This document provides an overview of an orientation for new residents on approaching chest pain. It discusses the differential diagnosis for chest pain and lethal causes. It also covers evaluating chest pain, including vital signs, EKG, and physical exam findings. Five case studies are presented: 1) a 49-year-old male with severe chest pain and elevated troponin, 2) a 25-year-old female with aortic dissection, 3) a 25-year-old postpartum female with localized chest pain, 4) a 55-year-old female with chest pain after stopping warfarin, and 5) a 70-year-old female with chest pain after surgery who develops takotsubo cardiomyopathy.

1. PROMPT Course (Proper Recognition and Management of Acutely Ill Patients)
Orientation for the New R1 Residents - Academic year 2019-2020
Wednesday, 25 September 2019
Approach to Chest Pain
2019
Dr Ihab Suliman MBBS ECFMG MRCP (UK) MRCP Spec( DM&Endoc)
CBNC ABcv FESC
Consultant
Advanced Cardiac imaging
King Abdul-Aziz Cardiac Center
0505244473
Ihab.suliman@ngha.med.sa
Twitter@IhabFathiSulima
https://www.slideshare.net/isuliman

2. Differential
 Cardiac
 MI
 Pericarditis
 Myocarditis
 Aortic Stenosis
 Pulmonary
 PE
 PNA
 Asthma/COPD
 Acute Chest Syndrome
 Pleura
 Pleuritis
 Pneumothorax
 Aorta
 Dissection
 Perforated ulcer
 Chest wall
 Costocondiritis/musculos
keletal
 Esophagus
 Esophageal Spasm
 Eosinophilic Esophagitis
 Esophageal
Rupture/Perforation
 GERD
 Mediastinitis
 RUQ pathology
 Panic attack

4. Lethal Causes of Chest Pain
▣ 1- Acute Coronary
Syndrome(STEMI/NSTEMI/UA)
▣ 2- Acute Aortic dissection Type A.
▣ 3-Massive Pulmonary Embolism.
▣ 4-Pericardial Tamponade.
▣ 5-Esophageal Rupture.
▣ 6-Tension Pneumothorax.
▣ * Fulminant Myocarditis
▣ x

5. Pearl: ALWAYS have
the patient point to
the pain!

6. Typical vs. Atypical Chest Pain
Typical (Ischemic)
Characterized as
discomfort/pressure rather
than pain, Include Upper
Abdomen.
Time duration >2 mins.
Provoked by activity/exercise.
Radiation (i.e. arms, jaw).
Does not change with
respiration/position.
Associated with
diaphoresis/nausea.
Relieved by rest/nitroglycerin.
▣ Atypical
▣ Pain that can be
localized with one finger.
▣ Constant pain lasting for
days.
▣ Fleeting pains lasting for
a few seconds.
▣ Pain reproduced by
movement/palpation.

7. Typical vs. Atypical Chest Pain
UpToDate

8. Evaluation of Chest Pain
Case 1:
▣ Ask nurse for most current set of vital
signs
▣ Ask nurse to get an EKG
▣ See the patient!

9. Evaluation of Chest Pain
▣ Once at bedside, determine if patient is stable
or unstable
▣ Perform focused history and physical exam
▣ Read and interpret the EKG. Compare EKG to
old EKG if available
▣ If patient looks unstable or has concerning EKG
findings, call ER/Cardio On call for help
▣ Write a clinical event note!

10. Evaluation of Chest Pain
Important Physical signs
▣ focused physical exam for chest pain
� Vital Signs: tachycardia, hypertension/hypotension or
hypoxia
� General: Sick appearing, actively having chest pain
� HEENT: JVD, carotid bruits
� Chest: Rales, wheezes or decreased breath sounds
� CVS: New murmurs, reproducible chest pain, s3 gallop
� Abd: Abdominal tenderness, pulsatile mass
� Ext: Edema, peripheral pulses
� Skin: Rash on chest wall

11. CASE 1 49 years old male with severe CP

16. Criteria for type 1 MI
▣ Detection of a rise and/or fall of cTn values with at
least one value above the 99th percentile URL and
with at least one of the following:
▣ Symptoms of acute myocardial ischaemia;
▣ New ischaemic ECG changes;
▣ Development of pathological Q waves;
▣ Imaging evidence of new loss of viable
myocardium or new regional wall motion
abnormality in a pattern consistent with an
ischaemic aetiology;
▣ Identification of a coronary thrombus by
angiography including intracoronary imaging or by
autopsy.a

20. Case 2
▣ 25 years old lady suddenly developed chest pain that is L-sided, 8/10 and

21. ECG

22. CT Angiogram

23. Incidence
▣ Ranges from 2-10 per 100,000 person-years
▣ Evidence of dissection is found in 1-3% of all
autopsies

24. Who’s affected?
▣ International Registry of Acute Aortic
Dissection (IRAD)
◼ 65% men
◼ mean age 63yrs
◼ Women tend to present older (67 vs. 60yrs)
▣ Highest incidence in patients 50 to 70 years old.
▣ Male-to-female ratio 2:1
▣ Half of dissections in females before age 40
occur during pregnancy

25. Clinical Features
▣ Abrupt onset of severe, sharp or "tearing"
posterior chest or back pain (70-90%)
▣ Pulse deficit
◼ weak/absent carotid, brachial, or femoral pulse
resulting from intimal flap or compression by
hematoma
▣ HTN at initial presentation is more common in
those with a type B dissection .%)

26. Management
▣ Untreated aortic dissection or intramural
hematoma
◼ 25% die within 24hrs
◼ 50% by 48hrs
▣ Basic management
◼ Type A dissection  surgery
◼ Type B dissection  medical management/BP
management
▣ Surgery -- prevents medial extension reaching
the pericardium and producing fatal
tamponade or worsening other complications

27. Case 3
25 years old female 7th day PP with severe localized CP

28. Case 3

29. Case 4
55 years old lady stopped Warfarin for uterine surgery came with
CP Severe SOB
MECHANICAL MVR

30. What TO DO if No Click
▣ What should be done if No Click
▣ Fluoroscopy or CT.
▣ Valve Thrombosis

31. Case 5
▣ 70 years old lady with malignant ascites.
▣ Sent for surgery.

32. MV
calcification
more
posteriorly

33. Gastric thickening
liver lesion ascites

34. PRE OP ECG
Normal

35. POST OPE ECG

36. Troponin

37. Nef HM, et al. Tako-tsubo
Cardiomyopathy (Apical
Ballooning). Heart. 2007; 93:1309-
1315.

39. Stress Induced Cardiomyopathy
Sharkey SW, Lesser JR, Zenovich AG, et al. Acute and reversible cardiomyopathy provoked by stress in
women from the United States. Circulation 2005;111:472–9.
▣ Women 95% cases
▣ Mean age 68
▣ Not just emotional stress
◼ Intense physical stress
◼ Acute medical illness (ICU)
◼ No stress in 10%
▣ Probably 2% of ACS cases
Etiology ???
◼ Wall motion abnormality doesn’t correlate to single coronary
distribution
◼ Catecholamine induced vascular spasm?
◼ Catecholamine induced reversible myocyte injury?
� Is LV apex more sensitive to injury?

40. END
▣ Thanks a lot