IT contain 78 beautiful slides about chest pain.

1. CHEST PAIN
Dr Yumnam Bidyalakshmee Devi
Moderator- Dr
Javed

2. Topics covered
1. Introduction
2. Definition
3. Site
4. Types
5. Pathophysiology of pain
6. Referred pain
7. Causes of chest pain
8. Assessment Of D/D
9. Conclusion

3. Introduction

4. Introduction
 The majority of patients with chest pain referred for a respiratory
opinion have either acute pleuritic pain or persistent, well-localized
pain.
 Cardiac pain rarely presents in this manner, although it should be
considered in exertional pain or in the presence of risk factors for
ischaemic heart disease.
 Within the respiratory system, pain may arise from the parietal pleura,
major airways, chest wall, diaphragm, and mediastinum; the lung
parenchyma and visceral pleura are insensitive to pain.

5. Continued
 Processes involving the upper parietal pleura cause a pain localized to that
part of the chest.
 The lower parietal pleura and outer region of the diaphragmatic pleura are
innervated by the lower six intercostal nerves, and pain here may be
referred to the abdomen.
 The central region of the diaphragm is supplied by the phrenic nerve
(C 3, 4, 5) and pain may be referred to the ipsilateral shoulder tip .
 Tracheobronchitis tends to be associated with retrosternal pain.

6. What is pain? Definition?
• Pain is an unpleasant sensation localised to a part of the
body. It is a vital function of the nervous system in
providing the body with a warning of potential or actual
injury.
• It is both a sensory and emotional experience, affected by
psychological factors such as past experiences,beliefs
about pain, fear or anxiety.

7. Nociceptors
Nociceptors are the specialised sensory receptors responsible for the
detection of noxious (unpleasant) stimuli, transforming the stimuli into
electrical signals, which are then conducted to the central nervous
system.They are the free nerve endings of primary afferent Aδ and C
fibres.
Distributed throughout the body (skin, viscera, muscles, joints, meninges)
they can be stimulated by mechanical, thermal or chemical stimuli.
Inflammatory mediators (eg bradykinin, serotonin, prostaglandins,
cytokines,and H+) are released from damaged tissue and can stimulate
nociceptors directly. They can also act to reduce the activation threshold
of nociceptors so that the stimulation required to cause activation is less.
This process is called primary sensitisation.

8. Types of pain

12. A - BETA A-DELTA C
Diameter Large Small 2-5μm Smallest <2μm
Myelination Highly Thinly Unmyelinated
Conduction
velocity
> 40 ms-1 5-15ms-1 < 2ms-1
Receptor
activation
thresholds
Low High and low High
Sensation on
stimulation
Light touch,
non-noxious
Rapid, sharp,
localised pain
Slow, diffuse,
dull
pain
Characteristics of primary afferent fibres

13. Ascending pain pathways. DRG dorsal root ganglion, PAG periaqueductal grey matter

14. Referred pain physiologgy

17. Definition
• Chest pain can be broadly defined as any discomfort
in anterior thorax occurring above the epigastrium
and below the mandible.

18. Site of chest pain

21. History

25. Causes of acute chest pain include:
• Pulmonary infarction following embolism.
• Pneumonia
• Pneumothorax
• Pericarditis
• Pleural infection (empyema, tuberculous)
• Autoimmune disease ie. SLE,RA.
• Musculoskeletal -Fractured rib

26. chronic chest pain
 Causes include:
• Malignant pleural disease or chest wall infiltration
• Benign musculoskeletal pain
• Pleural infection (empyema, tuberculous)
• Benign asbestos-related pleural disease
• Autoimmune disease (e.g. SLE, RA)
• Recurrent pulmonary infarction (emboli, vasculitis)

27. continued
Pain from malignant chest wall infiltration is often
‘boring’ in character and may disturb sleep; it is
frequently not related to respiration.
Causes
• include 1° lung cancer, 2° pleural malignancy,
mesothelioma, and rib or sternal involvement from
malignancy (including myeloma and leukaemia)
• Chronic thromboembolic disease tends to present
with breathlessness;when chest pain occurs, it is
usually episodic, rather than persistent.

28. Consideration of
assessment of patient
with chest pain

29. ASSESSMENT
• It is essential to obtain a thorough assessment that
includes:
• Characteristics of pain, including location, duration,
radiation, quality and accompanying symptoms.
• Carefully observe for associated symptoms:Heavy
pressure or squeezing in the chest area, episodic or
exertional triggers, diaphoresis, N&V, weakness,
anxiety and palpitations.
• Chest pain with diaphoresis is the most common
presentation with an acute MI. Often the patient will
describe the pain by using the “Levine Sign” –
placing a clenched fist over the sternum.

30. * chest discomfort be due to an acute,potentially life threatening
condition,
that warrant urgent evaluation and management.
1. Acute coronary syndrome (Acute MI/Unstable angina)
2. Aortic dissection
3. Tension Pneumothorax
4. Pulmonary embolism
5. Esophageal rupture

31. Acute coronary syndrome
• Onset/duration -Sudden onset of unrentling pain
• Quality -Tearing or ripping, knifelike
• Location -anterior chest often radiating to back
• Associated features -hypertension,underlying
connective tissue disease,loss of peripheral pulse

32. Myocardial ischemia
• Onset/duration – stable angina –percipitated by
Exertion,cold and stress
2-10 min.
unstable angina- increasing pattern or at
rest
MI- >30 min.
• Quality –Pressure,tightness,heaviness,squeezing,burning
• Location –retrosternal,often radiated to
jaw,neck,arm,shoulder,epigastrium
• Associated features -S4 gallop

41. Pulmonary embolism
• Onset/duration -sudden onset
• Quality -pleuritic
• Location -often lateral,on the side of embolism
• Associated features -
dyspnoea,tachypnoea,hypotension,tachycardia

44. Sign Pathology
1. Westermark sign Area of peripheral oligemia
2. Palla's sign/knuckle sign Enlarged Right descending pulmonary artery
3. Hampton's hump Peripheral wedge shaped opacity with
convexity towards the hilum
4. Melting sign Infarct shows rapid clearing in contrast to
pneumonic consolidation
5. Fleishner's sign Elevated hemidiaphgram
PULMONARY EMBOLISM: Plain x- ray sign

46. PALLA'S SIGN

48. Spontaneous Pneumothorax
• Onset/duration -sudden onset
• Quality -pleuritic
• Location -lateral to side of pneumothorax
• Associated features -dyspnoea,decreased breath
sounds on the side of pneumothorax

55. • Could the chest discomfort be due to chronic
conditions likely to lead serious complications
1. Stable angina
2. Aortic stenosis
3. Pulmonary hypertension

56. 1. Angina pain

57. ANGINA

58. Aortic stenosis
• Onset/duration -gradual in onset
• Quality -feel tight or squeezed,get worse with activity
• Location -reaches into arm,neck or jaw
• Associated features -SOB specially on exertion,become
easily tired,palpitations,fainting,weakness,dizziness with
activity,weak and delayed pulse and murmur

59. AORTIC STENOSIS

60. Pulmonary hypertension
• Onset/duration -variable,often exertional
• Quality -pressure
• Location -substernal
• Associated features -dyspnoea,sign of increse
venous pressure

62. • Could the chest discomfort be due to an acute
condition that warrant specific treatment
1. Pericarditis
2.Pneumonia/pleuritis
3.Herpes zoster

63. Pericarditis
• Onset/duration -variable
hours to days,often episodic
• Quality -pleuritic,sharp
• Location -retrosternal or towards cardiac apex
• Associated features -may be relieved by sitting up
and leaning forward, pericardial friction rub

65. Pneumonia/pleuritis
• Onset/duration -variable
• Quality -pleuritic
• Location -unilateral,often localised
• Associated features -dyspnoea,cough,fever,rales

66. • Shingles can present as acute chest pain. The pain is
usually burning and unilateral, following the
dermatomes.
• Chest pain from Shingles can occur before the onset
of vesicles thus making a reliable diagnosis difficult.

68. Could the chest discomfort be due to another treatable chronic
conditions
1. Esophageal reflux
2.Esophageal spasm
3.Peptic ulcer disease
4.Gall bladder disease
5.Cervical disc disease
6.Arhritis of shoulder or spine
7.Costochondritis
8. Anxiety

69. Esophageal reflux
• Onset/duration -10 to 60 min
• Quality -burning
• Location -substernal
• Associated features -worsened by postprandial
recumbency, relieved by antacids

70. ESOPHAGEAL REFLUX

71. Esophageal spasm
• Onset/duration -2 to 30 min
• Quality -pressure,tihgtness,burning
• Location -retrosternal
• Associated features -can closely mimic angina

72. Peptic ulcer disease
• Onset/duration -prolonged, 60 to 90 min after meals
• Quality -burning
• Location -epigastric,substernal
• Associated features -relieved with food or antacids

73. Gall bladder disease
• Onset/duration - prolonged
• Quality -aching,colicky
• Location -epigastric,right upper
quadrant,shoulder(murphy sign)
• Associated features -may follow meal

75. Psychological
• Onset/duration -variable,may be fleeting or prolonged
• Quality -variable, often menifest as
tightness,dyspnoea with feeling of panic or doom.
• Location -variable,often retrosternal
• Associated features -situational factors may
percipitate symptoms, h/o panic attacks or
depression

76. APPROACH TO CHEST PAIN BY ATS

77. Approach to chest pain

79. • Chest pain is a common presenting problem and has
many causes, of which many can be life threatening.
• Cardiac and noncardiac causes must be considered.
• A thorough assessment is vital in order to
distinguish all the potential causes and determine the
appropriate intervention in a timely manner.