Good Morning!I am Dr. Farjad Ikram

House Officer, Cardiology, Shalamar Hospital

Chest Pain

Contents

Case Scenario

Cardiac causesPulmonary causes

Gastrointestinal causesOther causes

• Mr. Arshad• 60 Years, Male

• Weight 86 kg• Height 142 cm

• Diabetic for 10 years

• Ex-smoker• Family history of

IHD

Case• Presented in E.R

• Chest heaviness (30 min)

• Sudden onset• Retrosternal• Radiates to left arm• Aggravates on

exertion• Relieved by rest• Associated with

sweating

Case (cont.)Physical Examination:• Pulse - 76 b/m, regular• B.P. - 150/90 mmHg• R.R. - 27 b/m• SpO2 - 95% on room air• Temp - 98° F

• BSR - 117 mg/dl

• S1 + S2 + 0• Vesicular breathing• Abdomen non-tender• GCS - 15 / 15• No edema, pallor or

jaundice

• 12 Lead ECG was carried out

ECG at ER admission

ECG 20 minutes later

Case (cont.)What are your differential diagnoses?

• Acute coronary syndrome• Aortic stenosis• R. T. I• Myocarditis• Pericarditis

1.Introduction

Chest pain is one of the most common complaints...

One of the chief complaints in E.R• Chest Pain is the second most common presentation in

E.R visits, after abdominal pain.

• Can represent range of diseases from benign to life threatening.

• It is upto the clinician to exclude the life threatening causes first.

History Taking✘ Site✘ Onset✘ Character✘ Radiation✘ Association✘ Time✘ Exacerbating / relieving

factors✘ Severity✘ Risk factors

Typical vs Atypical vs Non-CardiacAggravate

d by

exertionor

emotional stress

Relievedby rest or

nitroglycerin

Diffuse retrosternal chest pain

or discomfort

3 / 3Typical

2 / 3Atypical

1 / 3Noncardia

c

Causes of Chest PainCARDIAC RESPIRATORY GASTROINTESTINAL MISC.

Ischemic Heart Disease Bronchospasm Reflux Disease (GERD) Rib Fracture

Aortic Stenosis Pulmonary Embolism Acid Peptic Disease Precordial Catch

Mitral Valve Prolapse Respiratory Tract Infection

Esophageal Motility Disorders

Acute Chest Syndrome

Pericarditis Pleurisy Esophageal Rupture Costochondritis

Myocarditis Pneumothorax Pancreatitis Herpes Zoster

Cardiac Tamponade Hemothorax Cholecystitis Anxiety Disorder

Aortic Dissection Empyema Biliary Colic Panic Disorder

Triple Rule Out C.T Angiography• TRO-CTA provides a cost-effective evaluation of aorta,

coronaries, and pulmonary arteries in patients presenting with acute chest pain.

• Rules out three life threatening causes: 1 - Coronary Artery Disease 2 - Pulmonary Embolism 3 - Aortic Dissection +/- Cardiac Tamponade

• Can safely eliminate the need of further testing in 75% of the patients.

2.Cardiovascular

causes of Chest Pain

Ischemic Heart Disease

• IHD must be excluded in all patients presenting with chest pain.

• Especially in middle and old age groups. Initial suspicion is on history.

• ECG may be normal in early stages of ACS, so a normal ECG doesn’t exclude ACS.

• Angina Pectoris is typical chest pain < 30 min (similar episodes in past)

- Seen in stable angina, coronary vasospasm

• Acute Coronary Syndrome (ACS) is typical / atypical chest pain > 30 min

- Seen in unstable angina (38%), NSTEMI (25%), STEMI (30%)

Ischemic Heart Disease

• Unstable Angina (UA) - occurs at rest or with minimal exertion - it is severe and van be of new onset - it can occur with a crescendo pattern (distinctively more severe, prolonged, and frequent than previous episodes) - may or may not be relieved by rest or S/L nitrates - can precede myocardial infarction• Decubitus Angina

- Typical chest pain which appears after lying down - Due to increase in venous return and preload - Seen in heart failure and/or severe underlying CAD

Angina Pectoris / ACSFeatures of chest pain in Angina Pectoris and ACS

Site Diffuse, retro-sternalCharacter Discomfort, tightness, heaviness, squeezing, sinkingRadiation Left arm, neck, jaw, shoulders, back, right arm, epigastrium

Association Diaphoresis, dyspnea, nausea, vomitingTime course Constant, non-spasmodic, non-pleuritic

Exacerbated by Exertion and emotional stressRelieved by Rest, S/L nitroglycerin (stable angina)

Not relieved by rest, S/L nitrates (unstable angina, MI)Risk factors Age, Sex, Smoking, Diabetes, Hyperlipidemia, F/H of IHD

Levine Sign

Classification Of Angina

Canadian Classification Scale (CCS) of AnginaClass I Angina on strenuous, rapid or prolonged exertion

No limitation of ordinary activity like walking or climbing stairs

Class II Slight limitation of ordinary activities like walking or climbing stairs, in cold, in wind, after meals, or emotional stress

Class III Marked limitation of ordinary activitiesi.e . after walking 1-2 blocks, or climbing 1-2 flight of stairs

Class IV Unable to perform any physical activity without discomfortAngina may be present at rest

Ischemia VS InfarctionFeature Stable Angina Unstable Angina Myocardial Infarction

Onset On exertion On rest or exertion On rest or exertion

Relieved by rest Yes No No

S/L nitrates Relieves pain May relieve pain Does not relieve

Duration < 30 min > 30 min > 30 min

ECG Normal or transient changes

(ST depression and T wave flattening or

inversions)

Maybe normal initiallytransient changes

(ST depression and T wave flattening or

inversions)

Maybe normal initiallyST elevation and/or

depression (may be transient)T wave inversions (may persist)

Q waves (permanent)

Cardiac enzymes Within range Within range Raised

Medical Therapy in AnginaObjectives:• Prevent episodes of angina

Short-acting nitrates 5 min before planned exertion 1st line Anti-anginals - Beta Blockers and /or Calcium Channel Blockers 2nd line Anti-anginals - Long-acting nitrate, Ivabradin, Ranolazine, Nicorandil• Treat episodes of angina

During angina – Take a dose of short-acting nitrates If no relief after 5 min, repeat dose and call an ambulance• Secondary prevention of CV disease

- Lifestyle modifications - weight reduction, diet control, regular exercise - Anti-Platelet Therapy - Aspirin (+/- Clopidogrel) - Cholesterol lowering therapy - ideally with a statin (alt. is ezetimibe) - Treat hypertension if present - ideally with an ACEI or ARB - Refer to endocrinologist for diabetes management if present

Acute Pericarditis

• “Sharp” retrosternal chest pain• Aggravates on movement,

inspiration, cough and lying supine• Relieves on leaning forward• Signs: Tachycardia, pericardial

friction rub• There maybe history of recent MI

(Dressler’s syndrome)• ECG: diffuse ST elevation concave

upwards diffuse PR depression • Cardiac enzymes: may be

elevated

Acute Pericarditis

Acute Myocarditis

✘ “Sharp” retrosternal chest pain✘ Associated symptoms: palpitations, tachypnea✘ Sometimes concomitant with pericarditis, heart failure,

arrhythmias

✘ May preceded by pro-dromal symptoms like fever, rash, arthritis etc

✘ Seen with rheumatic fever, sarcoidosis, SLE or scleroderma

✘ Delayed complication = dilated CMP

✘ ECG – sinus tachycardia, QT prolongation, diffuse T wave inversions

✘ Increased troponin levels due to myocardial inflammation

Aortic Stenosis

• Angina mimic – sub-endocardial ischemia due to raised LVEDP

• Syncope (LVOT obstruction & hypotension)• Features of heart failure may be present• Ejection Systolic Murmur at aortic area• Causes: aortic sclerosis (aging), RHD, congenital bicuspid

AV

• ECG – LVH, P. mitrale, possibly conduction blocks like LBBB

• Echo – dilated aortic root, thickened / immobile AV, concentric LVH,

On the basis of AVPG, AV area can be determined, AS can be graded as: Mild, Moderate, Severe, Very Severe

Aortic Stenosis

SEVERITY OF AORTIC STENOSIS

Aortic Stenosis

Hypertrophic CMP

• Typical chest pain (angina mimic) due to: increased demand (hypertrophy) reduced blood supply (aberrant coronary flow)• Syncope or pre-syncope (LVOT obstruction in 30% cases,

HOCM)• Features of heart failure may be present• Palpitations (if complicated by arrhythmias)• ECG – LVH, P mitrale, possibly PACs, PVCs, SVTs or a. fib

Septal hypertrophy – narrow “dagger like” Q waves in lat. & inf. leads Apical hypertrophy - giant inverted T waves in chest leads• Echo is diagnostic – Asymmetrical Septal Hypertrophy

(ASH)

NORMAL HEART HOCM

Mitral Valve Prolapse

• Symptoms: atypical chest pain, panic, palpitations, pre-syncope, SOB

• Signs: Mid systolic click with a late systolic murmur Accentuated with standing and Valsalva maneuver• Significant MR can cause heart failure, and a holosystolic

murmur• Myxomatous degeneration of MV leaflets that bulge

backward into LA• Presents to us in second or third decade of life• ECG – may be normal, sinus tachycardia, LVH, P mitrale• Echo – concentric LVH, dilated LA, MR present

classic MVP - thickened mitral leaflets > 5mm - leaflet displacement > 2mm into LA during systole

Mitral Valve Prolapse

Cardiac Tamponade

• Symptoms: Atypical pain relieved by leaning forward, SOB, pre-syncope

• Signs: Beck’s triad (hypotension, engorged neck veins, muffled heart

sounds), pulsus paradoxus, pericardial rub, Ewart’s sign

• Fluid/blood in the pericardial sac resulting in the compression of heart

• Causes: trauma, heart rupture, aortic dissection, uremia, cancer, TB etc

• ECG – low voltage, tachycardia Electrical alternans – consecutive QRS complexes alternate in height, produced by heart swinging to and fro in a large fluid filled pericardium.• Echo is diagnostic. CXR is supportive. Cardiac markers may

be elevated.

Cardiac Tamponade

Cardiac Tamponade

Cardiac Tamponade

Aortic Dissection

• Symptoms: Sudden onset of severe “tearing” pain in the inter-scapular

region of the back, sweating, vomiting and lightheadedness• If ascending aorta is involved - there can be frontal chest

pain, and cardiac tamponade can occur (most common cause of death in A.D)• MI can occur if aortic root is involved as coronary arteries

arise from it• Abdominal pain and GI bleed due to mesenteric ischemia• Syncope due to cerebral hypo-perfusion, paralysis due to

stroke• Tear inside the aorta causes the blood to between the

layers of the wall• Etiology: chronic hypertension causing cystic medial

degeneration• CXR – normal, wide mediastinum, wide aortic knob, left

pleural effusion• CT angiogram is diagnostic. MRI is the gold standard.

Aortic Dissection

Other Cardio-vascular Causes• Arrhythmias• Heart Failure• Hypertensive Heart Disease• Aortitis (syphilis, autoimmune)• Thoracic aortic aneurysm

3.Respiratory

causes of Chest Pain

Pulmonary Embolism

• Symptoms: “Sharp” pleuritic chest pain, sudden SOB, hemoptysis

• Signs: pyrexia, cyanosis, tachycardia, hypotension, pleural rub

• Signs of DVT: calf tenderness, calf pain on dorsiflexion (Homans sign)

• Wells and Geneva scores: risk factor stratification of suspected PE

• ECG - most commonly normal, sinus tachycardia, RBBB, S1-Q3-T3 (10-15%)

• CXR - most commonly normal - elevated hemi-diaphragm, pleural effusions, band atelectasis - Westermark sign (dilated pulmonary artery, olegemia of the lung field) - Hampton’s hump (wedge shaped opacity, signifying lung infarct)• Echo - RV dilation, RV wall hypokinesis (McConnell’s sign), dilated

IVC• D-dimer (sensitive but non-specific), Cardiac markers (raised in 16-

47% cases)• CT Pulmonary Angiogram (diagnostic), V/Q scan, SPECT• Supportive - Doppler lower limbs (for DVT)

Pulmonary Embolism

Lower R.T.I

• Symptoms: dull/sharp localized chest pain, increases with inspiration/cough

• Associated: fever, cough +/- sputum, SOB, hemoptysis, weight loss

• Signs: pyrexia, coarse crackles, rhonchi, bronchial breathing

• Causes: pneumonia, lung abscess, tuberculosis

• ECG – can be normal, sinus tachycardia• Cardiac markers – not elevated• F/U – CXR, Montoux test, sputum (gram stain, AFB, C&S)

Other Pulmonary Causes

• Tracheitis• Bronchitis• Bronchiolitis• Bronchospasm• Hypersensitivity

pneumonitis• Sarcoidosis• Lung malignancy

Pleural Causes

• Pleurisy• Pneumothorax• Hemothorax• Pyothorax• Mesothelioma

4.Gastrointestinal

causes of Chest Pain

Gastro-esophageal causes

• Gastro-esophageal reflux disease (GERD)• Esophagitis• Acid peptic disease (APD)• Gastritis• Hiatal Hernia• Esophageal motility disorders (EMDs)• Boerhaave’s syndrome• Mediastinitis

Other G.I. causes

• Gas bloating• Nutmeg liver• Hepatitis• Liver abscess• Pancreatitis• Cholecystitis• Cholangitis• Biliary colic

5.Other causes of Chest Pain

Musculoskeletal Causes

• Rib fracture / flail chest – Splenic injury?

• Costochondritis• Fibromyalgia• Radiculopathy• Disc prolapse• Osteoarthritis• Thoracic outlet syndrome• Pott’s disease (tuberculosis)

Other Causes

• Empyema• Herpes Zoster (shingles)• Post Herpetic Neuralgia• Acute chest syndrome (sickle cell

disease)• Invasive breast cancer• Pain of unexplained origin (PUO) • Pre-cordial catch syndrome (PCS)

Psychosomatic Causes

• Da Costa’s syndrome: physical manifestation of an anxiety disorder• Generalized Anxiety Disorder (GAD)• Panic Disorder• Phobia i.e. agoraphobia• Post-traumatic stress disorder (PTSD)• Clinical depression• Conversion disorder• Hypochondriasis

• Mr. Arshad• 60 Years, Male

• Weight 86 kg• Height 142 cm

• Diabetic for 10 years

• Ex-smoker• Family history of

IHD

Case• Presented in E.R

• Chest heaviness (30 min)

• Sudden onset• Retrosternal• Radiates to left arm• Aggravates on

exertion• Relieved by rest• Associated with

sweating

Case (cont.)Physical Examination:• Pulse - 76 b/m, regular• B.P. - 150/90 mmHg• R.R. - 27 b/m• SpO2 - 95% on room air• Temp - 98° F

• BSR - 117 mg/dl

• S1 + S2 + 0• Vesicular breathing• Abdomen non-tender• GCS - 15 / 15• No edema, pallor or

jaundice

• 12 Lead ECG was carried out

ECG at ER admission

ECG 20 minutes later

Case (cont.)What are your differential diagnoses?• Acute coronary syndrome• Aortic stenosis• Respiratory tract infection• Myocarditis• PericarditisPROVISIONAL DIAGNOSIS: Acute Coronary Syndrome

thanks!Any questions?