10. history tacking
1. Analysis of symptom.
2. Risk factors of :
IHD.
VTE.
3. Past history of :
Heart diseases.
Chest diseases.
11. Chest pain
Analysis of symptom:
1. Onset.
2. Course.
3. Duration.
4. Site , character , radiation.
5. Precipitating factors.
6. Relieving factors.
7. Associated symptom.
8. Effect of TTT and last attack.
12. Risk factors of CAD:
S H A D E S O F D M
1. S: Smoking
2. H: HTN
3. A: Age
4. D: Dyslipidemia
5. E: Erectile dysfunction
6. S: Stroke
7. O: Obesity
8. F: Family history
9. DM: Diabetes mellitus
13. Risk factors of VTE
1. Immobility.
2. Recent surgery.
3. Dehydration.
4. Pregnancy .
5. History of recurrent abortions.
6. Use of OCP.
7. Past history of VTE.
8. FH of thrombotic tendency.
14. Past history of heart diseases
1. Atherosclerotic cardiovascular diseases.
2. Heart failure
3. Valvular diseases.
4. Previous imaging (e.g. echo, CMR, MSCT)
showing structural heart diseases:
15. Past history of lung diseases
1. COPD.
2. Bronchial asthma.
3. Interstitial lung fibrosis.
4. Respiratory tract infections.
16. REMEMBER
When you are analyzing a chest pain, you are
making a balance between features with and
features against being an angina pain.
17. Typical chest pain
• Retrosternal pain.
• Precipitated by exertion, stress or heavy
meals.
• Relieved by rest or nitrates.
Does that mean the chest pain at rest is not
typical?
18. Typical chest pain
• Retrosternal pain.
• Precipitated by exertion, stress or heavy meals.
• Relieved by rest or nitrates.
Does that mean the chest pain at rest is not
typical?
NO, because UA & MI usually present with a chest
pain at rest, and less common with exertion or
stress.
19. How to ask about chest pain?
Site & radiation
With anginal pain
1. Diffuse pain crossing the
midline.
2. Retrosternal area.
3. Shoulder.
4. Arms & forearms.
5. Epigastric area.
6. Jaw.
7. Back !! (common with
aortic dissection).
against anginal pain
1. Localized pain (the
patient can point to the
site by his finger).
2. Left sub mammary pain.
3. Left or right hemithorax.
4. Radiation to trapezius.
20. How to ask about chest pain?
Character
With anginal pain
1. Compressing.
2. Burning.
3. Squeezing.
4. Tightness.
5. Stabbing.
against anginal pain
1. Stitching.
2. Throbbing.
3. Clear superficial
tenderness on the
skin or the breast.
21.
22. pericarditis pain
1. Chest pain that increases on lying down and
decreases on leaning forwards.
2. It radiates to the trapezius ridge.
23. Chest pain with pulmonary embolism
• Mostly it is atypical pain caused by pleurisy
overlying regional lung infarction.
24. Chest pain with aortic dissection
• Severe agonizing tearing pain that is maximal
al the start and then decreases, usually
radiating to the back.
• It can propagate to the abdomen if the
pathology involves the abdominal aorta.
25. REMEMBER
Don’t depend on the character of pain in 3
groups:
1. Elderly.
2. Females.
3. Diabetics.
26. How to ask about chest pain?
Duration
With anginal pain
1. More than 5 minutes.
against anginal pain
1. Shorter than 1 minute.
2. Continuous pain for >
30 minutes without
evidence of myocardial
damage.
27. How to ask about chest pain?
Precipitating & relieving factors
With anginal pain
1. Precipitated by
exertion, stressful
situation or heavy
meals.
2. Precipitated by cold
weather.
3. Relieved by rest &
nitrates.
against anginal pain
1. Start after completion
of exercise.
2. Increase on deep
breathing or coughing.
3. Start or increase on
change of posture.
28. How to ask about chest pain?
Associated symptoms
With anginal pain
1. Nausea & vomiting.
2. Sweating.
3. Dizziness &
lightheadedness.
against anginal pain
There are no associated
symptoms that should
distract you from
diagnosing anginal pain
because CAD may coexist
with another non-cardiac
condition presenting with
non-cardiac symptoms.
29. Ischemic heart disease can present
by anything from S to S.
From Silent to Sudden cardiac death.
31. What should I look for in a targeted
examination?
1. Blood pressure (on both sides to detect aortic
dissection).
2. Pulse (tachycardiac, bradycardic or irregular).
3. Peripheral pulsations (poorly felt PP may suggest
presence of co-exisiting PAD or aortic dissection).
4. Cardiac auscultaion (murmurs, gallop or
pericardial rub).
32. Did I miss something in examination?
1. Pallor (may suggest that anemia or bleeding is the
cause of secondary unstable angina).
2. Limited shoulder movement (may suggest
shoulder joint disorders).
3. Fever (may suggest presence of pneumonia
causing pleuritic chest pain).
4. Abdominal rigidity & tenderness (may suggest
presence of pancreatitis or cholecystitis).
34. REMEMBER
Epigastric pain carries the possibility of
being an anginal pain, so any patient
presenting to the ER by epigastric pain
should have an ECG
35. 12 lead surface ECG
• Normal ECG.
• ST elevation/LBBB.
• ST depression (upsloping, horizontal or
downsloping).
• Symmetrical T wave inversion.
• Biphasic T waves.
41. What are the cardiac markers that may
rise in MI?
1. Cardiac Troponin “ the most specific” .
2. CK-MB.
3. LDH (starts to rise after 12h).
4. AST.
5. Myoglobin.
42. Cardiac Troponin (cTn)
• It starts to rise after 1 h (if using high-
sensitivity troponin assay), or after 3-4 h (if
using ordinary assays).
• It normalizes after 14 days.
• Troponin I is more specific than troponin T.
43. When to measure cTn in the ER?
1. Patient presents with query chest pain that isn’t
convincing as an anginal pain and isn’t
considered atypical chest pain, and his ECG is
normal.
2. Patient presents with chest pain that persisted
for >6h, but he is now CP free, normal ECG.
So we can say that we measure cTn in the ER if it
will make us decide to non-cardiac pain; not to
admit the patient as NSTEMI or refer as US.
44. Did I miss an essential tool?
Chest x-ray
1. Widened upper mediastinum (may suggest aortic
dissection).
2. Evidence of pneumonic shadow or pleural effusion
(alternative diagnosis).
3. RV enlargement and pruning of pulmonary vascular
markings (suggest pulmonary hypertension).
4. Cardiomegaly & kerley B lines (suggest decompensated
heart failure).
49. Do I need an echocardiography?
1. In query cases where we cannot make a
conclusion whether it is an anginal pain or
case of pulmonary embolism.
50. Do I need an echocardiography?
1. In query cases where we cannot make a
conclusion whether it is an anginal pain or
case of pulmonary embolism.
2. Suspected mechanical complications in cases
of STEMI or NSTEMI.
51. Do I need an echocardiography?
1. In query cases where we cannot make a
conclusion whether it is an anginal pain or
case of pulmonary embolism.
2. Suspected mechanical complications in cases
of STEMI or NSTEMI.
3. Suspected pulmonary embolism (but normal
echo doesn’t exclude it).
52. Do I need an echocardiography?
1. In query cases where we cannot make a
conclusion whether it is an anginal pain or
case of pulmonary embolism.
2. Suspected mechanical complications in cases
of STEMI or NSTEMI.
3. Suspected pulmonary embolism (but normal
echo doesn’t exclude it).
4. On elective basis in cases of SCAD.
53. But I suspect pulmonary embolism not
acute aortic syndrome
54. But I suspect pulmonary embolism not
acute aortic syndrome
CT pulmonary angiography
60. Case no 1
Male patient 36 y old , smoker , coming to
ER complaining of stitching chest pain of 6
hour duration , localized , increasing by
lying down , BP=120/80mmHg, HR=72b/m,
CTn negative , normal chest x ray , ECG
showing:
61. Case no 1
What is your provisional diagnosis?
What is the plan of management?
62. Case no 2
male patient 60 y old , smoker , diabetic
,hypertensive presented to ED by retrosternal
constricting chest pain of 3 hour duration
.radiating to Lt arm and jaw associated with
nausea and vomiting, BP=150/90mmHg,
HR=100b/m , clear chest, normal S1 and S2 , his
ECG show
63. Case no 2
What is your provisional diagnosis?
What is the plan of management?
