This document provides information on evaluating and diagnosing chest pain. It begins by defining chest pain and noting that it is a common reason patients present for medical care. It then discusses the causes of chest pain and provides details on distinguishing ischemic from non-ischemic chest pain. Key factors for ischemic cardiac pain are discussed such as onset during exertion and relief with rest. The document provides guidance on evaluating a patient's chest pain by taking a thorough history addressing 10 specific points. Differential diagnoses for chest pain are also reviewed.

1. Approach to
CHEST PAIN
DR.Bilal Natiq Nuaman,MD
CABM,FICMS,DIM,MBChB
2016-2017 1

2. Chest pain—broadly defined as any discomfort in the
anterior thorax occurring above the epigastrium and
below the mandible—can be one of the most
challenging problem managed by the physicians.
The typical patients’ concern with the first bout of
chest pain is their apprehension of the onset of
cardiac pathology, such as ischemic heart disease
(IHD).
Chest discomfort is among the most common reasons
for which patients present for medical attention at
either an emergency department (ED) or an
outpatient clinic.
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3. CAUSES OF CHEST PAIN
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Any adult male (more than 30 years), or
postmenopausal female, complaining of
retrosternal pain should be suspected to be
having myocardial ischemia, until proved
otherwise.

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History taking
Ask the patient the following 10 points about chest pain:
1. Onset
2. Site of pain
3. Character (Quality)
4. Duration
5. Radiation
6. Aggravating factor
7. Relieving factor
8. Local tenderness
9. Associated symptoms
10. Severity.

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16. Ischemic Vs
Non Ischemic
Chest Pain
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18. • Chest pain due to ischemic heart disease (IHD) may manifest as:
Angina pectoris :2-10 min., relieved by rest , not associated with vomiting
Myocardial infarction :>30 min., not relieved by rest , associated with
vomiting
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19. Characteristics of cardiac pain
• Onset. The pain of MI typically takes several minutes
or even longer to develop; similarly, angina builds up
gradually in proportion to the intensity of exertion.
The pain of aortic dissection, massive pulmonary
embolism or pneumothorax is usually very sudden or
instantaneous in onset.
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20. • Site. Cardiac pain is typically located in the Centre of
the chest because of the derivation of the nerve supply
to the heart and mediastinum.
• Radiation. Ischemic cardiac pain may radiate to the
neck, jaw, and upper or even lower arms. Occasionally,
cardiac pain may be experienced only at the sites of
radiation or in the back.
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21. • Character. Cardiac pain is typically dull, constricting,
or 'heavy’, and is usually described as squeezing,
crushing, burning but not sharp, stabbing, pricking.
They typically use characteristic hand gestures (e.g.
Open hand or clenched fist) when describing ischemic
pain(Levine's sign).
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22. Levine's sign
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23. • Provocation. Anginal pain occurs during (not after)
exertion and is promptly relieved (in less than 5
minutes) by rest. The pain may also be precipitated or
exacerbated by emotion but tends to occur more
readily during exertion, after a large meal or in a cold
wind.
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24. • Relief of chest discomfort within minutes after
administration of nitroglycerin is suggestive of myocardial
ischemia.
Esophageal spasm may also be relieved promptly with
nitroglycerin.
Pain that occurs after rather than during exertion is usually
musculoskeletal or psychological in origin.
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25. • Associated features. The pain of MI, massive
pulmonary embolism or aortic dissection is often
accompanied by autonomic disturbance, including
sweating, nausea and vomiting.
Breathlessness, due to pulmonary congestion arising
from transient ischemic left ventricular dysfunction, is
often a prominent and occasionally the dominant
feature of MI or angina (angina equivalent).
Breathlessness may also accompany any of the
respiratory causes of chest pain and can be associated
with cough, wheeze or other respiratory symptoms.
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29. Major adverse cardiac events (MACE) 29

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31. DIFFERENTIAL DIAGNOSIS
• Acute, sudden and severe chest pain described as tearing that
is maximal at onset and radiates to interscapular area raises
the possibility of aortic dissection.
Important diagnostic feature is the inequality in the pulses, e.g.
carotid, radial and femoral, and a blood pressure differential of
greater than 20 mm Hg
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32. • Severe chest pain, retrosternal, accompanied by dyspnea,
cough, and hemoptysis developing in a patient who has been
immobilized or bedridden is suggestive of pulmonary embolism
• Chest discomfort due to pericarditis is typically retrosternal,
aggravated by coughing, deep respiration, or change in
position; worse in supine, and relieved in sitting upright and
leaning forward
• The pain of esophageal spasm is commonly an intense,
squeezing discomfort that is retrosternal in location and, like
angina, may be relieved by nitroglycerin
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33. • Pain in a dermatomal distribution can also be caused by herpes
zoster
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34. • Stable angina NON ischemic chest pain
ECG
50%
DIAGNOSTIC
TREADMILL TEST
75%
DIAGNOSTIC
CORONARY
ANGIOGRAPHY
DIAGNOSTIC
95%
CXR
PULMONARY
CAUSES
ABDOMINAL U/
S , OGD
ABDOMINAL
CAUSES
ECHO
EXCLUDE
VALVE LESION
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36. THANK YOU
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