chest pain is one of the commonest presentation in the primary care setting . This power point presentation is about how to evaluate these patients

1. Evaluation Of Patient With
Chest Pain In Primary Care
Dr Ogechukwu Mbanu
Family Medicine Department
AKTH Kano Nigeria
5 / 9 /18

2. PRE - TEST
1. A patient with acute chest pain ,what is the most
important investigation
a) Chest xray
b) Ecg
c) Ct
d) Blood gasses
e) RBS

3. 2 . A 60 year-old male present to the A&E Department
with gripping central chest pain. When questioned he says
it is tight. Examination is unremarkable apart from an
increase in heart rate to 90 per minute and occasional
extrasystoles. Blood pressure is 140/90. The patient is
noted to be sweating slightly. The most likely diagnosis is:
a. Dissection of the thoracic aorta
b. Acute myocardial ischaemia
c. Acute pleuritic pain
d. Lobar pneumonia
e. Acute oesophagitis

4. 3. 32 year-old male presents to the A&E Department with
central chest pain radiating to the mid-back. Patient is
rather cold and clammy. Blood pressure is 180/100. Heart
rate is 100. The heart sounds are normal. Examination is
otherwise unremarkable. The most likely diagnosis is:
a. Myocardial ischaemia
b. Pancreatitis
c. Acute peptic ulceration with possible posterior
perforation
d. Dissection of the thoracic aorta
e. Cholecystitis

5. 4 . A 40 year-old woman with no previous history presents to the A&E
Department with acute epigastric pain radiating to the lower chest. She
is nauseated but has not vomited. She is somewhat overweight.
Examination discloses a regular pulse of about 85 per minute.
Temperature is 38 degrees Physical examination discloses a blood
pressure of 150/90, normal heart sounds, no added sounds and slight
tenderness in the epigastrium and in the right hypochondrium. The most
likely diagnosis is:
a. Inferior myocardial infarction
b. Acute cholecystitis
c. Acute peptic ulceration
d. Pancreatitis
e. Mesenteric ischemia

6. OUTLINE
1. Introduction
2. What is chest pain
3. Goals of evaluation
4. Epidemiology
5. Causes of chest pain
6. Types of chest pain
7. Chest pain location
8. History
9. Physical examination
10.Investigations
11 .Brief study of selected disorders
• Angina pectoris
• GERD
• Pleuritis
• Acute coronary syndrome
• Costochondritis
• Pericarditis
• Aortic dissection
• Pulmonary embolism
• Esophageal spasm
12. Chest pain in the elderly /children
13. Algorithm for evaluation of chest
pain
14. Conclusion

7. INTRODUCTION
•Common presentation to a&e
•Many people with chest pain fear a heart attack
•Trivial to life-threatening causes
•Key to diagnosis is history
•Negative baseline investigations do always not rule out
serious conditions
•For the life threatening cases the family physician should
offer reasonable first aid then facilitate fastest possible
conveyance to secondary /tertiary facility

8. WHAT IS CHEST PAIN ?
•Chest pain is discomfort or pain that
the patient feels anywhere along the
front of the body between the neck
and the upper abdomen
•Can be broadly classified as Cardiac
chest pain and Non – cardiac chest
pain
•can be categorized as
•(1) new, acute, and ongoing;
•(2) recurrent, episodic; and
•(3) persistent, e.g., for days at a
time.

9. GOALS OF EVALUATION

10. EPIDEMIOLOGY
•Community-based studies with their undifferentiated
populations see high rates of non-cardiac chest pain
•studies based in A&E have higher proportions of cardiac chest
pain, as patients are already self-selected based on the severity
of symptoms, or referred
•Chest pain is a common symptom, accounting for about 1% of
GP visits,
• 5% of A&E visits and
• 40% of emergency hospital admissions
• The incidence of chest pain consultations increases with age
and is more common for men

11. EPIDEMILOGY 2
•The majority of cases seen in primary care are due to
more benign conditions - eg, GERD , muscle sprains, panic
disorder
•Combined hospital and primary care data produced an
incidence of cardiac chest pain of 6.5 per 1,000 general
population per annum
•Population-based questionnaire studies show about 20%
of adults reporting chest pain over the course of a year.
•Cardiac disease accounts for only 8-18% of all cases of
chest pain

12. CAUSES OF CHEST PAIN
•Causes of chest pain can be classified into
•Cardiovascular
•Pulmonary
•Chest wall
•Gastrointestinal
•psychiatry

13. STRUCTURES THAT CAN BE INVOLVED
•Skin
•Muscles
•Bones
•Joints
•Heart and vessels
•Lungs and
Airways
•Oesophagus
•Nerves

14. CAUSES OF CHEST PAIN -2

15. CAUSES OF CHEST PAIN - 3

16. CAUSES OF CHEST PAIN – 4

19. HISTORY
•Focus of History , physical exam, and initial investigations
 excluding life-threatening causes of chest pain
•Assess for presence or absence of coronary risk factors
•These risk factors include
• older age, hypertension, DM , hyperlipidemia,
• smoking, obesity, excessive alcohol intake ,
•sedentary lifestyle , a family history of premature CAD
• no of risk factors =  likelihood of chest pain of
ischeamic origin

20. HISTORY - 2
•BIODATA
•PC / HPC
•Hx of Trauma
•ROS – Associated symptoms eg Nausea, vomiting , Shortness
of breath , Diaphoresis , Cough (productive or nonproductive) ,
Fever , Dizziness or change in level of consciousness ,
Palpitation,
• BRIEF OBS/GYN
•PMH/SH – viral infections, CAD , CHF , recent
immobilization(surgery) ,

21. HISTORY - 3
•DRUG H – on any drugs now or in the past , reaction to drugs
•FH/SOCIAL H– use of drugs
•Hx of long distance travel
•For children HX OF DEV MILESTONES , IMMUNIZATIONS,
NUTRITION MAY BE IMPORTANT
•F I F E
• Fears
• Ideas
• Function
• Expectations

22. Focused history

23. Focused history

24. Physical examination
•“Look” –
• in painful distress ,
•sweating profusely ,
•breathing rapidly , anxious
•Generally check for
• palor ,
•cyanosis ,
•lymphadenopathy ,
•finger clubbing ,
•feel for pulses
• pedal edema
•Inspect the chest and
abdomen
• Accessory muscles
• Chest retractions
•Palpate –
• Tenderness
• Organomegaly
•Auscultate --
• Abnormal heart sounds
• Abnormal breath sounds
•Examination of other systems
as indicated by history

25. INVESTIGATIONS
• The most important single test in the initial evaluation of patients with
chest pain is the ECG,
• Within primary care, the following investigations can be done
• ECG - – remember to ask for or check file for previous ECG ( if there is )
• Chest x – ray
• FBC
• Urinalysis
• Serum E / U / CR
• LFT
• Abdominal ultrasound
• Fasting lipids and glucose
• Serial cardiac enzymes ( CK-MB , troponin I and T)
• Amylase and lipase

26. INVESTIGATIONS -2
•Second-line investigations
when indicated include
• echocardiography,
•angiography,
• exercise testing,
• myocardial perfusion scan,
•CT/ spiral CT/MRI scan,
•upper gastrointestinal
endoscopy,
• lung ventilation/perfusion
(V/Q) scan
Esophageal studies
•Endoscopy
•Barium swallow
•Esophageal manometry
•Radionucleide transit studies
•Esophageal motility studies
•Trans esophageal echo
•These investigations are
usually done at specialized
centers

27. BRIEF STUDY OF
SELECTED DISORDERS

28. Angina pectoris
•chest pain , usually due to not enough blood flow causing
oxygen deprivation to the heart muscle.
• Pressure, fullness, squeezing pain in the center of the
chest.
•Discomfort in the neck, jaw, shoulder, back or arm
•Caused by partial obstruction of the
of coronary arteries
•obstruction atherosclerosis
•Other causes  anemia, abnormal
heart rhythms and heart failure

29. ANGINA PECTORIS - 2
•Three main types : Stable , Unstable , prinzmetal
•Stable angina – precipitated by exertion , cold weather ,
heavy meals , emotional stress
•Unstable angina occurs at rest or with minimal exertion ,
severe and of new onset ,prolonged, or more frequent
than before
•May be a serious indicator of an impending heart attack
•Patient may be breathless ,sweating, pulse , BP
•Prinzmetal's angina— normal coronary arteries or
insignificant atherosclerosis

30. ANGINA PECTORIS -3
•caused by spasms of the artery.
•Occurs more in younger women
•Antacids, simple analgesics do not relieve the pain
•ECG may be normal
•Exercise ECG test ("treadmill test") depression
of ST segment > 1 mm or down sloping ST
depression
•Stress Echocardiography unable to take
treadmill test

31. GASTROESOPHHAGEAL REFLUX DISEASE
Caused by transient relaxation of the lower esophageal sphincter
• Risk factors include pregnancy , hiatal hernia ,obesity
Typical presentation:
• A retrosternal burning sensation (heartburn)
• Begins in the epigastrium and radiates upward
• Typically occurring within one hour of a meal, during exercise, or
when lying down
• relieved by antacids. Not relieved by nitroglycerine
• Water brash (excess salivation),
• bitter taste, globus sensation (throat fullness) , halitosis, and
otalgia are also seen

32. GASTROESOPHHAGEAL REFLUX DISEASE – 2
•EXAM – epigastric tenderness
•ALARM SYMPTOMS -- dysphagia, odynophagia, weight loss,
anemia, long-standing symptoms, blood in stool, age > 50
•Barium esophagography: Has a limited role, but can
identify strictures
Second line investigations include
• Upper endoscopy with biopsy – standard exam in the
presence of alarm symptoms
•Ambulatory esophageal pH monitoring -- The gold
standard but not usually done

33. PLEURITIS
•Inflammation of the pleura is due to underlying causes e.g
pneumonia (viral ,fungal or bacterial), pulmonary infarction ,
tumour infiltration or connective tissue disease (e.g. SLE).
•Often sudden onset
•Pain usually localized without radiation
•Sharp , knife-like continuous pain with sharp exacerbations
•Aggravated by inspiration, sneezing and coughing ,lying than
when sitting
•May be associated dyspnoea, cough, haemoptysis
•Pleural rub on exam
•Chest x ray ,FBC ,sputum m/c/s

34. Acute Coronary Syndromes
•STEMI, non-ST-segment-elevation MI (NSTEMI), and
unstable angina.
•Etiologies include
•unstable plaques with non occlusive thrombosis (unstable
angina and NSTEMI) and
• thrombotic occlusion of a coronary artery (STEMI)
• Ischemic chest pain is often described as
• dull or squeezing substernal or
• left sided discomfort associated with dyspnea and
diaphoresis,
with radiation down the left arm or into the neck

35. Acute Coronary Syndromes
•Take note of risk factors and any initial ECG
•The initial goal is to rule out STEMI that requires
immediate referral for reperfusion therapy.
•In patients without ST-segment elevation, cardiac
enzymes will determine if patients have NSTEMI or
unstable angina
•There is Presence of pathological q waves in STEMI

36. ECG CHANGES IN ACS

38. COSTOCHONDRITIS
•Mild to moderate anterior chest wall pain
•Can radiates to the back or abdomen.
•Usually unilateral, sharp in nature
•Exaggerated by breathing, physical activity or a
specific position.

39. COSTOCHONDRITIS – 2
•May be preceded by exercise
•Can persist for several months
•Diagnosed by eliciting tenderness at the costochondral
junction of the affected ribs
•Relieved by anti inflammatory agents

40. PERICARDITIS – 1
•Pericardial inflammation that results in chest pain
• Common etiologies are viral illness,
•Connective tissue disease eg SLE
•Metastasis , radiation to chest ,renal failure
•Recent upper resp. tract infection
• post-MI (Dressler’s syndrome)
•May also be idiopathic
• Sharp ,pleuritic chest discomfort
•Worsens while supine and eases while leaning
forward.

41. PERICARDITIS – 2
• A pericardial friction rub is the hallmark best heard by
sitting patient forward
•ECG shows
• diffuse ST-segment elevation, PR-segment depression
not compatible with a single coronary distribution
•PR-segment elevation in aVR.
•Echocardiography – pericardial effusion often visualized

43. AORTIC DISECTION
• associated with uncontrolled hypertension, medial degeneration of the
aorta (Marfan’s syndrome, Ehlers - Danlos syndrome), cocaine use,
coarctation, congenital bicuspid valve, trauma, cardiac surgery,
pregnancy, and syphilitic aortitis
• SUDDEN -onset “tearing” or “ripping” sensation originating in the
chest and radiating to the back
• cardiac tamponade may be present
• BP is elevated (although hypotension may be associated with
tamponade)
• pulse deficits or unequal pulses between the right and left arms
• CXR will show a widened mediastinum
• Trans esophageal echo can be done if available

44. Pulmonary embolism
• Dramatic onset following occlusion of the pulmonary artery or a major branch
• Pain is Retrosternal , pleuritic in nature
• syncope , breathlessness , hypotension,
• acute right heart failure or cardiac arrest occurs with a massive embolus
• Can present with cough and haemoptysis.
• Hx of long distance travel should be sought ,medications like OCPs(pills)
• Patient may have leg edema
• Normal D-dimer makes diagnosis unlikely
• On ECG --
• presence of T wave inversion at V1–V4
• P wave = right atrial enlargement
• Right axis deviation
• S1 , Q3 , T3

46. ESOPHAGEAL SPASM
•Etiology is unknown
•2 major variant
•Diffuse esophageal spasm ( DES ) and
•Hypertensive peristalsis( HP ) also known as nutcracker
esophagus or jackhammer esophagus
•DE – Contractions are of normal amplitude but are
uncoordinated, simultaneous, or rapidly propagated
•HP -- contractions proceed in a coordinated manner but
the amplitude is excessive.
• vague symptoms and difficult to in diagnose

47. ESOPHAGEAL SPASM
•Symptoms – dysphagia , regurgitation , retrosternal chest
pain
•Chest pain is precipitated by meals
•Not exertional
•The connection between unexplained chest pain &
esophageal spasm was first discovered by William Osler in
1892
•Barium swallow ,CT scan , ultrasonography and
manometry tests can be used to diagnose this disorder

48. Chest pain in the elderly
• Chest pain is a very important symptom in the elderly
• Life -threatening cardiovascular conditions such as myocardial
infarction and angina, dissecting aneurysm and ruptured aorta
increase with age
• The elderly patient presenting with chest pain for the first time should
be evaluated to rule out angina or myocardial infarction.
• They may have atypical presentation of MI such as , confusion ,
weakness ,syncope ,vertigo ,nausea ,abdominal pain

49. Chest pain in children
•Chest pain in children is rarely the result of serious
pathology but is an important complaint, especially in
adolescents.
•Common causes include musculoskeletal disorders, cough-
induced pain, costochondritis, psychogenic , asthma.
•Chest pain in children younger than 12 years old is more
likely to have a cardiorespiratory cause, Such as asthma,
pneumonia or heart disease,

50. SOME NOTABLE ISSUES
• Be aware of certain terminologies patient use to describe pain eg
• Sharp to mean severe
• Chronic to mean severe
• Travelling to mean radiating
• Hearing to mean feeling etc
• Women and diabetics are known not to have classic
symptomatologies
• Pains that radiate to the back think of the retroperitoneal organs
• Suprarenal gland ,aorta , duodenum , pancreas , esophagus
• Pericarditis and pleuritic chest pain present at maximum
intensity

51. SOME NOTABLE ISSUES – 2
•Whether left or right chest pain still take it serious
•Active chest pain = NO STRESS TEST
•Stress tests only in centers where there is easy
access to defibrilator
•Do not give IM injections if possible if u suspect
cardiac events until you are sure – it can raise some
cardiac enzymes
•If you are not sure whether it is cardiac or not
,admit , monitor , reevaluate

53. CONCLUSION
•History and physical examination is very important
•Diagnostic tests good but, they should NOT replace history and
physical examination (H&P)
•In all discharged patient a close follow up is needed
•Patient must understand events that mandate immediate
return to the hospital
•Resuscitate unstable patients and know when to refer
•ECG: be mindful of ST elevation
•Encourage Risk factor reduction
•Finally NEVER IGNORE CHEST PAIN

54. REFERENCE
• Ruigomez A, Rodriguez LA, Wallander MA, et al; Chest pain in general practice:
incidence, comorbidity and mortality. Fam Pract. 2006 Apr23(2):167-74. Epub
2006 Feb 3
• . Flook N, Unge P, Agreus L, et al; Approach to managing undiagnosed chest pain:
could gastroesophageal re􀀽ux disease be the cause? Can Fam Physician. 2007
Feb53(2):261-6.
• Colin Tidy, chest pain , making life better . 24 Jun 2014 .accessed 26 Jul 2018
• College of south Nevada ; Advanced EKG interpretation 32bravo711 . 2011 .sep
29 ,12 lead interpretation
• Bolin p ,crash medical review series .2015 Nov 21,Approaching Patient with chest
pain
• Chest pain by Maryam Jamilah Binti Abdul Hamid
• Chest pain by Iman Noufal
• Approach to a patient with chest pain by Dr Jayanta Paul

55. REFERENCE
• Diagnosing The Cause Of Chest Pain By Dr Shashidi Ahamad
• Cayley W.E ; Diagnosing The Cause Of Chest Pain American Family Physician Nov
.15 2005 Vol 72 (10) :2012 – 2021
• Differential Diagnosis Of Chest Pain By Dr Muhmmed Farooque
• Evaluation Of Chest Pain By Dr Adeyemi Johnson
• Malas A Esophageal Spasm Medscape Oct 24 2017
• Longo D L , Fauci A S Dannis L K Hauser S L Jameson J L Loscalzo J Harrison’s
Manual Of Medicine USA : Mcgraw – Hill Companies ; 2013
• Nice Clinical Guideline 144 , Two Level Wells Score: Templates. For Deep Vein
Thrombosis And Pulmonary Embolism . June 2012
Www.Nice.Org.Uk/Guidance/CG144
• Murtagh J ;Murtaghs General Practice Sixth Ediyion 2015 Mcgraw – Hill Australia