This document discusses the approach to evaluating a patient presenting with chest pain in a primary care setting. It emphasizes that the history is the most important factor in diagnosis, not investigations alone. It provides examples of several cases presenting with chest pain and the most likely diagnosis based on factors like the patient's age, medical history, characteristics of the pain, and findings on examination. Common life-threatening causes of chest pain are discussed along with the limitations of some diagnostic tests.

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. Chest Pain Common presentation. Trivial to life-threatening causes. Key to diagnosis is history NOT INVESTIGATIONS. Negative baseline investigations DO NOT ruleout serious conditions

3. Life-threatening Causes of Chest Pain Myocardial infarction(ACS). Thoracic aortic dissection. Pulmonary embolus. Tension pneumothorax. Oesophageal rupture.

4. Investigations ECG most important But history is more important. 20% of patients having an MI will have a normal ECG initally. Negative cardiac enzymes in A&E are not helpful. CXR useful to rule out other causes like pneumonia.

5. 26 yr old thin man with sudden onset of severe L sided sharp chest pain ,tachypnoeic.

6. Right Pneumothorax

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. 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 . Anterior (extensive) Myocardial infarction. Why ? Male 65 years. H/O DM+HTN( remember INTERHEART study) Crushing chest pain. Associated sweaty,clammy,vomiting.

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 Most likely diagnosis is ? AMI ?PE ?Esophagear Rupture ?Aortic Dissection

11. Aortic Dissection Severe, sharp, “tearing” posterior chest pain or back pain (occurs in 74-90% of pts) Pain may be associated with syncope, CVA, MI, or CHF Painless dissection relatively uncommon 15% Chest pain is more common with Type A dissections Back or abdominal pain is more common with Type B dissections

12. Physical Examination Pulse deficit Weak or absent carotid, brachial, or femoral pulses these patients have a higher rate of mortality Acute Aortic Insufficiency Diastolic decrescendo murmur Best heard along the right sternal border

13. TEE of Aortic Dissection & CT aorta

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. Likely diagnosis ?ACS ?PE ?Aortic Dissection Esophageal submucosal tear(mallory weiss syndrome).

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.

16. Pulmonary Embolism Why ? Young female Pegnancy hypercoagulable state Occurrence one week post partum

17. 50 years old female with chronic renal failure,chest pain & dizziness she is hypertensive on lisinopril

18. Hyperkalemia,tall tented T-wave & bradycardia. Why ? Chronic renal failure Patient on lisinopril

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

20. Acute Pericarditis

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 .

22. Resolved Pericardtis.

25. Diagnostic limitations History: 25% have ‘atypical’ histories ECG: 55% of pts with AMI have a normal 1 ST 12-lead ECG Convential Cardiac Markers : Normal for the first 3- 4 hours

26. Take home points History 90% ECG: if ST elevated act fast Risk factor reduction Never ignore chest pain