it is about chest pain

1. CHEST
PAIN

2. DEFINITION
A general term for any dull, aching pain in the
thorax. It can be cardiac or non-cardiac related.

4. ETIOLOGY
Cardiac
• Myocardial ischemia & trauma
• Angina pectoris
• Acute Coronary Syndromes

5. Non-Cardiac
• Aortic stenosis
• Aortic dissection
• Pericarditis
• Pulmonary embolism
• Pulmonary hypertension
• Pneumonia/pleuritis
• Spontaneous hypertension
• Esophageal reflux
• Esophageal spasm
• Peptic ulcer
• Gallbladder disease
• Musculoskeletal disease
• Herpes zoster
• Emotional & psychiatric
conditions

7. EVALUATE CHEST PAIN
1)Could the chest discomfort be due to an acute, potentially life-
threatening condition that warrants immediate hospitalization
and aggressive evaluation?
-Acute ischemic heart disease
-Aortic dissection
-Pulmonary embolism
-Spontaneous pneumothorax

8. 2)If not, could the discomfort be due to a chronic condition likely to lead
to serious complication?
-Stable angina
-Aortic stenosis
-Pulmonary hypertension
3. If not, could the discomfort be due to an acute condition that
warrants specific treatment?
-Pericarditis
-Pneumonia/pleuritis
-Herpes zoster

9. 4) If not, could the discomfort be due to another
treatable chronic condition?
-Oesophagel reflux, oesophageal spasm, peptic ulcer
disease, other GI condition, cervical disc disease,
arthritis of the shoulder or spine, costochondritis,
other musculoskeletal disorders, anxiety state

10. CHARACTERISTICS OF ISCHAEMIC CARDIAC PAIN
• Characteristic of pain
• Site
• Radiation
• Provocation
• Onset
• Associated features

11. CHARACTER
• Dull, constricting, choking or heavy
• Squeezing, crushing, burning or aching
• Breathlessness
• Discomfort > pain

12. SITE
• Centre of the chest
• Derivation of the nerve supply to the heart &
mediastinum (sensory sympathetic cardiac nerves; T1-
T5, mostly dorsal root ganglion Lt.)

13. RADIATION
• Radiate to neck, jaw & upper or even lower arms
• Occasionally, at the sites of radiation or in the
back

15. PROVOCATION
• Angina pain: during exertion and promptly relieved by rest (<5
minutes), pain may exacerbated by emotion but occur more readily by
exertion; large meal, cold wind
• Crescendo/Unstable angina: similar pain can be precipitated by
minimal exertion or at rest
• Decubitus angina: increase venous return/preload by lying down can
provoke pain in vulnerable patients

16. ONSET
• Myocardial infarction (MI): Pain of MI takes
several minutes or longer to develop
• Angina: Pain builds up gradually in proportion to
the intensity of exertion

17. • Aortic dissection, massive pulmonary embolism
or pneumothorax : Pain is very sudden or
instantaneous
• Musculoskeletal or psychological: Pain occur
after exertion

18. ASSOCIATED FEATURES
• Autonomic disturbance; sweating, nausea,
vomiting
• Breathlessness: pulmonary congestion from
transient ischaemic Lt. ventricular dysfunction

20. DIFFERENTIAL DIAGNOSIS OF CHEST PAIN
• Anxiety/emotion
• Cardiac
• Aortic
• Oesophageal
• Lungs/pleura
• Musculoskeletal
• Neurological

21. ANXIETY
1. Common cause for atypical chest pain
2. Lack of relationship with exercise
3. Receiving bad news

22. CARDIAC
1. Myocardial ishaemia (angina), MI, myocarditis, pericarditis, mitral
valve prolapse
2. Myocarditis & pericarditis:
• Pain felt retrosternally, to the Lt. of the sternum, or in the Lt./Rt.
Shoulder
• Intensity varies with movement and phase of respiration. 'sharp' and may
'catch' during inspiration, coughing or lying flat.
• Occasionally, history of prodromal viral illness

23. AORTIC
• Aortic dissection, aortic aneurysm
• Aortic dissection:
• Pain is severe, sharp and tearing
• Penetrating through to the back
• Abrupt in onset
• Pain follows path of the dissection

25. OESOPHAGEAL
1. Oesophagitis, oesophageal spasm,Mallory-Weiss syndrome
2. Pressure, tightness, burning
3. Retrosternal
4. Mimic angina very closely : Sometimes precipitated by exercise,
Sometimes relieved by nitrates
5. Elicit history of chest pain to supine posture or eating, drinking or
oesophageal reflux
6. Radiates to the back

26. LUNGS/PLEURA
1. Bronchospasm, pulmonary infarct, pneumonia, tracheitis,
pneumothorax, pulmonary embolism, malignancy, tuberculosis
2. Bronchospasm :Reversible airways obstruction (e.g. asthma):
exertional chest tightness that is relieved by rest. Difficult to
distinguish from ischaemic chest tightness
3. Pneumonia, pleuritis and pulmonary embolism: Pleuritic pain
(sharp pain when breathing)

27. MUSCULOSKELETAL
• Osteoarthritis, rib fracture/injury, costochondritis (Tietze's syndrome),
intercostal muscle injury, epidemic myalgia (Bornholm disease-by
coxsackievirus)
• Aching
• Very variable in site and intensity
• Vary with posture and movement of upper body
• Can be accompanied by local tenderness over a rib or costal cartilage
• Injuries related to everyday activities or viral infection

28. NEUROLOGICAL
1. Prolapsed intervertebral disc
2. Herpes zoster (Sharp or burning)
3. Thoracic outlet syndrome

34. THANK YOU