The document outlines the approach to evaluating and treating a 55-year-old male patient presenting with chest pain, with a focus on differential diagnosis and essential clinical assessments. Key priorities include assessing clinical stability, potential life-threatening causes, and recognizing atypical symptoms of myocardial ischemia. The recommended treatment includes medications and diagnostic tests, emphasizing the importance of timely intervention and a structured evaluation process.

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Approach to
chest pain
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Dr.Saeid Soltani.MD.MPH.Cardiologist
IUMS
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2. 02/05/2025 Dr.Saeid Soltani.MD.MPH.Cardiologist 2
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A 55-year-old male presents to ED with chest pain.CP is new,
retrosternal /pressure like/15 min/on, off/with nausea and
sweating, he has HTN and DM2,he takes Valsomix 160/10 daily
and Glotrio 1000/5/25 daily.
Physical examination is notable for obesity.
BP:120/70 HR:90 BMI:32 o2sat:95% on air

3. 02/05/2025 Dr.Saeid Soltani.MD.MPH.Cardiologist 3
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Chest discomfort is among the most common reasons for
which patients present for medical attention at either an
emergency department (ED) or an outpatient clinic.

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 the priorities of the initial clinical encounter include assessment of:
(1) the patient’s clinical stability
(2) the probability that the patient has an underlying cause of the
discomfort that may be life threatening.
 The evaluation of CP relies heavily on the clinical history and
physical examination to direct subsequent diagnostic testing.

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Prescription  Onset : Sudden onset/Gradual
 Quality : Chest pressure, burning, or heaviness/ ripping
,tearing/Pleuritic pain
 Location : Retrosternal/ abdomen or epigastrium / radiating to
the back, particularly between the shoulder blades
 Pattern : Crescendo pattern / reaches its peak intensity
immediately / Lasting only a few seconds / many hours to days)
 Provoking and Alleviating Factors :Rest/TNG/Food/ changes in
position/cold weather/
 Associated Symptoms : diaphoresis, dyspnea, nausea, fatigue,
faintness, syncope/melena/ fever/cough
 Past Medical History : DM/HTN/DLP/ THORACIC SURGERY/smoker

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8. 02/05/2025 Dr.Saeid Soltani.MD.MPH.Cardiologist 8
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 Nevertheless, data from large populations of patients with acute
chest pain indicate that ACS occurs in those with atypical
symptoms at sufficient frequency that no single factor suffices
to exclude the diagnosis of acute ischemic heart disease.
 Clinicians should be mindful of “angina equivalents” such as jaw
or shoulder pain in the absence of chest pain or dyspnea, nausea
or vomiting, and diaphoresis. In particular, women, older persons,
and individuals with diabetes may experience atypical symptoms
of myocardial ischemia or infarction.

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11. 02/05/2025 Dr.Saeid Soltani.MD.MPH.Cardiologist 11
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12. 02/05/2025 Dr.Saeid Soltani.MD.MPH.Cardiologist 12
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 Check Vital sign
 P/E(Pulses/Auscultation OF lung and heart/neurological exam
 BP (both arm)
 ECG(with post and right) AND Repeat q15-30min if needed
 CXR(PA and Lateral)
 cTn (0/3-6h)
 D-Dimer IF needed

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STEMI
NSTEMI
Pericarditis

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pneumothorax pneumonia
tamponade

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PTE
Aortic dissection

16. 02/05/2025 Dr.Saeid Soltani.MD.MPH.Cardiologist 16
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1)Tab ASA 300mg(chew nonentric-coated ) 2) Tab plavix300mg
3)Tab Atorvastatin 80mg 4) o2 with cannula if o2sat<90%
5)Pearl TNG > check BP>>repeat if needed 3 times 6) serial ECG +post and right ECG
7)Amp Pantoprazol 40mg iv+plazil5mg iv 8)Amp morphine 3-5 mg iv if sBP>100
After
30
min

17. 02/05/2025 Dr.Saeid Soltani.MD.MPH.Cardiologist 17
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Approach
TO
STEMI

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Fibrinolytic
Agents

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Fibrinolytic
Agents

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Fibrinolytic
Agents
contraindication

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Q
AND
A
Thanks