (ACS).
10 % present with life-threatening non cardiac chest pain
• MC Cause- Gastrointestinal
• Triage of patients should be done like:
1. Myocardial Ischemia
2. Other Cardiopulmonary Causes
3. Non- Cardiopulmonary Causes
• 2-6 % of patients with chest discomfort due to Ischemic causes are
missed and later present with Myocardial Infarction.
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5. DefiningChestPain
Chest pain refers to many unpleasant or uncomfortable sensations in the anterior chest.
Patients often report pressure, tightness, squeezing, heaviness, or burning.
Locations other than the chest, including the shoulder, arm, neck, back, upper
abdomen, or jaw .
COR LOE Recommendations
1 B-NR
1. An initial assessmentof chest painis recommendedto triage patientseffectivelyon the basis
of the likelihood that symptomsmaybe attributable to myocardialischemia.
1 C-LD
2. Chest painshouldnot be described as atypical,becauseit is not helpfulin determining the
cause and can be misinterpreted as benign in nature. Instead,chest painshouldbe described as
cardiac,possibly cardiac, ornoncardiac because these termsare more specific to the potential
underlying diagnosis.
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6. Figure2.Indexof SuspicionThatChest“Pain”IsIschemic in Origin
on theBasisof CommonlyUsedDescriptors.
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7. Top 10Causesof ChestPainintheED Based onAge (WeightedPercentage).
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11. APPROACH
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• Quick History
• Physical Examination
• Stability – R/O
• High risk conditons:
- ACS
- Acute Aortic Syndrome
- Pulmonary Embolism
- Tension Pneumothorax
- Pericarditis with
tamponade
- Esophageal Rupture
• Investigation
• Ecg, biomarkers
• Immediate intervention
and further diagnostic
and therapeutic
interventions
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12. Diagnostic approach
• Clinical stability------------------stable vs unstable
• Immediate prognosis------------------good or poor
• Safety of triage options-------------------discharge or further investigate
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13. HISTORY
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 If stable do assess
• Quality of pain
• Location
• Radiation
• Pattern
• Agrravating & Relieving Factors
• Associated Symptoms
• Past Medical History
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14. Chest PainCharacteristics and CorrespondingCauses
Nature
Anginal symptoms are perceived as retrosternal chest discomfort (e.g., pain, discomfort,
heaviness, tightness, pressure, constriction, squeezing
Sharp chest pain that increases with inspiration and lying supine is unlikely
related to ischemic heart disease (e.g., these symptoms usually occur with acute
pericarditis).
Onset and duration
Anginal symptoms gradually build in intensity over a few minutes.
Sudden onset of ripping chest pain (with radiation to the upper or lower back) is unlikely to
be anginal and is suspicious of an acute aortic syndrome.
Fleeting chest pain—of few seconds’duration—is unlikely to be related to ischemic heart
disease.
Location and radiation
Pain that can be localized to a very limited area and pain radiating to below the umbilicus or
hip are unlikely related to myocardial ischemia.
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15. Severity
Ripping chest pain (“worse chest pain of my life”), especially when sudden in onset and occurring
in a hypertensive patient, or with a known bicuspid aortic valve or aortic dilation, is suspicious of an
acute aortic syndrome (e.g., aortic dissection).
Precipitating factors
Exertion, emotional, meal, rest .
Positional chest pain is usually nonischemic
Relieving factors
resting and nitroglycerin is not necessarily diagnostic of myocardial ischemia and should not be used as
a diagnostic criterion.
Associated symptoms
Common symptoms associated with myocardial ischemia include, but are not limited to, dyspnea,
palpitations, diaphoresis, lightheadedness, presyncope or syncope, upper abdominal pain, or heartburn
unrelated to meals and nausea or vomiting.
Symptoms on the left or right side of the chest, stabbing, sharp pain, or discomfort in the throat or
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17. PHYSICAL EXAMINATION
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• Vitals always the first
• Initial examinations focusing early finding of clue of potential
life-threatening condition or potential precipitating factors of
ischemia
• COPD
• CHF
• Cardiac tamponade
• R/O aortic dissection, pneumothorax
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18. Clinical Syndrome Findings
Emergency
ACS Diaphoresis, tachypnea, tachycardia, hypotension, crackles, S3,
MR
murmur; examination may be normal in uncomplicated cases
PE Tachycardia + dyspnea—>90% of patients; pain with inspiration
Aortic dissection Connective tissue disorders (e.g., Marfan syndrome), extremity
pulse
differential (30% of patients, typeA>B)
Severe pain, abrupt onset + pulse differential + widened
mediastinum on CXR >80% probability of dissection
Frequency of syncope >10% (8), AR 40%–75% (typeA)
Esophageal
rupture
Emesis, subcutaneous emphysema, pneumothorax (20%
patients),
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19. Other
Noncoronary cardiac:
AS, AR,
HCM
AS: Characteristic systolic murmur, tardus or parvus carotid
pulse
AR: Diastolic murmur at right of sternum, rapid carotid upstroke
HCM: Increased or displaced left ventricular impulse,
prominent a wave in jugular venous pressure, systolic murmur
Pericarditis
Myocarditis
Fever, pleuritic chest pain, increased in supine position, friction
rub
Fever, chest pain, heart failure, S3
Pneumonia Fever, localized chest pain, may be pleuritic, friction rub may be
present, regional
dullness to percussion, egophony
Pneumothorax Dyspnea and pain on inspiration, unilateral absence of breath
sounds
Costochondritis, Tietze
syndrome
Tenderness of costochondral joints
Herpes zoster Pain in dermatomal distribution, triggered by touch;
characteristic rash (unilateral
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20. INVESTIGATIONS
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• ECG--------early ECG saves time and increase probability of catching ACS
• CXR------------done for all patients can show pneumonia, pulmonary edema, pleural effusion
Pneumothorax may show rare features of PTE can show mediastinal dilation in AD
• Cardiac Biomarkers-----cardiac troponin T and I are proffered
• Provocative Testing
• Other Noninvasive Tests
- Echocardiography
- CT Angiography
- MRI
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21. Risk stratification
• Clinical decision pathways stratify patients in to categories to estimate
1. Probability of AMI
2. Risk of 30 day MACE
• Accordingly, patients are grouped in to Low, intermediate and High
risk groups by using
• Symptoms
• CAD risk factors
• ECG
• Biomarkers
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22. Introduction
 Pulmonary embolus (PE) refers to obstruction of the pulmonary artery or one
of its branches by material
 PE can be classified by the following:
The temporal pattern of presentation (acute, subacute, or chronic)
The presence or absence of hemodynamic stability (hemodynamically unstable or
stable)
The presence or absence of symptoms (symptomatic or asymptomatic)
The anatomic location (saddle, lobar, segmental, subsegmental)
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23. PTE
Diagnosis and treatment
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24.  Classification of acute PE can assist with prognostication and
clinical management.
 Massive PE accounts for 5% to 10% of cases.
 Submassive PE is more common, occurring in approximately 20%
to 25% of patients.
 Low-risk PE constitutes the majority of PE cases—approximately
70%.
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Classification of PE…

25.  HX and P/E
 Investigation including routine lab.
 Imaging
 The most useful approach is :
 a clinical assessment of likelihood, based on presenting symptoms and
signs,
 in conjunction with judicious diagnostic testing.
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Diagnosis of PE

26. Symptoms
 Unexplained dyspnea
 Chest pain, especially pleuritic or
“positional”
 Anxiety
 Cough
Signs
 Tachypnea
 Tachycardia
 Low-grade fever
 signs of right heart failure
 Hemoptysis
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Diagnosis

27.  PE should be suspected in hypotensive patients when there is evidence of
Venous thrombosis or predisposing VTE risk factors;
Acute cor pulmonale (acute right ventricular failure)
Echocardiographic findings of RV dilation and hypokinesis or
 ECG evidence of acute cor pulmonale manifested by
 A new S1Q3T3 pattern,
 A new right bundle branch block, or
 RV ischemia manifested by inferior T wave inversion or T wave inversion in leads V1
through V4.
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Diagnosis…

28.  Wells criteria include :
 Clinical symptoms of deep vein
thrombosis (DVT) (3 points)
 Other diagnoses are less likely than PE
(3 points)
 Heart rate >100 (1.5 points)
 Immobilization three or more days or
surgery in previous four weeks (1.5
points)
 Previous DVT/PE (1.5 points)
 probability of PE into a three-tiered
system
 Low (score <2)
 Intermediate (score 2 -6)
 High (score >6)
 can also be used to classify patients
into a two-tiered system:
 patients are likely (score >4) or
 unlikely (score ≤4) to have PE
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Diagnosis…

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The revised Geneva clinical prediction rule for
PE

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31. Diagnosis
• Role of D-dimer
• Is no specific marker used for less likelihood pateints
• Role of echo
• Ruling out mimics eg ACS and pericardial diseases
• rapid, practical, and sensitive technique for detection of right ventricular overload
among patients with established and large PE.
• CTPA diagnostic modality of choice
• Pulmonary angiography rarely used
• V/Q mismatch alternative
•
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32. Algorithm
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33. Treatment
• primary therapy --------------------
• For patents with massive PE and hemodynamically unstable For
submissive or stable patients anticoagulant is preferred
• Secondary therapy
• For hemodynamically stable patients
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34. Empiric Anticoagulation

35. POST-RESUSCITATION
 Do the diagnostic evaluation quickly:
• If no PE, stop anticoagulant therapy
• If PE, continue therapy .
Primary Therapy versus Secondary Prevention
 Primary therapy: consists of thrombolysis or embolectomy
 Secondary prevention: heparin and warfarin or IVC filter for prevention
of recurrent PE
DOAC and NOAC

36. ACS
Spectrum diagnosis and treatment
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38. Initial goals of therapy are to:
Quickly identify via 12-lead ECG whether patient has ST elevation and
therefore is a candidate for immediate reperfusion therapy
Relieve pain
Prevent/treat arrhythmias and mechanical complications
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39. Diagnosis
• Serial ECG
• Cardiac markers
• Initiate emergency care
• Echocardiography
• Coronary angiography
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40. Medical Management
 General measures
 Oxygen- for Spo2<90% or RD
 activity
 Diet
 Bowel management
 Sedation
 Chest discomfort
 Analgesics- Morphine- 4-8 mg IV, then 2-8 mg q 5-15 minutes
 Anti-ischemic medications- Nitrates and BB
 Antithrombotic therapy
 anti platelets
 Anticoagulants
 Others
 Statins , RAAS inhibitors , CCBs ,MRA 40
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42. PCI Vs CABG
PCI
 Faster revascularization
 A lower risk of stroke
 Absence of deleterious effects of
cardiopulmonary bypass on the ischemic
myocardium
 DES Preferred
CABG
• Disease of the left main coronary artery (LMA)
• MVD with
• LVEF < 40% and/or
• DM
• Contraindication to DAPT
• Need for concomitant Cardiovascular surgery
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43. NSTE-ACS
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• Patients with NSTE-ACS should be treated with an early medical
regimen similar to that used in STEMI with one exception:
• There is no evidence of benefit (and possible harm) from
fibrinolysis
• Early risk assessment is useful in identifying patients who would
derive the greatest benefit from an early invasive strategy

44. Risk Stratification
 Integrate patient characteristics
 Prognosis and optimal care
 TIMI risk score
http://www.mdcalc.com/timi-risk-score-for-stemi
 GRACE risk model
http://www.outcomes-
umassmed.org/grace/acs_risk/acs_risk_content.html
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45. 4/2/2024
•TIMI risk scores from 0 to 2
(low risk) to 5 to 7 (high risk)
•only patients at moderate to
high risk (score ≥3)
benefited from an early
invasive strategy
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