This document provides an overview of chest pain for medical professionals. It discusses the most common causes of chest pain, important characteristics to assess, life-threatening conditions to consider, appropriate diagnostic tests and initial management strategies. Key points include that 20% of emergency visits for chest pain are due to acute coronary syndrome, a thorough history and physical exam are essential for diagnosis, and ECG, cardiac enzymes and CXR are commonly performed initial tests.

2. S/L
DR AAMIR HUSSAIN
MEDICAL SPECIALIST/ASSISTANT PROF
PAF HOSPITAL /FAZIA MEDICAL COLLEGE

3. CHEST PAIN
AN APPROACH

4. Presentation objectives
• At the end of this presentation, you will be
able to
o Understand the causes of chest pain
o Realize the life threatening causes of chest
pain
o Understand the importance of history taking
o Order the common investigations
o Learn common ECG changes
o Provide initial management
o Minimize cost and hospitalization in patients
with chest pain of benign Aetiology.

5. CHEST PAIN
• ACUTE CHEST PAIN ACCOUNTS 7 MILLIONS
EMERGENCY VISITS ANNUALLY
• APPROXIMATELY 20 % OF PATIENTS ACTUALLY
HAVE ACS
• ALMOST 65 % THOSE ADMITTED OR DETAINED
,ARE TURNED OUT TO BE NON CARDIAC
• ACS IS THE NUMBER ONE CAUSE OF DEATH
WORLDWIDE, ACCOUNTS FOR 12% OF DEATHS
• NEARLY 3% ACS ARE MISSED AND DISCHARGED
FROM EMERGENCY

6. CHEST PAIN:ORIGIN
• HEART
• VESSELS
• LUNGS
• ESOPHAGUS
• ABDOMEN
• MUSCULOSKELETAL
• NERVE ROOTS/NERVES
• BRAIN!

8. LIFE THREATENING CAUSES OF
CHEST PAIN
• ACUTE CORONARY SYNDROME
o STEMI
o NSTEMI
o USA
• AORTIC DISSECTION
• PULMONARY EMBOLISM
• TENSION PNEUMOTHORAX

9. FINAL DIAGNOSIS PERCENTAGE OF EPISODES
MUSCULOSKELETAL PAIN 30%
GASTROINTESTINAL(GERD) 25%
ANGINA 10%
MYOCARDIAL INFARCTION 3%
PSYCHOGENIC/PANIC 20%
RESPIRATORY DISEASE 5%
NO DIAGNOSIS 7%
CAUSES OF CHEST PAIN IN THE PRIMARY CARE (OPD)SETTING

10. DIAGNOSIS
• CLINICAL DIAGNOSIS BASED ON GOOD HISTORY AND
PHYSICAL EXAMINATION.
• NEEDFUL INVESTIGATIONS
• 3 COMMONLY PERFORMED ARE
ECG, CARDIAC ENZYMES/TROP, CXR
• OTHER IMPORTANT ARE
ETT, ECHO, CT SCAN, MRI, THALLIUM, AND CORONARY
ANGIOGRAPHY.

11. CHARACTERISTICS OF
PAIN. socrates.
• 1. SITE/POSITION
• 2.ONSET
• 3.CHARCTER/QUALITY
• 4.RADIATION
• 5.ASSOCIATED SYMPTOMS
• 6.TIMING
• 7.EXACERBATING AND RELIEVING FACTORS
• 8.SEVERITY

12. CHARACTERISTICS CARDIAC NON CARDIAC
LOCATION CENTRAL,DIFFUSE PERIPHERAL,LOCALIZED
RADIATION JAW,NECK,SHOULDER,
ARM
NO RADIATION
CHARACTER TIGHT,SQUEEZING,
CHOKING
SHARP,STABBING,
CATCHING
PRECIPITATION BY EXERTION,EMOTION SPONTANEOUS,
PROVOKED BY
COUGH,POSTURE,
PALPATION,
RELIEVING FACTORS REST,NITRATES NOT
ASSOCIATED FEATURES BREATHLESSNESS RESP,GASTR,LOCO,
CHEST PAIN

14. CHEST PAIN SITE AND RADIATION

15. NOT CHARACTERISTIC OF ANGINA
• SHARP OR KNIFE LIKE PAIN BROUGHT ON BY
RESPIRATORY MOVEMENTS OR COUGH
• PAIN LOCALIZED BY TIP OF ONE FINGER OVER
LEFT CHEST
• PAIN REPRODUCED WITH MOVEMENT OR
PALPATION OF CHEST WALL
• CONSTANT PAIN THAT PERSISTS FOR MANY
HOURS/DAYS
• VERY BRIEF EPISODES OF PAIN THAT LASTS FOR
SECONDS
• PAIN IN THE MIDDLE OR LOWER ABDOMEN
• PAIN THAT REDIATES TO LOWER LIMBS

16. RED FLAGS
• ABNORMAL VITAL SIGNS
• SIGNS OF HYPOPERFUSION
• SHORTNESS OF BREATH
• HYPOXEMIA ON PULSE OXIMETRY
• ASYMMETRIC PULSES OR BREATH
SOUNDS
• NEW HEART MURMURS
• DISTENDED JVP

17. PITFALLS TO AVOID
• THE ECG WAS NORMAL
• THE TROP T WAS NORMAL
• THE CHEST XRAY WAS NORMAL
• LBBB WAS OLD
• YOUNG PATIENTS CAN NOT HAVE MI
• SHORTNESS OF BREATH/ANGINAL
EQUIVALENT
HISTORY AND EXAMINATION ARE MORE IMPORTANT THAN……

18. Chest pain scenario
• A 60-YEAR-OLD BUSINESSMAN
COMPLAINS OF CENTRAL CRUSHING
CHEST PAIN RADIATING TO BOTH
ARMS AFTER RUNNING TO CATCH A
BUS.PAIN WAS RELIEVED BY REST AND
HIS ECG RECORDING 1 HOUR LATER
WAS UNREMARKABLE……..WHAT IS
THE LIKELY DIAGNOSIS……

19. CHEST PAIN SCENARIO
• A 23-YEAR-OLD FEMALE PRESENTS
WITH LOCALIZED LEFT-SIDED CHEST
PAIN THAT IS EXACERBATED BY
COUGHING. THE AREA IS TENDER TO
LIGHT PRESSURE. PAIN IS RELIEVED
BY ASPIRIN. THE ECG RECORDING IS
UNREMARKABLE……WHAT IS THE
LIKELY DIAGNOSIS…….

20. CHEST PAIN SCENARIO
• A 22 YEAR-OLD-MALE PRESENTS TO EMERGENCY
DEPARTMENT WITH SEVERE CENTRAL CHEST
PAIN.HE HAS HAD A RECENT FLU LIKE ILLNESS.THE
PAIN IS DESCRIBED AS HEAVY AND STABBING. IT IS
MADE WORSE WHEN LYING DOWN AND RELEIVED
BY SITTING FORWARD.
• ON EXAMINATION,PULSE IS 90 BPM,BP 120/80 mm
Hg, JVP IS RAISED AT 2 CM. HEART SOUNDS ARE
OBSCURED BY PROMINET RUBBING SOUND.
• CHEST IS CLEAR.OTHER SYSTEMS ARE NORMAL.
• ECG SHOWS ST SEGMENT ELEVATION

22. ST SEGMENT ELEVATION

23. CHEST PAIN SCENARIO
• A 68-YEAR-OLD FEMALE PRESENTS WITH CENTRAL
TEARING CHEST PAIN THAT RADIATES TO HER
BACK FOR 2 HOURS. SHE DESCRIBES PAIN
SEVERITY AS 10/10.. SHE IS OBESE AND SMOKES
20 PACK-YEAR. SHE HAS A HISTORY OF POORLY
CONTROLLED HYPERTENSION. SHE IS PALE AND
SWEATY. BLOOD PRESSURE IS 210/100 mm Hg IN
RT ARM AND 190/80 IN LT ARM,PULSE IS 106 bpm.
• ON EXAMINATION,SHE WAS UNCOMFORTABLE .
• A LOUD DIASTOLIC MURMUR OF AORTIC
REGURGITATION WAS AUDIBLE.
• CARDIAC BIOMARKERS NEGATIVE

26. CHEST PAIN SCENARIO
• A 55-YEAR-OLD MAN HAS JUST ARRIVED IN
EMERGENCY DEPARTMENT COMPLAINING
OF 20 MINUTES OF CENTRAL CRUSHING
CHEST PAIN. IT RADIATES TO INFERIOR
ASPECT OF LEFT ARM….HE IS ANXIOUS,
NAUSEATED AND SWEATY...HE IS SMOKER
AND TAKES ZESTRIL 5 MG AND AMARYL 1
MG DAILY.
• HIS PULSE 98 bpm, AND BP 160/90 mm Hg.
• REST OF THE EXAMINATION IS
UNREMARKABLE.
• ECG SHOWS……….

27. 12 LEAD ECG

29. ST SEGMENT ELEVATION AND/OR DEPRESSION

30. LEFT VENTRICULAR WALL

38. RIGHT LEADS

39. EASY TO MISS,,…….PLEASE SEE IT CAREFULLY

40. CHEST PAIN SCENARIO
A 40-YEAR-OLD FEMALE HAS PRESENTED TO
THE EMERGENCY DEPARTMENT WITH CHEST
PAIN AND SHORTNESS OF BREATH FOR 12
HOURS. THE PAIN IS LOCATED AROUND THE
RIGHT SIDE OF HER CHEST AND IS MADE
WORSE ON DEEP INSPIRATION. SYMPTOMS
HAD COME ON SUDDENLY AT REST. SHE
DENIES ANY SYMPTOMS OF COUGH OR
FEVER. HER HISTORY IS SIGNIFICANT FOR
TWO MISCARRIAGES AND A DVT IN HER LEFT
LEG.
ON EXAMINATION,
BP 100/60mm Hg, PULSE 120 bpm, RR 32 BPM,
OXYGEN SAT 88% AT ROOM AIR.
ECG SHOWS……

44. CHEST PAIN SCENARIO
• A 28-YEAR-OLD YOUNG MALE PRESENTS TO
EMERGENCY DEPARTMENT WITH SUDDEN ONSET
OF RIGHT SIDED CHEST PAIN.THE PAIN STARTED
AS SHARP BUT NOW DULL BUT INCREASES WITH
INSPIRATION.
• HE HAS COUGH AND SHORTNESS OF BREATH
WHICH HE RELATES WITH HIS SMOKING.
• ON EXAMINATION,PULSE 102 bpm, BP 120/80 mm
Hg, RR 26 bpm. OXYGEN SATURATION IS 97% AT
ROOM AIR.
• CHEST AUSCULTATION DEMONSTRATED
DECREASED AIR ENTRY ON RIGHT SIDE .
• ECG REPORTED AS NORMAL..
• NEXT INVESTIGATION…….

46. ACS
INITIAL TREATMENT
AND SECONDARY
PREVENTION

47. ACS TREATMENT PROTOCOL
• OXYGEN
• MORPHINE/NALBINE+MAXOLON
• NITROGLYCERINE(SPRAY/SL)
• ASPIRINE/CLOPIDOGREL/TICAGRELOR
• METOPROLOL/CONCOR
• HEPARIN(IV/SC) OR FONDAPARINUX
• CLOSE MONITORING WITH ECG/TROP/CK-MB
• THROMBOLYSIS VS PCI
• GP IIB/IIIA
• MEDICATIONS(BETA BLOCKERS/ACE/STATINS)

48. SECONDARY
PREVENTION
• ANTI PLATELET…..ASPIRIN
• ANTIPLATELET…..CLOPIDOGREL
• BETA-BLOCKER….BISOPROLOL
• ACE INHIBITORS…RAMIPRIL
• STATINS……………ATORVASTATIN
• GOOD BYE TO SEDENTARY LIFE STYLE.

49. NON CARDIAC
• PROTON PUMP INHIBITOR
• ANTIDEPRESSANT
• COGNITIVE BEHAVIORAL THERAPY

50. LIFE THREATENING
CAUSES
FOR PULMONARY EMBOLISM
• STABILIZATION
• THROMBOLYTICS
• ANTICOAGULANT
o INJECTABLE
o ORAL

51. PNEUMOTHORAX
• STABILIZATION
• REST
• NEEDLE DECOMPRESSION
• CHEST TUBE INSERTION
• PLEURODESIS

52. AORTIC DISSECTION
• STABILIZATION
• MORPHINE
• IMMEDIATE REDUCTION IN BP
• SURGICAL /MEDICAL
• NO THROMBOLYTIC
• NO ANTI-PLATELET
• NO ANTICOAGULANT

55. THANK YOU