Case Scenario Chest Pain Evaluation for undergraduates
Case ScenarioCentral Chest Pain Evaluation
Central Chest Pain EvaluationDr. Md.Toufiqur Rahman MBBS, FCPS,
MD, FACC, FESC, FRCP, FSCAI, FAPSC, FAPSIC, FAHAAssociate Professor
of CardiologyNational Institute of Cardiovascular
DiseasesSher-e-Bangla Nagar, Dhaka-1207
[email protected]
Objectives
Establish a differential diagnosis for chest pain Know what
clues to obtain on history to rule-in or out MI, PE, pneumothorax
and aortic dissection Identify risk factors for MI Know how to do a
focused physical exam, identifying features that would distinguish
between MI, PE, pneumothorax and aortic dissection. Identify
investigations required in diagnosing MI Outline management
strategy in MI
3
EtiologiesMyocardial ischemia or infarction Pulmonary embolus
Pneumothorax Pericarditis Tamponade Pneumonia Aortic dissection
Gastritis, peptic ulcer disease Musculo-skeletal Shingles
4
Case Scenario----1A 65 years old hypertensive, smoker, diabetic
and dyslipidemic gentleman from Mymensingh district presented with
central chest tightness on exertion for last 1 months. His pulse
was 104 b/min, BP-150/95 mm Hg, HbA1c-8.2%. His ECG was normal .
What should be his next investigation? What was the probable cause
of his chest tightness? a. Esophageal spasm b. Chronic stable
angina c. acute coronary syndrome d. acute pericarditis
Case Scenario----2A 55 years old hypertensive, smoker, diabetic
and dyslipidemic gentleman from Dhanmondi presented with central
chest tightness with excessive sweating for last 30 minutes not
relieved by taking sublingual nitrates. His pulse was 104 b/min,
BP-150/95 mm Hg, HbA1c-8.2%. His ECG showed ST segment elevation in
V1-V5 . What was the probable cause of his chest tightness? a.
Esophageal spasm b. Chronic stable angina c. acute coronary
syndrome(STEMI) d. acute pericarditis
Case Scenario----3A 55 years old hypertensive, smoker, diabetic
and dyslipidemic gentleman from Tejgaon presented with central
chest tightness with excessive sweating for last 30 minutes not
relieved by taking sublingual nitrates. His pulse was 104 b/min,
BP-150/95 mm Hg, HbA1c-8.2%. His ECG showed ST segment depression
in V1-V5 . His Troponin I level is 30 ng/L. What was the probable
cause of his chest tightness? a. Esophageal spasm b. Chronic stable
angina c. acute coronary syndrome(NSTEMI) d. acute pericarditis
Case Scenario----4A 52 years old hypertensive, smoker, diabetic
and dyslipidemic gentleman from Bashaboo presented with central
chest tightness with excessive sweating for last 20 minutes not
relieved by taking sublingual nitrates. His pulse was 110 b/min,
BP-140/95 mm Hg, HbA1c-9.2%. His ECG showed T inversion in V1-V4 .
His Troponin I level is normal. What was the probable cause of his
chest tightness? a. Esophageal spasm b. Chronic stable angina c.
acute coronary syndrome(Unstable angina) d. acute pericarditis
Case Scenario----5A 32 years old smoker gentleman from Naogaon
presented with central chest pain for last 5 days with fever. His
pulse was 120 b/min, BP-140/95 mm Hg. His ECG showed ST segment
elevation in lead V1-V6 and lead 2, 3 and aVF . What was the
probable cause of his chest pain ? a. Esophageal spasm b. Chronic
stable angina c. acute coronary syndrome d. acute pericarditis
Case Scenario----6A 42 years old smoker gentleman from Rajshahi
presented with central chest pain for last 35 days increased at
night lying flat relieved by taking antacid syrup. His pulse was 80
b/min, BP-130/85 mm Hg. His ECG showed normal. What was the
probable cause of his chest pain? a. Reflux esophagitis b. Chronic
stable angina c. acute coronary syndrome d. acute pericarditis
Case Scenario----7A 22 years old lady from Khulna district
presented with central chest pain with palpitations for last 5
months. Her pulse was 110 b/min, BP-120/80 mm Hg. Her ECG showed
normal , Echocardiography showed normal study, ETT done previously
for 2 times were negative. What was the probable cause of his chest
pain? a. Reflux esophagitis b. Chronic stable angina c. acute
coronary syndrome d. Generalized Anxiety Disorder
Case Scenario----8A 25 years old lady from Kustia district
presented with central chest heaviness with palpitations with low
grade fever for last 2 months. Her pulse was 110 b/min, BP-110/70
mm Hg. Her ECG showed low voltage , Echocardiography showed echo
free space in pericardium. What was the probable cause of his chest
pain? a. Reflux esophagitis b. Chronic stable angina c. Pericardial
Effussion d. Generalized Anxiety Disorder
Case Scenario----9A 25 years old lady from Kustia district
presented with central chest heaviness with palpitations with low
grade fever for last 2 months. Her pulse was 110 b/min, BP-110/70
mm Hg. Her ECG showed low voltage , Echocardiography showed echo
free space in pericardium. What was the probable cause of his chest
pain? a. Reflux esophagitis b. Chronic stable angina c. Pericardial
Effussion d. Generalized Anxiety Disorder
Case Scenario----10A 19 years old smoker gentleman from
Panchagor presented with central chest pain for last 5 days with
fever and shortness of breath. His pulse was 120 b/min, BP-110/75
mm Hg. His ECG showed T inversion in lead V1-V6 . His
echocardiography showed global hypokinesia with EF-40%, Troponin I
positive. What was the probable cause of his chest pain ? a.
Myocarditis b. Chronic stable angina c. acute coronary syndrome d.
acute pericarditis
Case Scenario----11A 27 years old gentleman from Chuadanga
district presented with occasional chest pain with palpitations for
last 2 years. His pulse was 110 b/min, BP-110/70 mm Hg. His ECG
showed normal , Echocardiography showed echo mitral valvular
disease. What was the probable cause of his chest pain? a. Mitral
valve prolapse b. Chronic stable angina c. Pericardial Effusion d.
Generalized Anxiety Disorder
Case Scenario----12A 21 years old gentleman from Sathkhira
district presented with occasional central chest pain with
palpitations for last 3 years. He was diagnosed as a case of
Marfans Syndrome. His pulse was 112 b/min, BP-110/70 mm Hg. His ECG
showed normal , Echocardiography showed echo aortic root dilataion.
What was the probable cause of his chest pain? a. Mitral valve
prolapse b. Chronic stable angina c. Pericardial Effusion d. Aortic
Aneurysm
Case Scenario----13A 50 years old hypertensive, smoker, diabetic
and dyslipidemic gentleman from Jatrabari presented with severe
tearing central chest pain with excessive sweating for last 30
minutes not relieved by taking sublingual nitrates. His pulse was
104 b/min, no pulse in lower limbs BP-150/95 mm Hg, HbA1c-8.2%. His
ECG showed left ventricular hypertrophy . What was the probable
cause of his chest tightness? a. Esophageal spasm b. aortic
dissection c. acute coronary syndrome(STEMI) d. acute
pericarditis
Case Scenario----14A 70 years old hypertensive, smoker, diabetic
and dyslipidemic gentleman from Jessore presented with central
chest pain with burning sensation in mouth while taking food. His
pulse was 86 b/min, BP-140/95 mm Hg, HbA1c-8.2%. Oral examination
showed oral thrush. His ECG showed left ventricular hypertrophy .
What was the probable cause of his chest tightness? a. Esophagitis
( Fungal infection) b. aortic dissection c. acute coronary
syndrome(STEMI) d. acute pericarditis
26 Old army officer had flu last week,felt chest pain while
driving his car,pain increased by deep breath,he has no history of
DM or HTN,nonsmoker,lipid profile LDL 2.0 MMMOL/L
A 26 year old woman presented 1 week post delivery of her first
baby. She has sharp L sided chest pain and she is short of
breath.
Pulmonary EmbolismWhy ?Young femalePegnancy hypercoagulable
stateOccurrence one week post partum
65 year old man(H/O DM,HTN) presented with a 1 hour history of
severe central crushing chest pain. He is sweaty, clammy and has
vomited twice .
65 year old man(H/O DM,HTN) presented with a 1 hour history of
severe central crushing chest pain. He is sweaty, clammy and has
vomited twice .Anterior (extensive) Myocardial infarction. Why
?Male 65 years.H/O DM+HTN( remember INTERHEART study)Crushing chest
pain.Associated sweaty,clammy,vomiting.
70 years old male with long history of untreated HTN, nonsmoker
came complaining of chest pain migrated to interscapular region
& became severe(tearing), SBP 200,ECG mild inferior changesMost
likely diagnosis is? AMI?PE?Esophagear Rupture ?Aortic
Dissection
26 yr old thin man with sudden onset of severe L sided sharp
chest pain , tachypnoeic.
Myocardial ischemia or infarctionPressure-type of chest pain
Generally involves central to left-sided pain with radiation to jaw
or arms Exacerbated by activity, relieved with rest Relieved with
nitro spray Associated with nausea, diaphoresis, syncope, shortness
of breath Enquire about cardiac risk factors: age, sex, smoking
history, diabetes, hypertension, hyperlipidemia, previous
myocardial infarction and family history
26
Myocardial ischemia or infarctionBP indicates cardiogenic shock
JVP, pulsatile liver and peripheral edema seen in right-sided heart
failure Oxygen desaturation, crackles, S3 seen in left-sided heart
failure New murmurs: mitral regurgitation murmur in papillary
muscle dysfunction
27
Work-upEKG (should be knee-jerk reflex in chest pain
scenario!)
CXR to look for signs of congestive heart failure Cardiac
enzymes: CK (will begin to rise 6 hours after infarct and remain
elevated for 24-48 hours), troponin (will begin to rise 12 hours
after infarct and remain elevated for 2 weeks). Need to follow
serially if first set negative.
28
29
30
Management Strategy for NSTEMI
Initial therapyMorphine for pain Oxygen if hypoxic Nitro
spray/drip for pain Aspirin
31
Management Strategy for NSTEMI/NST Chest PainEstablish risk
level using the TIMI scoring system:
Low risk: May be discharged after symptom control
Moderate risk: Admit for further evaluation; add beta blockers ,
Ace inhibitors . Follow cardiac enzyme levels. If Mi ruled out,
Exercise or Adenosine stress test before discharge
High Risk: Admit for cardiac catheterization
32
Management Strategy for STEMIMorphine, oxygen, nitro,
aspirin
Beta blockers, Ace inhibitors
Early invasive strategy with either thrombolytic therapy or
percutaneous coronary intervention (preferred)
33
Pulmonary EmbolismSudden-onset sharp chest pain Exacerbated by
inspiratory effort Can be associated with hemoptysis, sycope,
dyspnea, calf swelling/pain from DVT Risk factors: immobilization,
fracture of a limb, post-operative complications, hypercoagulable
states (underlying carcinoma, high-dose exogenous estrogen
administration, pregnancy, inherited deficiencies of antithrombin
III, activated protein C, S, lupus anticoagulant, prior history of
DVT/PE [Virchows triad]
34
Pulmonary EmbolismAnxious patient, sense of impending doom
Tachycardia, tachypnea, hypoxia EKG: sinus tachycardia most common,
S1Q3invertedT3 with large embolus (classic, but rare!), look for
right-axis deviation V/Q scan very sensitive but not specific
Spiral CT with contrast show large, central emboli Pulmonary
angiogram is gold standard but carries risk Consider Doppler U/S of
legs
35
PneumothoraxCan be asymptomatic or present with acute pleuritic
chest pain and dyspnea Primary pneumothorax predominantly in
healthy young tall males Due to trauma (MVA accidents associated
with rib fractures, iatrogenic during line placement,
thoracentesis) Increased alveolar pressure from asthma or
barotraumas (BiPAP, ventilator-associated) Rupture of bleb in COPD
patients
36
PneumothoraxDecreased expansion of chest Decreased breath sounds
and Decreased tactile/vocal fremitus on side of
pneumothoraxHyperresonant percussion note Usually easily confirmed
by CXR
37
Aortic DissectionAbrupt onsetThe pain usually is described as
ripping or tearingTearing or ripping pain that is felt in the
intrascapular areaNew diastolic murmur, asymmetrical pulses, and
asymmetrical blood pressure measurementsRisk factors: HTN, Marfan
syndrome, coarctation of aorta..Widened mediastinum on a portable
anteroposterior (AP) radiographTEE considered diagnostic test of
choice
38
Key PointsNot every chest pain is MI, however every chest pain
should be considered as ischemic until proven otherwise
A good history and physical exam may help with the diagnosis
EKG is the best single diagnostic test to help rule out MI
Use the TIMI scoring system to help for the diagnosis and
prognosis of MI
Chest Pain DefinitionsAcute Chest Pain:Acute - sudden or recent
onset (usually within minutes to hours), presenting typically
