D.D of chest pain

1. IN THE NAME OF ALLAH
THE MOST GRACIOUS,THE MOST MERCIFUL

3. 1. Rapid recognition and management of true
Acute Coronary Syndrome
2. Recognition of other life-threatening
causes of chest pain
3. Minimize cost and hospitalization in
patients with chest pain of benign
etiology.

4.  5 Million emergency department visits
 2 million hospitalizations annually with cost of
more than $8 billion
 Cardiac etiology found in less than one third
 2% of patients with acute MI are unrecognized
and discharged from the ED

5.  HEART
 LUNGS
 OESOPHAGUS
 MUSCULOSKELETAL STRUCTURES OF
THORAX NECK,OR SHOULDER
 ABDOMEN
 ANXIETY MANIFESTATION

6. RECURRENT
OFTEN PAROXYSMAL
MILD OR MODERATE
ANGINA
MUSCULOSKELETAL PAINS
SEVERE PROLONGED
ASSOCIATED WITH
CLINICAL EVIDENCE OF ACUTE
SERIOUS ILLNESS
1 2

7.  HISTORY
 EXAMINATION
 ECG
 CARDIAC ENZYMES
 CXR
 OTHERS

8.  Assume the worst!
 100% Oxygen
 IV access
 Monitoring
 ECG quickly
 Done in the same time with history
taking

10.  HEART ATTACK
 ANSWER IS NO……
RELAX
 IS IT ENOUGH TO RULE OUT HEART
ATTACK?

11. • Myocardial Infarction
• Unstable Angina
• Aortic Dissection
• Tension Pneumothorax
• Pulmonary Embolus
• Ruptured Esophagus/Perforated
Ulcer

12.  ANXIETY
 CARDIAC
 AORTIC
 OESOPHAGEAL
 LUNGS/PLEURA
 MUSCULOSKELETAL
 NEUROLOGICAL
MYOCARDIAL ISCHEMIA(ANGINA)
MI
MYOCARDITIS
PERICARDITIS
Mitral valve prolapse
AORTIC DISSECTION
AORTIC ANEURYSM
ESOPHAGITIS
ESOPH SPASM
BRONCHOSPASM:::::PE:::PI
PNEUMONIA:::::TB
TRACHEITIS PLEURITIS
PNEUMOTHORAX
MALIGNANCY
Osteoarthritis
Intercostal MUSCLE INJURY
TEITZE`S SYND
PROLAPSED Intervertebral DISC
HERPES ZOSTER
THORACIC OUTLET SYNDROME

15.  P: pattern (temporal sequence)
 A: associated features
Nausea and vomiting, diaphoresis
fever, cough, chills
abdominal pain
 I: initiation and improvement
 N: nature (quality)

16. PAIN
 NATURE
 SITE
 SEVERITY
 RADIATION
 ONSET
 EXAC/RELIEVING FACTORS
 ASSOCIATED FEATURE
 DURATION
 PREVIOUS SIMILAR PAINS

17.  Vital signs and general appearance
 Carotids and JVP
 Lungs
 Cardiac exam
 Thoracic cage
 Abdominal exam
 Periphery (pulses)
 Skin

18. LOCATION CENTRAL,
DIFFUSE
PERIPHERAL
LOCALIZED
RADIATION JAW/NECK/SHOULDER/
OCCASIONALLY BACK
OTHER OR
NO RADIATION
CHARACTER TIGHT
SQUEEZING
CHOKING
SHARP
STABBING
CATCHING
PRECIPITATION EXERTION
EMOTION
SPONTANEOUS
NOT RELATED TO EXERTION
PROVOKED BY POSTURE,
RESPIRATION OR PALPATION
RELIEVING
FACTORS
REST
NITRATES
NOT RELIEVED BY REST
SLOW OR NO RESPONSE BY
NITRATES
ASSOCIATED
FEATURES
BREATHLESSNESS RESP; GIT,LOCOMOTOR, OR
PSYCHOLOGICAL
ISCHEMIC CARDIAC PAIN NON-CARDIAC PAIN
V/S

19. SITE OF ORIGIN OF PAIN CENTRAL

20. PLEURAL OR PERICARDIAL PAIN
MUSCULOSKELETAL PAIN
CHEST PAIN
OTHER THAN
CARDIAC CAUSES
SHARP
PAIN
EXACERBATED BY
COUGH
MOVEMENT
PAIN ASSOCIATED WITH
SPECIFIC MOVEMENT

22.  CHEST PAIN
 ANXIETY
 FEAR OF IMPENDING DEATH
 BREATHLESSNESS
 VOMITING
 COLLAPSE
 SYNCOPE
 SILENT
SEVERE
LASTS LONGER THAN ANGINAL
PAIN
TIGHTNESS
HEAVINESS
CONSTRICTION IN NECK
SYMPTOMS

23.  SIGNS OF SYMPATHETIC ACTIVATION
PALLOR
SWEATING
TACHYCARDIA
 SIGNS OF VAGAL STIMULATION
VOMITING
BRADYCARDIA

24.  SIGNS OF IMPAIRED MYOCARDIAL FUNCTION
HYPOTENSION
OLIGURIA
COLD PERIPHERIES
NARROW PULSE PRESSURE
RAISED JVP
S3
QUIET S1
DIFFUSE APICAL IMPULSE
LUNG CREPTS
 SIGNS OF TISSUE DAMAGE-------FEVER
 SIGNS OF COMPLICATIONS----MR,,,,,,,PERICARDITIS

25. ECG
 DIFFICULT INTERPRETATION IN PREVIOUS MI
PATIENTS AND OLD BBB
 RARELY NORMAL ECG
 IN 1/3 OF MI CASES INITIAL CHANGES MAY
NOT BE DIAGNOSTIC
 EARLIEST CHANGE ST ELEVATION
 LATER R WAVE SIZE DIMINUTION
 Q WAVES IN TRANSMURAL MI
 T WAVE INVERSION
 CHEK AREA OF INFARCTION

26.  CK-MB
 TROPONIN T & I

27.  CBC LEUCOCYTOSIS ON 1ST. DAY
 ESR RAISED
 CRP ELEVATED
 CXR PUMONARY EDEMA,,,CARDIOMEGALY
 ECHO

28. Similar pathophysiology
Similar presentation and
early management rules
STEMI requires evaluation
for acute reperfusion
intervention
 Unstable Angina
 Non-ST-Segment
Elevation MI
(NSTEMI)
 ST-Segment
Elevation MI
(STEMI)

29. Unstable
Angina STEMI
NSTEMI
Non occlusive
thrombus
Non specific
ECG
Normal cardiac
enzymes
Occluding thrombus
sufficient to cause
tissue damage & mild
myocardial necrosis
ST depression +/-
T wave inversion on
ECG
Elevated cardiac
enzymes
Complete thrombus
occlusion
ST elevations on
ECG or new LBBB
Elevated cardiac
enzymes
More severe
symptoms

30. Evidence of necrosis None Positive Positive
ECG early
ST-segment
depression
and/or
T-wave inversion
ST-segment
elevation
ECG late No Q No Q Q develops
Stable
angina
Unstable
angina
Non-STEMI STEMI
Antman EM. In: Braunwald E, ed. Heart Disease: A Textbook in Cardiovascular Medicine, 5th ed. Philadelphia, Pa: WB
Saunders; 1997.
ST-segment
depression
and/or
T-wave inversion

31. Substernal chest pain or pressure (>20-30
min)
 Localization or radiation to arms, back,
throat, jaw
 Accompanying features
 Dyspnea
 Nausea/vomiting
 Diaphoresis
 Weakness
Atypical presentation:
syncope, cerebrovascular accident

32.  At least 2 of the
following
 Ischemic symptoms
 Diagnostic ECG
changes
 Serum cardiac
marker elevations

33.  Patients with typical angina - An episode of angina
 Increased in severity or duration
 Has onset at rest or at a low level of exertion
 Unrelieved by the amount of nitroglycerin or rest
that had previously relieved the pain
 Patients not known to have typical angina
 First episode with usual activity or at rest within
the previous two weeks
 Prolonged pain at rest

34. ST Elevation or new LBBB
STEMI
Non-specific ECG
Unstable Angina
ST Depression or dynamic
T wave inversions
NSTEMI

39.  Troponin ( T, I)
 Very specific and
more sensitive than
CK
 Rises 4-8 hours after
injury
 May remain elevated
for up to two weeks
 Can provide
prognostic
information
 Troponin T may be
elevated with renal
diseases
 CK-MB isoenzyme
 Rises 4-6 hours after
injury and peaks at 24
hours
 Remains elevated 36-48
hours
 Positive if CK/MB >
5% of total CK and 2
times normal
 Elevation can be
predictive of mortality
 False positives with
exercise, trauma,
muscle diseases, DM,
PE

40.  A BREACH IN INTEGRITY OF AORTIC
WALL
 ARTERIAL BLOOD BURSTS INTO MEDIA OF
AORTA
 MEDIA SPLITS IN TWO LAYERS.
 FALSE LUMEN ALONGSIDE A TRUE
LUMEN.
 DOUBLE-BARRELLED OR BILUMINAL
AORTA.

41.  HTN
 AORTIC ATHEROSCLEROSIS
 NON-SPECIFIC AORTIC ANEURYSM
 AORTIC COARCTATION
 COLLAGEN DISORDERS MARFANS SYND,,,E D
SYNDROME
 FIBROMUSCULAR DYSPLASIA
 PREVIOUS AORTIC SURGERY CABG AV
REPLACEMENT
 PREGNANCY(3RD, TRIMESTER)
 TRAUMA
 IATROGENIC

42.  TEARING PAIN
 ABRUPT ONST
 COLLAPSE
 MARFAN`S SYNDROME
 PT APPEARS TO BE IN
SHOCK
 BP---NORMAL OR RAISED
 AC AR MAY DEVELOP
 ASYMMETRY OF PULSES
 MI
 PARAPLEGIA(SPINAL)
 ACUTE
ABDOMEN(MESENTERIC
CAELIAC)
 RENAL FAILURE
 ACUTE LIMB
ISCHEMIA(LEGS)

43. CLINICAL PRESENTATION:
 PAIN ----RETROSTERNAL OR IN THE SHOULDER
 INTENSITY--- VARIES IN WITH MOVEMENT AND
PHASE OF RESPIRATION
 SHARP ---PAIN MAY CATCH THE PATIENT DURING
COUGHING OR INSPIRATION
 HISTORY OF PRODROMAL VIRAL ILLNESS
 DYSPNEA
 PERICARDIAL FRICTION RUB
 FEVER
 LEUCOCYTOSIS

44. ECG

45.  CXR IN
PERICARDITIS
 SHOWS FLUID
COLLECTION
 MAY BE DRY
 ECHO ADVISED

47. CLINICAL FEATURES
 SHARP LEFT SIDED CHEST PAIN
 DYSPNEA
 FATIGUE
 PALPITATION
 FEMALES
 THIN
 CHEST WALL DEFORMITIES
 MID-SYSTOLIC CLICKS
 ECHO
 CARDIAC CATH

50.  PRESENCE OF AIR IN PLEURAL SPACE
 TRAUMATIC
IATROGENIC
NON-IATROGENIC

51.  SUDDEN-ONSET UNILAT. CHEST PAIN
 BREATHLESSNESS
 DECREASED OR ABSENT BREATH SOUNDS (IF
PNEUMOTHORAX MORE THAN 15%).
 RESONANT ON PERCUSSION
 MEDIASTINAL DISPLACEMENT TO OPPOSITE SIDE
 TACHYCARDIA
 HYPOTENSION
 CYANOSIS

52.  CLINICAL
 CXR

53.  RISK FACTORS FOR THROMBOEMBOLISM
 CLINICAL FEATURES DEPEND ON SIZE
 FAINTNESS OR COLLAPSE
 CENTRAL CHEST PAIN
 SEVERE DYSPNOEA
 PLEURITIC PAIN
 HAEMOPTYSIS

54.  MAJOR CIRCULATORY COLLAPSE
TACHYCARDIA
HYPOTENSION
Increased JVP
RT.VENTRICULAR GALLOP RHYTHM
SPLIT P2
SEVERE CYANOSIS
Decrease URINARY OUTPUT.

55. CXR
 USUALLY NORMAL
 PULM;OPACITIES
 WEDGE-SHAPED OPACITY
 HORIZONTAL LINEAR OPACITIES
 PLEURL EFFUSION
 OLIGAEMIC LUNG FIELDS
 ENLARGED PULMONARY ARTERY
 ELEVATED DIAPHRAGM

56.  ECG
S1,Q3,T3 PATTERN
RBBB
SINUS TACHY
RV HYPERTROPHY

57.  ABGs
MAY BE NORMAL
OR
DEC;PaO2
DEC;PaCO2
METABOLIC ACIDOSIS

58.  D-DIMER
 VENTILATION-PERFUSION SCANNING
 CT PULMONARY ANGIOGRAPHY
 MRI
 COLLOR DOPPLER
 ECHO

59.  PLEURAL PAIN
 RIB MOVEMENT
RESTRICTED
 PLEURAL RUB
 H/O RESPIRATORY
ILLNESS
 CXR

61. CAUSES
 MOST COMMON IATROGENIC (ENDOSCOPIC
PERFORATION)
 MALIGNANCY
 CORROSIVE STRICTURES PERFORATION
 POST RADIOTHERY STRICTURES

62. CLINICAL FEATURES
 SEVERE CHEST PAIN
 SHOCK
 SUB-CUTANEOUS EMPHYSEMA
 PLEURAL EFFUSION
 PNEUMOTHORAX
 PNEUMOMEDIASTINUM

63.  CAN MIMIC ANGINAL PAIN
 MAY GET PRECIPITATED BY EXERCISE
 MAY BE RELIEVED BY NITRATES
 RELATION WITH SUPINE
POSITION,EATING,DRINKING
 HISTORY OF REFLUX
 CAN RADIATE TO BACK

65. PAIN
 VARY WITH
POSTURE
 LOCAL
TENDERNESS
CAUSES
 ARTHRITIS
 COSTOCONDRITIS
 INTERCOSTAL
MUSCLE INJURY
 MINOR SOFT
TISSUE INJURIES

66.  PAIN ON
MOVEMENT
 CREPITUS
 WORSE AT END OF
DAY
 TENDER JOINT.

67.  LOCALIZED PAIN/TENDERNESS AT
COSTOCONDRAL JUNCTION
 ENHANCED BY
EMOTION,COUGHING,SNEEZING
 2nd.RIB MOST AFFECTED

69. THANK YOU