This document discusses the differential diagnosis of chest pain by describing various cardiac and non-cardiac causes. It outlines key factors in the history and physical exam that can help determine if chest pain is typical angina, atypical angina, or non-anginal. Common cardiac causes discussed include acute coronary syndromes, aortic dissection, and pericarditis. Common non-cardiac causes discussed include pulmonary embolism, pneumonia, gastrointestinal issues like pancreatitis and peptic ulcer disease. Diagnostic tests for different conditions are also mentioned.

1. Getting to the root of Chest Pain
Differential Diagnosis
Cardiac & Non Cardiac
By: Ms. Shanta Peter
1

2. Chest Pain-- cardiac or Not
• Treat patient as though he is critical --- until
proved otherwise
History
• Risk factors, H/O IHD, previous Rxs , Previous chest pain
• Pain- Heart burn - burning sensation – chest pain with
pressure /tightness
Remember ---–
……………treat with cause… there are many causes
2

3. Accuracy of Chest Pain Diagnosis Using the History
and Physical Examination
Determining whether pain is
• Sub-sternal,
• Provoked by exertion
• Relieved by rest or nitroglycerin
helps to clarify whether it is ……………………
1. Typical anginal pain (has all 3characteristics)
2. Atypical anginal pain (has 2 characteristics
3. Nonanginal pain (has 1 characteristic).
3

4. Common Causes of Chest Pain
• Aortic
• Esophageal/GI
• Lungs & Pleura
• Musculo-Skeletal
• Neurological
• Psychological/
others
Aortic dissection, Aortic aneurism
Esophagitis, Esop. Spasm , esophageal tear
Pancreatitis, Biliary /GB disease , GERD, Peptic
Ulcer
Bronchospasm, PE, Pneumonia ,TB,
Trachitis, Pleuritis, PneumThorax , Malignancy
, Asthma.
Ost. Arthritis, Rib#, I. Costal Muscle injury,
Costochondritis, Cerv. Disc Disease
Prolapsed disc, Herpez Zoster,
Thoracic Outlet Syndrome
Panic Attack/Anxiety Disorders ,
Cocaine abuse
4

5. Chest Pain That Can Kill ….
• Acute Coronary –
Syndrome
• Pulmonary-
Embolism
• Aortic-
Dissection
• Esophageal Rupture
• Pneumothorax
• Pneumonia
5

6. Sudden & Instantaneous Chest Pain
Tension Pneumthorax
• Spontaneous
• Open
Pulm. Embolism
DVT, Obesity, Pregnancy, Prolonged
immobilization, CHF ….
6

7. Pneumothorax
7

8. Pneumothorax
Sharp C. Pain. Dyspnea ,absence of breath- sound
in the affected side
• Radionuclide studies – Gated pool
• SPECT – Single proton emission computed Tomography
• PET – Positron Emission Tomography
Pulm. Embolism
Sudden pleuretic substernal pain with dyspnea ,
T cardia , fever or cough , diaphoresis – mimic MI/angina
• VQ Scan
• D DIMER
• Spiral CT-- best Diag –
(Pneumonia )
8

9. Pneumonia
• Infection of pulm. tissue – Interstitial spaces,
alveoli, bronchioles
• Chest pain – pleuritic , come sin suddenly
• Febrile – chills , cough with copious/blood
stained sputum
• Rales--- rhonchi wheezes
• Hypoxia
(Ca)
9

10. Sub sternal – epi-gastric Chest Pain
intensified with swallowing
10

11. 11
Pan . C Cys.G U,DU

12. G Intestinal
Pancreatitis : Pain in the LUQ, substernal. Radiate to back
, difficulty in breathing, tachycardia, vomiting, worse in
supine , better while leaning forward
• Cholecystitis :
Pain in RUQ – precipitate by meal
• Gastric Ulcer
Pain Lt Epigastrium – radiation to back
• Duodinal Ulcer
Mid Epigastric pain – cramping- 2-4 hrs after
meal
(E rupture ) 12

13. Esophageal Rupture Mallory–Weiss syndrome
Sudden severe C. Pain – followed by vomiting,
or UGI tract procedure
CXR: ( early )shows
mediastinal or free
peritoneal air
Hours to days later:
widening of
mediastinum, pleural
effusion
13

14. Coronary Arteries
14

15. 15

16. 16
H .Disease begins
when cholesterol,
fatty material & Ca
deposit in the
arteries.
Atherosclerosis

17. 17

18. 18

19. Cardiac Chest Pain
• Dissecting Aortic
aneurisms
• Cardiac Tamponade
* Heart Failure
• Peri/endo/myocarditis
• Cardiogenic shock
• MVP /M.stenosis
Acute Coronary
Syndromes
*Myocardial Ischemia
*Stable Angina
*Unstable Angina
*Myocardial Infarction
*Pericarditis
19

20. ANGINA PECTORIS . Myocardial ischemia
Expected companion of IHD …….
20

21. Accuracy of Chest Pain Diagnosis Using the History
and Physical Examination
Determining whether pain is
• Sub-sternal,
• Provoked by exertion
• Relieved by rest or nitroglycerin
helps to clarify whether it is ……………………
1. Typical anginal pain (has all 3characteristics)
2. Atypical anginal pain (has 2 characteristics
3. Non-anginal pain (has 1 characteristic).
21

22. Levine’s sign
22

23. 23
S Ang

24. 24

25. Angina ..Myocardial ischemia
A. Stable Angina(Exertional Angina)Stable pattern
of onset ……………… relieved by Rest/GTN
B. Unstable Angina(PreinfarctionAngina)unpredictable,
NOT relieved by GTN
C. Variant Angina ( Prinzmetal- vasospastic) ,
without relation to effort, Occur at REST-
between midnight & early morning
ST Elevation ---
25

26. D. Intractable Angina –
Chronic, incapacitating, unresponsive to
treatment
E. Pre-infarction Angina( Last more than 15 mts)
F. Post infarction Angina ( after MI ,residual
ischemia)
26

27. PERICARDITIS
27

28. Pericarditis
• Sharp Pre-cordial pain, deep and diffuse
• Worse in supine position- relieved while
leaning fore ward
• Aggravated during inspiration coughing
• H/O viral infection , MI…….
28

29. 29
TAA

30. T. Aortic Dissection of Aneurism
Blood violates aortic
intimal and adventitial
layers
False lumen is created
Dissection may extend
proximally, distally, or in
both directions
30

31. T.A Aneurism dissection
• Constant and boring chest pain
• Deep diffuse – in supine position
• Cough, dyspnea, stridor
• Aphonia ( loss of voice) --
31

32. H Attack signs in Women
1. Pain or discomfort in one or both arms, the back,
neck, jaw or stomach.
2. Shortness of breath with or without chest
discomfort.
3. breaking out in a cold sweat, nausea or
lightheadedness.
4. As with men, women’s most common heart attack
symptom is chest pain or Chest dis comfort, other
common symptoms, particularly shortness of
breath, nausea/vomiting and back or jaw pain.
32

33. Complications
Cardiac arrest ----------------------
33

34. 34
Possible Factors -6Hs & 5Ts
cardiac arrest
• Hypovolemea
• Hypoxia
• Hypothermia
• Hypoglycemia
• Hypo- Hyperkalemia
• Hydrogen ion ( Acidosis)
• Toxins
• Trauma
• Thrombosis ( coronary- pulmonary)
• Tension pneumothorax

35. 21 yrs old young male – was lifting weights –in
the GIM .
He had sudden onset of sharp chest pain,
and SOB …
Brought him to ER …
HR 122. RR 34, BP 70/? Sat 88%
Decreased breath sounds on left side of the
chest .. ???????
35

36. • Mr. Mohd in CCU with Ext Ant MI,
complicated with vent arrhythmia
treatments are continuing. No more chest
pain
• Today is the 4th day , he is febrile 38- 39C
since 3rd day , ESR and WBC is high, He
suddenly complaining of severe sharp
precordial pain, cannot breath-in or cannot
lie down. He is bending down his chest and
crying
36

37. • Ms .A 61yrs,had severe Asthmatic attack ,as
the O2 sat was 89% . Put on Mech Ventilator
Mode : PEEP .
• 3rd day sedations stopped and started to
wean her. Suddenly she screamed of severe
chest pain and dyspnea
What will be the possible condition ?
37

38. • OPD – Endoscopy room
Ms K had gastroscopy ? D.Ulcer , she is in the
recovery room after the procedure. BP and
other vital signs stable. She is coming out of the
sedation . Suddenly she is complaining of pain
holding her chest , breathless.
???????
38