APPROACH TO CHEST PAIN.pptx cause evaluation

Includes all causes

1. APPROACH TO CHEST PAIN Dr.SHALINI TOM

2. Symptoms characterized by discomfort,pressure ,tightness or pain in the chest area It can be described as Sharp or Stabbing Dull or aching Burning or squeezing Radiating pain

3. We can triage the patient with a/c chest discomfort around 3 categories MI Other cardiopulmonary causes like myopericardial disease aortic emergencies and pulmonary conditions Non cardiopulmonary causes

4. Approach to chest discomfort When a patient presets to ER with acute chest pain Initially asses clinical stability –Vitals Principle concerns for ACS,Acute aortic syndrome,Pulmonary embolism,Tension Pneumothorax,Pericarditis with tamponade,Esophageal rupture

5. Ask for proper history Pattern ,quality and location of pain Aggrevating and releving factors Radiation of pain Any assoaciated symptoms Duration of pain,Onset Any similar previous episodes

6. Example- Substernal pain with radiation to neck jaw and shoulder a/w diaphoresis-likely MI ,Discomfort builds over minutes- inc by activity and mitigated by rest Pain that is highly localized which can be demarcated by the tip of one finger is highly unusual for angina Retrosternal pain s/o esophageal causes Sudden tearing pain radiates to back between shoulder blades s/o a/c aortic syndrome-immediately reaches its intensity

7. Aggrevating and relieving factors In MI – Patient prefer to sit-subsides on taking nitrates-esophageal spasm also Musculoskeltal -Intensity changes with change in position-local tenderness Pericarditis-Pain worse in supine –gets relieved by sitting up and leaning forward GI- aggrevates with food intake

8. MI a/w diaphoresis dyspnea fatigue, blood tinged frothy sputum in severe heart failure Pulmonary embolism/Pneumothorax-Sudden onset of dyspnea a/w chest pain –also may be a/w hemodynamic instability From past medicl history-asses risk fo ACS and thromboembolism H/o CTD like Marfans –Inc risk of pnemothorax

9. Physical Examination General:Patient may be pale cyanotic diaphoretic in case of MI Levings sign Uncontolled BP- inc risk of dissection Body habitus-Marfan Tachycardia and hypotension-a/w cardiogenic shock/massive PE/tamponade/tension pneumothorax Tachypnea and hypoxemia-s/o pulmonary cause

10. Systemic Examination Resp: u/l absence of breath sound-pneumothorax-features of pneumonia Cardiac- raised JVP- right heart failure S3s4+ in systolic and diastolic dysfunction Murmer of AR a/w aortic dissection-extended to valve Pericardial friction rub P/A- look for any localized tenderness Localised tenderness in costochondritis Extremities- pulse deficits-c/c arthromatous plaque-CAD risk a/c UL ischemia with loss of pulse and pallor-dissection

11. Investigations ECG In first 10 mints itself---ST segment elevation ST seg depression and T inv atleast 0.2mv in NSTEMI Serial ECG in suspected cases Pul embolism –S1Q3T3 pattern with RAD Pericarditis- Difuse lead involvement –concave ST elevation-distinguishing feature from ACS

12. CXR -For pulmonary pathologies Opacities in pneumonia Bat wing appearance in pulmonary edema Widening of mediastinum in aortic dissection Hampatons hump or westermark’s sign in PE Pericardial calcification in c/c pericarditis

13. Cardiac biomarkers Hstrop I Dx of MI is reserved for a/c myocardial injury that is marked by rising/falling pattern atleast one value exceeding the 99 th percentile reference limit BNP/D-dimer

14. Role of decision aids HEART SCORE EDACS SCORE Helps to categorize patients for probability of a major CVS event

15. Role of CT Angiograpghy Come serially after cardiac biomarkers Negative predictive value of a finding of no significant stenosis or coronary plaque Can exclude aortic dissection,pericardial effusion and pulmonary embolism

16. Stress nuclear perfusion imaging or stress echocardiography Abnormal rest perfusion imaging cannot discriminate between old and new myocardial defects Exercise ECG Echo- RWMA-complications of MI and tamponade

17. Gadolinium enhanced cardiac MRI Early detection of MI Defining areas of necrosis

18. Thank you