This document provides guidance on evaluating and treating chest pain. It outlines many potential causes of chest pain including cardiac, pulmonary, gastrointestinal and musculoskeletal issues. For serious potential causes like myocardial ischemia, pericarditis or aortic dissection, the document describes relevant history, examination findings and initial investigations. It emphasizes doing an ECG, reviewing risk factors and considering stress testing to evaluate for possible cardiac ischemia as the cause of chest pain. The document also reviews how to treat different potential underlying etiologies once identified.

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