1) The document provides guidance for evaluating a patient presenting with chest pain, including conducting a primary survey, focused history, physical exam, and selecting initial diagnostic tests and investigations based on clinical suspicion. 2) Key considerations in differentiating potential deadly causes of chest pain like acute coronary syndrome, pulmonary embolism, aortic dissection, and pneumothorax include analyzing the description of pain, patient history, exam findings, and basic tests like ECG and CXR. 3) While chest pain descriptions and presentations can overlap between conditions, distinguishing features like radiation patterns, exacerbating/relieving factors, exam findings help prioritize the most concerning diagnoses for urgent treatment or further testing. Scoring systems and

1. Dr Md Seebat Masrur
Indoor Medical Officer
Department of Cardiology
TMC & RCH
Chest pain
Evaluation
ALLPPT.com _ Free PowerPoint Templates, Diagrams and Charts

2. Chest Pain

3. Emergency Physician

5. When a Patient comes in with chest pain
• Primary Survey
• ECG

6. Primary Survey
• Assess vital signs and oxygenation
• Placing an IV
• Place on cardiac monitor
• Focused History & Physical
Aim is to determine if the patient is Stable or
Unstable
• If Unstable
-Stabilize the patient: ABCs and reassess

7. Focused History
Questions to ask Ref Swap. C. J & Nagurney J T (2005)
Element Question
Quality In your own word how would you describe the pain ? what adjectives would you
use?
Location Point your finger to where you are feeling the pain.
Radiation If pain moves out of your chest, trace where it travels with your finger.
Distribution With your finger, trace the area on your chest where the pain occurs
Severity If 10 is the most severe pain you have ever had. On this 10-point scale how severe
was this pain?
Time of onset & continuity Is the pain still present? Has it gotten better or worse since it began? when did it
begin?
Duration Second ,Minutes, Hours. How long is a typical episode?
First Occurance First time you ever had this pain?
Frequency How many times per hour or per day has it been occurring?
Similar to previous cardiac
ischemic episodes
If you have had a heart attack or angina in the past, is this pain similar to the pain
you had then?is it more or less severe?

8. Precipitating or Aggravating
factors
Questions to ask Ref Swap. C. J & Nagurney J T (2005)
Pleuritic Is the pain worse if you take a deep breath or cough?
Positional Is the pain made better or worse by your changing of
body position? If so, what position makes the pain better
or worse?
Palpable If I press on your chest wall, does it reproduce the pain?
Exercise Does the pain come back or get worse if you walk quickly,
climb stairs, or exert yourself?
Emotional stress Does becoming upset affect the pain?
Relieving factors Are there any thing that you can do to relieve the pain,
once it has begun?
Associated symptoms Do you typically get other symptoms when you get this
chest pain?

9. AETIOLOGY

10. Cardiovascular
Pericardium-Pericarditis
Myocardium-Myocarditis
-Heart Failure exacerbation
-HOCM
-Takotsubo
cardiomyopathy
Valves-Aortic Stenosis
Conducting System
-Tachyarrhythmia
Vessels
-ACS
-Aortic Dissection
-Hypertensive Emergencies
Pulmonary
Pleura-Pleuritis
-Pneumothorax
Airways-Asthma Exacerbation
Alveoli-Pneumonia
Vessels-Pulmonary embolism
-Pulmonary
hypertension
Lung Cancer

11. GI
Esophagus-GERD
-Oesophagitis
-Oesophageal spasm
-Boerhaav`s
(Oesophageal rupture)
Stomach -Gastritis
-PUD
MSK
Rib Fractures
Costochondritis

12. Miscellaneous
• Severe Anemia
• Herpes zoster(a.k.a Shingles)
• Acute intoxication with cocaine or
amphetamines
• Acute chest syndrome in sickle cell anemia
• Psychiatric-Panic attack,Somatization

13. Chest Pain:Physical Exam
• Vital Signs-heart rate, temp, BP in both arms and
check for pulsus paradoxus, O2 Sat
• Chest wall-Palpation, signs of trauma
• Cardiac Exam-palpation, rhythms, murmurs, gallops,
rubs, JVP
• Pulmonary Exam-Symmetric, wheeze, crackles, focal
consolidations
• Abdomen-Palpation of all quadrants, auscultation for
aortic bruit, palpation of liver
• Extremities-Edema,pulses,pain

14. Investigations
•ECG
•CXR
• Bloods
– FBC, U&E, LFT, D-dimer (if
considering PE and low
Wells score), troponin if
suspected IHD
• ABG if patient acutely
unwell or sats under 95%
• Echo/ CT if large proximal
PE or aortic root
dissection suspected
– Also can echo for regional
wall motion abnormality in
MI

15. Rule out Deadly
• Acute Myocardial infarction
• Cardiac Temponade
• Aortic Dissection
• Pulmonary embolism
• Tension Pneumothorax
• Boerhaav`s (Oesophageal
rupture)
If they are hemodynamically unstable we need
to assume they have one of these problems
until proven otherwise
The most important
consideration is to
determine as quickly as
possible if the patient
might have an emergent
life threatening problem
specifically

16. So How Do we Diffenrentiate
between pain of Most of these
deadly causes???
Description of pain,PMH,Physical
examination and bed side
diagnostic test

17. Acute Coronary Syndrome
Acute Coronary Syndrome
Description
of Chest Pain
Onset over mins
Substernal/midline
Radiation down either arm or to jaw, epigastric region, back
Exertional
Non-pleuritic
‘’Pressure’’, ‘’tightness’’
Diaphoresis, nausea and vomiting
PMH(risk
factors)
Smoking, DM, HTN, Hyperlipidaemia, Elderly male
Exam Often normal, but may have S3, high JVP, and crackles if HF
has developed
CXR Usually normal
ECG ST/T elevations,depression, dynamic ST/T changes or even be
unremarable

18. Diagnostic next steps
Serial Troponins
If troponin elevated, ST segments elevated or
dynamic , persistent chest pain or patient
unstableCath Lab
However troponins can be elevated in
Pulmonary embolism, myocarditis among other
diagnosis.

19. Relieved by
Nitroglycerin?
Something that you notice is not listed
as a feature is that pain related to ACS
is relieved with Nitroglycerin.
Historically it was thought that a
patient presenting to the ED with
chest pain was more likely to have
myocardial ischemia if the pain was
relieved by Nitro.
However this is been shown to be
untrue.
Relief with nitroglycerin is useless as a
diagnostic test.

20. Pulmonary Embolism
Description of
Chest Pain
Onset over secs-mins
Lateralized to one side
No specific radiation
Non exertional
Pleuritic
‘’Sharp’’
PMH(risk
factors)
Recent hospitalization
Immobilization
Malignancy
Exam Unremarkable
May have evidence of DVT
Right sided S3 or RV heave if massive PE
CXR Usually normal
ECG Classic S1Q3T3 pattern is much less common than plain
sinus tachycardia

21. Diagnostic next steps
If clinical suspicion is relatively lowd-
dimer
If clinical suspicion is High or d-dimer
elevatedCT angiogram

22. Aortic Dissection
Description of
Chest Pain
Onset over secs-mins
Substernal/midline
Radiation to back
Non-exertional
Non-pleuritic
‘’Tearing’
PMH(risk
factors)
HTN
Smoking
Exam If not yet ruptured BP elevated
If ruptured hypotension
May have discordant BP between two arms
Unequal pulses
Focal weakness/numbness
CXR May have widened mediastinum
ECG No Specific findings

23. Diagnostic next steps
If patient relatively stable CT
angiogram
If patient unstableTEE at bedside

24. Pneumothorax
Description of
Chest Pain
Onset over secs
Lateralized to oneside
No specific radiation
Non-exertional
Pleuritic
‘’Sharp’’
PMH(risk
factors)
COPD
Cystic Fibrosis
Recent Trauma
Exam Unilateral diminished/absent breath sounds
Unilateral hyperresonance
Elevated Jugular vein
CXR Pneumothorax
ECG No Specific findings

25. Cardiac Temponade
Description of
Chest Pain
Acutely or Gradually
Crushing, Compression
PMH(risk
factors)
Cancer or Uremia
Penetrating chest trauma
Exam Beck`s Traid(Hypotension, Distant muffled Heart sound,
Jugular Vein Distension)
Pulsus Paradoxus(classic Sign)
CXR Enlarged Cardiac Silhoutte(water bottle shaped)
ECG Low voltage and electrical alternans
Bed side ECHO Confirmatory

26. Diagnostic next steps
Additional diagnostic work-up
usually unnecessary

27. Pericarditis
Common distinguishing feature
Pleuritic pain that is relieved by sitting up
and leaning forward.
Percardial friction rub is uncommonly
present on exam.
Diffuse ST elevations on ECG

28. Myocarditis
Common distinguishing feature
Mild to moderate
Troponin elevation
Non-exertional
Lasting hours to days

29. Pleuritis
Common distinguishing feature
Pain lateralizes to affected side,
and pleuritic.
Pleural friction rub is
uncommonly present on exam
CXR usually reveals an associated
pleural effusion

30. GERD
Common distinguishing feature
Pain associated with eating
specially spicy meal, or onset
within minutes to a few hours
after lying down

31. Boerhaave`s(Esophageal ruptu
re)
Common distinguishing feature
Sharp
Radiating to abdomen and back
Hematemesis
Hypotension
Hamman's sign or Hammond's
crunch[

32. MSK
Common distinguishing feature
Focal chest wall tenderness on
exam(reproducible)

33. Zoster
Common distinguishing feature
Pain described as ‘’burning’’ and
limited to single dermatome

34. Now these vast aforementioned causes don’t
make the diagnostic algorithm easier to
approach, there are still some scoring and
pathways and pain rule present to help us guide
towards a specific diagnosis as soon as possible

35. Chest pain score overview

36. HEART SCORE

37. HEART PATHWAY

38. VANCOUVER CHEST PAIN RULE