Chest pain

chest pain related to cardiovascular and other systemic dysfunction

1. Chest pain Presenter:- Rekha Marbate [CVRS]

2. Content: Types of Chest Pain Types of Cardiogenic Pain Type of Non-cardiogenic Pain

3. Introduction: Because heart disease is the leading cause of death all over world, it is important to diagnose a cardiac etiology in patients presenting with acute chest pain . But don’t forget that certain non-cardiac causes may be life threatening as well .

4. Type of Chest Pain References: Textbook of Internal Medicine by H arrison’s Cardiac Cause A] Ischemic B] Non-ischemic Non-Cardiac Cause A] Gastro- esophagial B] Pulmonary C] Musculoskeletal Dermatological cause A] Herpes Zoster

5. • Non-ischemic : causes of chest pain A] Pericarditis , B ] Dissecting Aortic Aneurysm , C] Mitral Valve Prolapse. Ischemic: causes of chest pain: A]Myocardial Infarction (MI), B] CAD (Angina pectoris), C] Aortic Stenosis, D] Coronary Vasospasm, E] Hypertrophic Cardiomyopathy.

6. Presentation of ischemic Chest pain

7. Myocardial infarction Anterior MI’s often present with chest pain and dyspnea due to left ventricular involvement. Inferior MI’s often present with chest pain, Nausea, vomiting, diaphoresis and singultus (hiccups) due to possible Vagus nerve involvement. Lateral MI’s often present with chest pain and left arm pain.

8. Coronary Artery Disease (CAD) Caused by - insufficient myocardial oxygen supply. Pain is transient or episodic. Frequently described as heavy pressure occurring after exertion or stress or emotional upset. Associated symptoms: diaphoresis, Nausea, vomiting and weakness . CAD chest pain is often relieved by NTG.

9. Aortic Stenosis Frequently coexists with CAD. Chest pain is usually on exertion. Assess for systolic murmur, unusual carotid pulse.

10. Hypertrophic Cardiomyopathy Assess for dyspnea with chest pain. Syncope can be typical with post exertion . Listen for loud systolic murmur . Pain complaints are similar to angina.

11. Coronary Vasospasm Also called “ Prinzmetal’s angina” or “variant angina ”. Caused by vasospasm of coronary arteries - drug induced vasoconstriction [ example: Cocaine and other stimulants] More common in females younger than 50 . Typically occurs early in Morning. Chest pain is usually recurrent , most often while at rest.

12. Dissecting Aortic Aneurysm Typically presents with complaints of severe anterior chest pain, radiating to upper back. HTN is usually present . Listen for murmur and radial pulse inequality.

13. Pericarditis Causes; viral infection, TB, autoimmune disease and post MI complication . Chest pain is pleuritic , usually alleviated by leaning forward –exacerbated by lying down . Listen - systolic murmur. Friction rub is the hallmark for Pericarditis.

14. Mitral Valve Prolapse Can present with chest pain, usually sharp near the apex . Associated symptoms: dyspnea , fatigue and palpitations . Pain is reduced by lying down . Listen for systolic murmur , heard best at the apex . Happens most often with thin females.

15. Non Cardiogenic Chest Pain

16. Gastro esophageal Pain Roughly 42% of patients presenting with acute chest pain, in whom MI is ruled out, GE induced chest pain. Causes: Esophagitis , esophageal perforation esophageal spasm, reflux disease, PU disease , Pancreatitis, and Cholesystitis. •Esophageal spasm pain can be relieved by NTG!

17. Pulmonary Pain Chest pain from pulmonary disease is typically “ pleuritic ” [ the pain varies with the respiratory cycle] . increases during inspiration and is made worse by coughing , deep breathing or movement. Pleuritic pain is most often caused by lower respiratory infections. Other causes: spontaneous pneumothorax , pulmonary embolism, pneumonitis, bronchitis or neoplasm .

18. Musculoskeletal Pain Roughly 28% of patients presenting with chest pain, in whom an MI has been ruled out , suffer from musculoskeletal or chest wall pain. Causes - costocondritis rib fracture and myalgia . Pain is usually reproducible upon palpation . Passive extension , flexion and rotation of the cervical and thoracic spine can be helpful in reproducing musculoskeletal chest pain.

19. Herpes Zoster (Shingles) 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.

20. Summary It is essential to obtain a thorough assessment : Characteristics of pain , location, duration, radiation , quality and accompanying symptoms. Carefully observe for associated symptoms : Heavy pressure or squeezing in the chest area, episodic or exertional triggers, diaphoresis, Nausea and vomiting , weakness, anxiety and palpitations. Chest pain with diaphoresis is the most common presentation with an acute MI.