A practical approach to a common problem

1. Approach to chest pain
Do not panic

2. Pain
Subjective symptom

3. Pain sensitive structures
 Skin
 Breast
 Muscles
 Bones, joints
 Parietal pleura
 Myocardium
 Pericardium
 Esophagus
 Aorta- adventitia
 Nerve roots

4. Common causes
 Cardiac- CAD (angina/MI), pericarditis
 Vascular- aortic dissection, PE
 Pulmonary- pleuritis, pneumothorax
 GI- esophageal reflux/spasm/rupture
 Skeletal- costochondritis, arthritis
 Nervous- radicular pain, H. zoster
Tumors, abscesses, muscle cramps etc.

5. How to go?
 Serious or catastrophic causes
 Cardiac ischemia
 Pericarditis
 Aortic dissection
 Pulmonary emboli
 Esophageal rupture

6. Back to basics
History & examination

7. Myocardial ischemia
 Pain- described as
heaviness/pressure/squeezing/tightness
 Onset/worsening with exertion/meals
 Location- substernal/retrosternal
 Radiation to arms/jaw/shoulder/back
 Duration- <20 mins. or >20 mins.
 Relieved with rest, S/L NTG, morphine
 Associated with nausea/sweating/sense of doom
 h/o DM, HT, smoking
 Family history of CAD

8. Other causes
 Pericarditis- ant. chest/back, pleuritic,
worse when supine and relieved by
sitting upright & leaning forward
 Aortic dissection- abrupt onset, rapidly
worsens, retrosternal, radiates to back,
lasts hours, no relief with analgesics
 GI causes- UGI symptoms
 Costochondritis- elicitable pain

9. Relevant examination
 Vitals- equal pulses, BP, tachypnea
 Local tenderness or skin lesion
 LNE (tumor)
 Crepitations, pleural rub
 S3/S4, murmur
 Upper abdominal examination

10. Relevant investigation
 ECG, trop T  stress tests
(TMT/ECHO)
 Chest X-ray
 D-dimer
 CT scan chest
 Other X-rays- spine, shoulder

11. Treatment of pain
 Angina- NTG
 MI- morphine
 Pericarditis/PE- NSAIDs
 Aortic dissection/esophegeal rupture- Surgery
 Esophageal reflux- PPI/H2RB
 Zoster- amitriptyline, carbamazepine,
pregabalin, gabapentin
 Bone/joint/muscle pain- NSAIDs

12. Palpitation
Unpleasant awareness of
forceful, rapid, irregular
heart beat

13. Causes
 Cardiac
 Sinus bradycardia
 Any tachycardia
 PVC/PAC
 Sick sinus syndrome
 Advanced AV block
 Aortic regurgitation
 Non-cardiac
 Fever
 Anemia
 Thyrotoxicosis
 Pheochromocytoma
 Drugs
 Alcohol, Cocaine
Anxiety/Panic disorder

14. Evaluation
 History
 Onset/offset, frequency, rate, rhythm
 Aggravating/relieving factors, associated symptoms
 h/o cardiac disease
 Examination
 Pulse- rate, rhythm
 Pallor, e/o hyperthyroidism
 Cardiac examination
 Investigation
 ECG, ECHO, Holter, Hb., TSH
 Treatment- of underlying etiology