1. Acute coronary syndrome can present with substernal chest pressure, pain radiating to the shoulders, or pain with exertion. ECG may show ST elevations or new left bundle branch block indicating AMI. Troponin and CK-MB elevations are needed to diagnose AMI. 2. Aortic dissection often presents with sudden, severe chest pain and may be suggested on ECG by discrepancies in blood pressure between arms or signs of ischemia. Chest X-ray may show a widened mediastinum. 3. Pulmonary embolism presentations can vary widely but often include dyspnea. ECG may show signs of right heart strain. Most chest X-rays are normal but some show

1. D.Basem elsaid enany
Lecturer of cardiology
Ainshams university

2. Acute coronary syndrome
History:
• Substernal/left sided chest pressure or tightness is
common
• Onset is gradual
• Pain radiating to shoulders or pain with exertion increases
relative risk
• "Atypical" symptoms (eg, dyspnea, weakness) more
common in elderly, women, diabetics

5. Examination:
Nonspecific
• May detect signs of HF

6. ECG:
• ST segment elevations, Q waves, new left bundle
branch block are evidence of AMI
• Single ECG is not sensitive for ACS
• Prominent R waves with ST segment depressions in V1
and V2 strongly suggests posterior AMI

7. Chest x ray:
• Nonspecific
• May show evidence of HF

8. Additional tests:
• Troponin and/or CK-MB elevations diagnose AMI
• Single set of biomarkers is not sufficiently sensitive to
rule out AMI

9. Additional data:
Assume symptoms of ACS within days or a few weeks of
PCI or CABG is from an occluded artery or graft

10. Aortic dissection
History:
• Sudden onset of sharp, tearing, or ripping pain
• Maximal severity at onset
• Most often begins in chest, can begin in back
• Can mimic: stroke, ACS, mesenteric ischemia, kidney stone

11. Examination:
• Absent upper extremity or carotid pulse is suggestive
• Discrepancy in systolic BP >20 mmHg between right
and left upper extremity is suggestive
• Up to 30 % with neurologic findings
• Findings vary with arteries affected

12. ECG:
• Ischemic changes in 15 %
• Nonspecific ST and T changes in 30 %

13. Chest X ray:
• Wide mediastinum or loss of normal aortic knob
contour is common (up to 76 %)
• 10 % have normal CXR
Additional tests:
TEE, MSCT

15. Additional data:
• Can mimic many diseases depending on branch
arteries involved (eg, AMI, stroke)

16. Pulmonary embolism
History:
• Many possible presentations, including pleuritic pain
and painless dyspnea
• Often sudden onset
• Dyspnea often dominant feature

17. Examiantion:
• No finding is sensitive or specific
• Extremity exam generally normal
• Lung exam generally nonspecific; focal wheezing may
be present; tachypnea is common

18. ECG:
• Usually abnormal but nonspecific
• Signs of right heart strain suggestive (eg, RAD, RBBB,
RAE, sinus tachycardia)

19. Chest X ray:
• Great majority are normal
• May show: atelectasis, elevated hemidiaphragm,
pleural effusion

20. Additional tests:
• A high-sensitivity D-dimer is useful to rule out PE only
when negative in low-risk patients
• Echo: RV dilatation, hypokinesia, may see embolus in
PA
• MSCT

21. Tension pneumothorax
History:
• Often sudden onset
• Initial pain often sharp and pleuritic
• Dyspnea often dominant feature

22. Examiantion:
• Ipsilateral diminished or absent breath sounds
• Subcutaneous emphysema is uncommon

23. Chest X ray:
• Demonstrates air in pleural space

24. Pericarditis:
History:
• Pain from pericarditis is most often sharp anterior chest
pain made worse by inspiration or lying supine and relieved
by sitting forward
• Dyspnea is common

25. Examination:
• Severe tamponade creates obstructive shock, and
causes jugular venous distension, pulsus paradoxus
• Pericarditis can cause friction rub

26. ECG:
• Decreased voltage and electrical alternans can appear
with significant effusions
• Diffuse PR segment depressions and/or ST segment
elevations can appear with acute pericarditis

27. Chest X ray:
• May reveal enlarged heart

28. Additional investigation:
• Ultrasound reveals pericardial effusion with
tamponade

29. Mediastinitis
History:
• Forceful vomiting often precedes esophageal rupture
• Recent upper endoscopy or instrumentation increases risk of
perforation
• Coexistent respiratory and gastrointestinal complaints may occur

30. Examiantion:
• Ill-appearing; shock, fever
• May hear (Hamman's) crunch over mediastinum

31. Chest X ray:
• Large majority have some abnormality:
pneumomediastinum, pleural effusion, pneumothorax

34. Noninvasive stress testing is best indicated in patients with an intermediate pretest
probability of disease. The addition of an imaging modality to stress is best indicated
in patients in whom an exercise ECG will be nondiagnostic for ischemia, eg, LBBB,
ventricular pacing, greater than 1 mm of resting ST segment depression. A man over
the age 40 and a woman over the age of 60 with typical angina have a high
pretest probability for coronary disease and all things being equal should be referred
for coronary angiography directly for the diagnosis. A 50-year-old asymptomatic
woman has a very low pretest probability for disease and does not warrant further
investigation. A 45-year-old woman with a history of atypical chest pain also has a low
pre-test probability of disease and may not require a stress test. With a normal resting
ECG a stress ECG would be the preferred initial modality. Despite her young age, the
symptoms of typical angina, even in a 30-year-old woman, place her at an intermediate
risk of coronary disease, increased further by the presence of resting ST segment
depression. Given that she would have a nondiagnostic stress ECG a stress imaging
study is appropriate.

35. -Thallium and technetium are the two most commonly
used isotopes in Nuclear Cardiology tests. Technetium
has a higher energy, less radiation danger as better
penetration
-Sestamibi no redistribution after 24 h , not used in
viability

37. What are some of the common causes of chest pain that
can be identified on a chest radiograph?
Aortic dissection
Pneumonia
Pneumothorax
Pulmonary embolism
Subcutaneous emphysema
Pericarditis (if a large pericardial effusion is suggested by the
radiograph)
Esophageal rupture
Hiatal hernia

38. Thank you…….