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ORIGIN OF THE PAIN

Heart

Lungs

Oesophagus

Musculoskeletal structures of thorax or shoulder

Abdomen

Anxiety

DIFFERENTIAL DIAGNOSIS OF CHEST PAIN

DIFFERENTIAL DIAGNOSIS OF CHEST PAIN

ISCHEMIC CARDIAC PAIN

V/S
V/S

NON-CARDIAC PAIN

LOCATION

CENTRAL,

PERIPHERAL

DIFFUSE

LOCALIZED

RADIATION

JAW/NECK/SHOULDER/ ARM (OCCASIONALLY BACK)

OTHER OR NO RADIATION

CHARACTER

TIGHT

SHARP

SQUEEZING

STABBING

CHOKING

CATCHING

PRECIPITATION

EXERTION

SPONTANEOUS

EMOTION

NOT RELATED TO EXERTION PROVOKED BY POSTURE, RESPIRATION OR PALPATION

RELIEVING

REST

NOT RELIEVED BY REST SLOW OR NO RESPONSE BY NITRATES

FACTORS

NITRATES

ASSOCIATED

BREATHLESSNESS

RESPI, GIT, LOCOMOTOR, OR PSYCHOLOGICAL

FEATURES

Cardiac causes of chest

pain

1. Myocardial ischemia (angina)

2. AMI

3. Pericarditis

4. Aortic dissection

5. Aortic aneurysm

6. Mitral valve prolapse

MYOCARDIAL ISCHEMIA (ANGINA)

Angina is a clinical syndrome characterized by :

Discomfort in chest, jaws, shoulder, back or arms.

Typically aggravated by exertion or emotional stress.

Relieved by rest or nitroglycerin (GTN).

Angina is caused by an imbalance between myocardial

oxygen supply and demand which most commonly due to

atherosclerosis.

There are many types of angina, including microvascular angina, variant (Prinzmetal) angina, stable angina/angina pectoris and unstable angina.

RISK FACTORS
RISK FACTORS

Unhealthy cholesterol levels

High blood pressure

Smoking

Diabetes

Overweight or obesity

Metabolic syndrome

Inactivity

Unhealthy diet

Older age (The risk increases for men after 45 years of age and for women after 55 years of age.)

Family history of early heart disease

STABLE ANGINA
STABLE ANGINA

Pathophysiology : Fixed stenosis

Clinical features :

Demand-led ischemia

Symptoms at exertion, relieved by rest

Lasts 2-5 minutes

Risk assessment :

by rest  Lasts 2-5 minutes  Risk assessment :  Symptoms on minimal exertion 

Symptoms on minimal exertion

Exercise testing (Duration, degree of ECG changes, abn BP response)

ACUTE CORONARY SYNDROME

Is a spectrum of disease ranging from UA/NSTEMI to

STEMI depending on the acuteness and severity of the coronary occlusion.

Pathogenesis :

ACS occurs due to atherosclerotic plaque rupture, fissure

or ulceration with superimposed thrombosis and coronary

vasospasm.

3 criterias for STEMI :

Chest pain (ischemic type)

ECG changes (new onset ST elevation/presumed new LBBB)

Cardiac biomarkers elevated (injury/necrosis)

3 criterias for UA/NSTEMI :

Chest pain (ischemic type)

ECG changes (ST depression, T inversion, etc)

Cardiac biomarkers elevated (Troponin T, CK, CK-MB)

UNSTABLE ANGINA
UNSTABLE ANGINA

Pathophysiology :

Dynamic stenosis

Clinical features :

Supply-led ischemia

Symptoms at rest

Unpredictable

Lasts > 10 minutes

Risk assessment :

ECG changes at rest

ECG changes with symptoms

Elevation of troponin

> 10 minutes  Risk assessment :  ECG changes at rest  ECG changes with

UNSTABLE ANGINA/NSTEMI

NSTEMI is similar with UA with addition to Myocardial necrosis (elevated cardiac biomarkers)

Class of UA:

New onset severe angina, no rest pain

Angina at rest within 1 hour but not within 48 hours (angina at rest, subacute)

Angina at rest (>20 mins) within 48 hours (acute angina)

Further classified into :

Primary (develop in absence of extracardiac disease)

Secondary to extracardiac disease :

Increase myocardial oxygen demand (eg in fever, thyrotoxicosis)

Reduced coronary blood flow (due to hypotension)

Reduced myocardial oxygen delivery (eg in anaemia,

hypoxemia)

HISTORY

Chest pain

Site (retrosternal, central)

Onset (sudden/gradual)

Character (burning, squeezing, pressing, crushing, tightness)

Radiation (jaw, upper limbs)

Association (profuse sweating, N/V, SOB, palpitation, PND, orthopnea, swelling, syncope)

Time (>20 mins indicates STEMI)

Exacerbation/relieving factor (rest low stress activity)

Severity (pain score)

EXAMINATION

Normal or diaphoresis

Pale cool skin

Tachycardia

S4

Basilar rales

ECG :

ST depression

T-wave inversion

Cardiac biomarkers :

CK-MB elevated

Cardiac specific

troponins elevated

History :

Symptoms :

STEMI

Chest pain (similar to angina)

Nausea/vomiting

Weakness

Light headedness with syncope

Sweating

25% are insidious and silent.

Other significant history :

Prev history of IHD/PCI/CABG

Risk factors for atherosclerosis

Prev TIA/CVA

Family history of IHD/CVA/DM/HTN

Social (smoker, alcoholic, occupation)

PHYSICAL EXAMINATION

Physical examination :

Pallor

Diaphoresis

Tachycardia

S4 heart sound

Dyskinetic cardiac impulses

In MI + CHF :

Rales

S3

Jugular venous extension

INVESTIGATIONS

ECG : ST elevation, new LBBB

CXR : TRO pneumothorax, aortic dissection, etc

Serum Cardiac markers highly specific (These serum should

be assess at presentation of chest pain, 6-9 hours after attack, and at 12-24 hours) :

Troponin T/Troponin I (Remain elevated for 7-10 days)

Creatine phosphokinase

Rise within 4-8 hours

Peaks at 24 hours

Normalize by 48-72 hours *CK-MB is more specific for MI but elevated in myocarditis.

MANAGEMENT
MANAGEMENT

GOALS :

Pain relief

Early perfusion

Treat complications

Pre-Hospital management

At home : 1 tab GTN every 5 mins (3x)

At GP :

Chew/swallow 1 tab aspirin

Sublingual GTN

Oxygen if hypoxia

ECG (if ischemic changes) -> 300 mg Clopidogrel

IV access -> IV morphine 3-5 mg slowly

To hospital

In Hospital Management :

Admit to RED ZONE

Quick history and vital signs

Confirm diagnosis by ECG

Sublingual GTN if pain persist, cont ECG

monitoring, Aspirin, Clopidogrel, O2, IV access.

Reperfusion strategy (fibrinolytic/PCI)

COMPLICATIONS

1. Arrythmias.

Ventricular arrythmias

Ventricular tachycardia

Ventricular fibrillation

Supraventricular arrythmias

Bradyarrythmias and AV block

2. Heart failure

3. Cardiogenic shock

4. RV infarction -

hypotension, clear lung field, raised JVP

5. Pericarditis

-

pain worsen on deep inspiration, relieve

on

sitting and leaning forward, pericardial

rub

6. Ventricular aneurysm

PERICARDITIS

Is the inflammation of pericardial sac.

More common in men.

Between 20-50 years old.

Etiology :

Viral illness (Coxsackie, Echovirus, mumps etc)

AMI

Bacterial infection

Tuberculous, fungal pericarditis

Malignant pericarditis

Clinical presentation

Sharp central chest pain.

Exacerbated by movement, respiration and lying down.

Relieved by sitting forward

Dyspnea

fever

PERICARDITIS

Investigations :

Lab investigations (ESR, CBC, cardiac profiles- CK-MB, troponins TRO AMI, rheumatoid factors)

ECG (ST elevation, PR interval depression, ST depression in

aVR and V1)

CXR (cardiac silhoutte enlarged, heart appears globular)

Echocardiogram

enlarged, heart appears globular)  Echocardiogram • Management :  NSAIDs  Analgesia •

Management :

NSAIDs

Analgesia

Complications :

Pericardial effusion

Cardiac tamponade

Constrictive pericarditis

AORTIC ANEURYSM

Abnormal dilatation of the abdominal or thoracic aorta.

Defined as permanent dilatation of the artery to twice its normal

diameter.

Primarily due to atherosclerosis.

HISTORY

Maybe clinically silent.

Thoracic aortic aneurysm deep diffuse chest pain radiating to upper back.

Rupture associated with hypotension, tachycardia.

Stridor compressed bronchial tree

Hoarseness compression of recurrent laryngeal nerve

Hemoptysis aortobronchial fistula

Dry cough

Abdominal aortic aneurysm abdominal pain

PHYSICAL EXAMINATION :

Abdominal aortic aneurysym often palpable in periumbilical area.

Ascending thoracic aneurysm features of Marfan Syndrome.

INVESTIGATION :

Thoracic AA CXR enlarge aortic shilouette.

Confirm by echocardiogram.

AAA plain film rim of calcification.

Treatment

Control hypertension (Beta blocker)

If aneurysm is >6cm then operative surgical repair or stenting may be appropriate.

Endovascular aneurysm repair is the choice of treatment for descending thoracic aneurysms.

AORTIC DISSECTION

INTRODUCTION

Potentially life threatening.

Disruption or aortic intima allows dissection of blood into vessel walls.

Ascending aorta (type II)

Descending aorta (type III)

Both (type I)

Another classification :

Type A ascending aorta. Most lethal.

Type B transverse or descending aorta.

AORTIC DISSECTION

PREDISPOSING FACTORS

HTN

AORTIC ATHEROSCLEROSIS

NON-SPECIFIC AORTIC ANEURYSM

AORTIC COARCTATION

COLLAGEN DISORDERS MARFANS SYNDROME

FIBROMUSCULAR DYSPLASIA

PREVIOUS AORTIC SURGERY

PREGNANCY(3RD, TRIMESTER)

TRAUMA

IATROGENIC

CABG

AV REPLACEMENT

AORTIC DISSECTION

CLINICAL FEATURES

CENTRAL CHEST PAIN

TEARING PAIN

ABRUPT ONSET

RADIATES TO BACK AND ARM

COLLAPSE

PT APPEARS TO BE IN SHOCK

BP---NORMAL OR reduced

ASYMMETRY OF PULSES

ABSENT PERIPHERAL PULSES

MI

PARAPLEGIA(SPINAL)

ACUTE ABDOMEN(MESENTERIC

CAELIAC)

RENAL FAILURE

ACUTE LIMB ISCHEMIA(LEGS)

• PARAPLEGIA(SPINAL) • ACUTE ABDOMEN(MESENTERIC CAELIAC) • RENAL FAILURE • ACUTE LIMB ISCHEMIA(LEGS)

Physical examination :

Sinus tachycardia

Cardiac tamponade (hypotension, pulsus paradoxus, pericardial rub)

Lab :

CXR widening of mediastinum.

Confirm by CT, MRI and Transesophageal echocardiography

Treatment :

Reduce cardiac contractility.

Reduce hypertension.

Maintain systolic BP 100-120 mmHg (sodium nitroprusside + beta blocker)

**if contraindicated use verapamil

Avoid direct vasodilator (hydralazine) increase shear stress.

Type B can be medically stabilized by oral hypertensive.

Respiratory causes of chest pain
Respiratory causes of
chest pain
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1
2
2

Pulmonary

embolism

Tension

pneumothorax

of chest pain 1 2 Pulmonary embolism Tension pneumothorax 3 4 Pneumonia Pleuritis or pleurisy
3 4 Pneumonia Pleuritis or pleurisy

3

4
4
3 4 Pneumonia Pleuritis or pleurisy

Pneumonia

Pleuritis or pleurisy

3 4 Pneumonia Pleuritis or pleurisy

Pulmonary embolism

(venous thromboembolism)

Cause : from venous thrombosis, clots break off and pass through the veins and the right side of the lung.

blood clot becomes lodged in a lung (pulmonary) artery, blocking blood flow to lung tissue, causes SOB and increase HR.

Inflammation of the tissue can cause pleuritic chest pain.

Features of pulmonary thromboembolism

Clinical presentation varies,depending on

number,size & distribution of emboli.

Symptoms : acute breathlessness, pleuritic chest

pain, hemoptysis, dizziness,

syncope.

Signs : pyrexia, cyanosis, tachypnoea, tachycardia, hypotension, raised JVP, pleural

rub, pleural effusion.

Pneumothorax

Definition: is when there is

air builds up in the pleural sac, between the outside

of the lung and the inside

the chest wall. The air can come from the lung or from outside the body if there is a chest injury.

lung and the inside the chest wall. The air can come from the lung or from

Classification of

Pneumothorax

a)

Based on general terms :

i.

Closed no opening from ext. chest ( in crashes, falls, MVAs)

ii.

Open opening from external chest wall into pleura (stabbing, gunshots)

iii.

Tension

b)

Based on origin :

i.

Spontaneous - Primary - Secondary

i.

Iatrogenic puncture or laceration of visceral pleural during medical treatment.

Clinical Manifestations of

Pneumothorax

Symptoms

Signs

sudden-onset

unilateral pleuritic

chest pain

Reduced expansion

Dyspnea

Hyperresonance

Diminished breath

Pleuritic chest pain/pleurisy : Sharp chest pain, aggravated by

deep breathing or

coughing. On examination, chest expansion may be restricted & pleural

sounds

Cyanosis

Tracheal Deviation

Investigation CXR-sharply defined edge of the deflated lung with complete translucency(absenc e of lung marking).It
Investigation
CXR-sharply defined
edge of the deflated
lung with complete
translucency(absenc
e of lung marking).It
also can show the
extent of any
mediastinal
displacement and
reveal any pleural
fluid or underlying
pulmonary disease.
CT scan-for small
pneumothorax that
CXR can miss exact
location

Management

* depends on whether it is a primary or secondary

pneumothorax

General mx : - high fowlers position - O2 therapy if needed - rest to decrease O2 demand

Evacuate the air : - chest tube insertion - surgery (thoracotomy)

Promote pleural symphysis : - chemical or medication is

injected into

the chest cavity - produces inflammatory reaction

between lungs and inner

chest cavity

PNEUMONIA

DEFINITION:

Acute lower respiratory tract illness associated with fever, symptoms and signs in the chest.

Pneumonia is also an inflammation of the parenchyma of the lung.

It is usually caused by bacteria but can also be caused by viruses and fungi.

TYPES OF PNEUMONIA
TYPES OF PNEUMONIA

CLINICAL FEATURES

1.

Chest pain:

This is commonly pleuritic in nature and is due to inflammation of pleura. A pleural rub may be heard early on in this illness. pain is usually at the mid chest.

Sharp or stabby chest pain ( might feel it more when cough or take a

deep breath.)

2.

Cough

3.

Breathlessness

4.

Fever

5.

Extrapulmonary features:

Myalgia, arthralgia and malaise are common, particularly infections are caused by Legionella and Mycoplasma.

Investigations

1. Full blood count

2. Blood C&S

3. Sputum culture and gram stain.

4. Pulse oximetry and ABG analysis

General management

ofpneumonia

1.

Antibiotic 3

rd

gen. cephalosporin

2. IV fluids if dehydration, shock

3. Oxygen in

4. Bed rest with patient sitting up

5. Analgesia

Oxygen in 4. Bed rest with patient sitting up 5. Analgesia Paco2 Complication: 1. general: ◦

Paco2

Complication:

1.

general:

Respiratory failure

Sepsis-multisystem failure

2. local:

Pleural effusion

Empyema

Lung abscess

PLEURISY / PLEURITIS

The pleura becomes inflamed

usually the lung slides along the chest wall

when a deep breath is taken.

On occasion, viral infections can cause the pleura to become inflamed

Instead of sliding smoothly, the 2 linings

scrape each other, causing pain.

GI causes of chest pain
GI causes of chest pain
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2
3
3
4
4

GERD

Oesophageal spasm

Pancreatitis

Peptic ulcer

4 5 6 7 7 Oesophagitis Mallory – Weiss syndrome Common bile duct obstruction Hiatal

4

5
5
6
6
7
7
7
7

Oesophagitis

Mallory Weiss syndrome

Common bile duct obstruction

Hiatal hernia Achalasia
Hiatal hernia Achalasia
Hiatal hernia Achalasia

Hiatal hernia

Achalasia

Hiatal hernia Achalasia
7 Oesophagitis Mallory – Weiss syndrome Common bile duct obstruction Hiatal hernia Achalasia

Gastro-oesophageal reflux

(GERD)

esophageal sphincter(LES) lead to abnormal reflux of gastric contents into the esophagus

causing mucosal damage.

Is digestive disorder that affects the lower

Often chronic and relapsing

the esophagus causing mucosal damage. ◦ Is digestive disorder that affects the lower ◦ Often chronic

Symptoms

Symptoms 1. Esophageal : ◦ Heartburn ◦ Dysphagia ◦ ◦ ◦ Belching 2. ◦

1.

Esophageal:

Heartburn

Dysphagia

Belching

2.

Cough

Wheezing

Hoarseness

Sore throat

Odynophagia

Regurgitation

Extraesophageal:

Globus sensation

Non-cardiac chest pain(NCCP)

(Burning pain behind the sternum associated with epigastric pain, dull in nature or sharp and related to meals)

INVESTIGATIONS

Barium swallow

Endoscopy

Ambulatory pH monitoring

Impedance-pH monitoring

Esophageal manometry

TREATMENT

NON-PHARMACOLOGICAL:

Weight reduction if overweight

Avoid clothing that is tight around the waist

Modify diet Eat more frequent but smaller meals Avoid fatty/fried food, peppermint, chocolate, alcohol, carbonated beverages, coffee and tea, onions, garlic.

Stop smoking

Elevate head of bed 4-6 inches

Avoid eating within 2-3 hours of bedtime

PHARMACOLOGICAL:

1.

Antacid

2.

Proton pump inhibitor

3.

Histamine H2-Receptor Antagonists

Peptic Ulcer Disease

Pathophysiology:

1. H Pylori - increases acid

secretion

2. NSAIDs - impairs mucosal defences

3. Smoking - Increase risk & cause

complication and slow healing of

ulcer

2. NSAIDs - impairs mucosal defences 3. Smoking - Increase risk & cause complication and slow

Clinical features:

1.

Burning epigastric pain - patient can point the pain to the epigastrium

2.

Nausea & vomiting

3.

Anorexia & weight loss

1.

Investigations:

Non invasive

Serology

C-urea breath tests

Fecal antigen test

2. Invasive biopsy

Histology

Rapid urease tests

Microbiological culture

Management:

1.

H. Pylori Eradication

2.

General measures: Avoid smoking, NSAIDs, & aspirin should be avoided

3.

Maintenance treatment: Not needed in successful

eradication

4.

Surgical treatment: partial gastrectomy

Complication:

Perforation

Gastric outlet obstruction: The presentation is with nausea, vomiting and abdominal distension. Large quantities of gastric content are often vomited, and food eaten 24 hours or more previously may be recognised.

Acute Pancreatitis:

Common causes:

1. Gallstones

2. Alcohol

3. Idiopathic

4. Post endoscope retrograde cholangio-

pancreatography (ERCP)

Clinical Features:

Typical Feature:

Severe and constant upper abdominal pain of increasing intensity.

Radiates to the back

Associated with nausea and vomiting

Epigastric tenderness

In severe case:

Hypoxic

Grey Turner's sign

Cullen's sign

Investigations:

*Raised serum amylase *Raised serum lipase *U/S or CT pancreatic swelling, gallstones, biliary obstruction *X-ray to exclude other causes

Management:

1.

Opiate analgesics should be given to treat pain and hypovolaemia should be corrected using normal saline or other crystalloids.

2.

Hyperglycaemia should be corrected using insulin, but it is not

usually necessary to correct hypocalcaemia by intravenous calcium injection, unless tetany occurs.

3.

Nasogastric aspiration is only required if paralytic ileus is present.

4.

Enteral feeding, if tolerated, should be started at an early stage in

patients with severe pancreatitis because they are in a severely catabolic state and need nutritional support

5.

Patients who present with cholangitis or jaundice in association with severe acute pancreatitis should undergo urgent ERCP to diagnose

and treat choledocholithiasis

Esophageal Motility

Disorders

Impaired esophageal motility occurs when the muscle contractions of

the esophagus (peristalsis) which is responsible for pushing food into

the stomach is either too weak or too strong, delayed or uncoordinated.

It may also be hampered by partial or complete obstruction of the esophagus.

In terms of slow motility, the ball of food (bolus) causes prolonged stretching of the esophagus and this triggers pain.

Some of the causes of impaired esophageal motility :-

- achalasia

- diffuse esophageal spasm

- esophageal cancer or compressions from surrounding structures

like the heart, aorta or tumors outside of the esophagus.

Musculoskeletal causes of chest pain
Musculoskeletal causes of chest pain
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Costochondritis

Trauma (Rib fracture,

intercostal muscle injury )

COSTOCHONDRITIS

Acute inflammation of the costal cartilage.

Associated with scoliosis, ankylosing spondylitis,

rheumatoid arthritis and infection of the costoternal joint.

CF : Pain/tenderness on the sides of the sternum,

worsened with coughing/deep breathing/exercise. Severe inflammation associated with painful swelling is referred to as TIETZE'S SYNDROME.

Treated with NSAIDs (ibuprofen) or analgesics (acetaminophen), opioids, TCA or corticosteroids if patient is unresponsive to NSAIDs.

Neurogical causes of chest pain
Neurogical causes of chest pain
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1
2
2

Herpes zoster (Shingles)

Thoracic outlet syndrome

HERPES ZOSTER

Shingles can present as acute chest pain.

The pain is usually burning and unilateral, following the dermatomes.

Chest pain from Shingles can

occur before the onset of vesicles thus making a reliable diagnosis difficult.

 Chest pain from Shingles can occur before the onset of vesicles thus making a reliable