Chest pain(CP)powerpoint presentation.pdf

Chest pain(CP)powerpoint presentation.pdf

1. Approach To A Patient
With Chest Pain
SWAPNIL PARVE, MD
DEPT. OF PRIMARY CARE & GENERAL PRACTICE
KAZAN STATE MEDICAL UNIVERSITY

2. OutlineMISC.
Definition
Epidemiology
Causes of Chest Pain
Initial Approach
Management in Primary Care
Cases

3. Definition
uUnpleasant or uncomfortable
sensations in anterior chest
uAcute vs Chronic
Circulation. 2021 Nov 30;144(22):e368-e454.

4. European Heart Journal (2002) 23, 1153–1176
Epidemiology
Circulation. 2021 Nov 30;144(22):e368-e454.

5. Causes of Chest Pain

6. Cardiac
Causes of
Chest Pain
uCAD: ACS & CCS
uPericarditis & Myocarditis
uAortic Dissection

7. Acute Coronary Syndrome (ACS):
u15-25% of chest pain in ED
uSubsternal “pressure” (⊕LR 1.3) → neck, jaw, arm (⊕LR 1.3 –2.6)
uSharp, pleuritic, positional, or reproduced all with ⊕L.R. ≤ 3.5
uDiaphoresis (⊕LR 1.4), dyspnea (⊕LR 1.2). Associated with
exertion (⊕LR 1.5 –1.8)͌Prior MI (⊕LR 2.2), ↓ with NTG or rest;
however, not reliable indicator of angina1
u±ECG Δs: ST Elevation, ST Depression, T-wave Inversion, Q wave,
u±↑ Troponin
1Diercks et al. Changes in the Numeric Descriptive Scale for Pain After Sublingual Nitroglycerin Do Not Predict Cardiac Etiology of Chest Pain. Annals EM. 2005;45:581)

8. Chronic Coronary
Syndromes (CCS):
1.Stable Angina
2.Asymptomatic angina
3.Ischemic
Cardiomyopathy
4.Prinzmetal’s&
Microvascular angina
5.Patients with a long-
standing diagnosis of
CCS
Clinical Classification of Chest Pain/Angina
Typical Angina
(Definite)
Meets the following 3
characteristics:
1.Constricting discomfort in
the front of the chest or in
the neck, jaw, shoulder, or
arm;
2.Precipitated by physical
exertion;
3.Relieved by rest or nitrates
within 5 min.
Atypical Angina
(Probable)Meets two of the above
Non-Anginal Chest
PainMeets none of the above
Eur Heart J. 2020 Jan 14;41(3):407-477.

9. CCS:
1.Stable Angina
2.Asymptomatic angina
3.Ischemic
Cardiomyopathy
4.Prinzmetal’s&
Microvascular angina
5.Patients with a long-
standing diagnosis of
CCS
Eur Heart J. 2020 Jan 14;41(3):407-477.

10. Pericarditis
&
Myocarditis
•sharp pain → trapezius
•↑ with respiration
•↓ with sitting forward
•±Pericardial friction rub
•Δs: (diffuse ST Elevation & PR ↓,
opposite in aVR
•±Pericardial effusion
Pericarditis
•same as above +
•↑ Troponins and
•±signs and symptoms of CHF and ↓
Ejection Fraction
Myocarditis

11. MUSCLES OF
THE BACK
Image credit: Medical gallery of Mikael Häggström 2014

12. Pericardial Friction Rub
Video credit: physicaldiagnosispdx.com

13. Pericarditis
Source: www.litfl.com

14. Aortic Dissection
uSudden onset severe tearing,
knifelike pain (absence ⊖LR 0.3)
u±Asymmetric (>20 mmHg) BP or
pulse (⊕LR 5.7)
uFocal neuro deficit (⊕LR >6),
uAortic Insufficiency
uCXR: widened mediastinum
(absence ⊖LR 0.3)
uFalse lumen on imaging
KlompasM. Does This Patient Have An Acute Thoracic Aortic Dissection. JAMA. 2002;287:2262Case courtesy of A.ProfFrank Gaillard, Radiopaedia.org, rID: 8886
CC BY-SA 4.0
Case courtesy of Dr Vincent Tatco, Radiopaedia.org, rID: 48452

15. Pulmonary
Causes of
Chest Pain
uPneumonia
uPleuritis
uPneumothorax
uPulmonary Embolism

16. Pneumonia
uPleuritic
uFever
uDyspnea
uCough
uSputum
u↑ RR, crackles
uCXR infiltrate
Case courtesy of Dr SajoschaSorrentino, Radiopaedia.org, rID: 14979.
CC BY-SA 4.0

17. Pleuritis (Pleurisy)
uSharp pleuritic pain
u±Pleuritic friction rub
Video credit: physicaldiagnosispdx.com

18. Pneumothorax
uSudden onset
uSharp pleuritic
pain
uHyperresonance,
↓ Breath Sounds
uPTX on CXR
Source: https://upload.wikimedia.org/wikipedia/commons/9/97/Rt_sided_pneumoD.jpg

19. Pulmonary Embolism
uSudden onset pleuritic
pain
u↑ RR & HR
u↓ SaO2
uECG Δs: Sinus
Tachycardia, REA, RBBB,
SIQIIITIII, T-wave Inversion in
V1–V4, occasional ST
Elevation in V1–V3
u⊕CT angiography or V/Q
u±↑ Troponins
Saddle PE

20. Source: www.ecgcases.com
Case courtesy of Dr Sam Ghali. Twitter: @EM_RESUS

22. Diagnosis: PE
Eur Heart J. 2020 Jan 21;41(4):543-603

23. GI Causes of
Chest Pain
uEsophageal reflux
uEsophageal spasm
uMallory-Weiss
uBoerhaavesyndrome
uPUD
uBiliary disease
uPancreatitis

24. Esophageal Reflux
uSubsternal burning
uAcid taste in mouth
uWater brash
u↑ by meals, recumbency
u↓ by antacids
uUpper GI endoscopy
uManometry
upH monitoring
Source: BruceBlaus(https://commons.wikimedia.org/wiki/File:GERD.png),
https://creativecommons.org/licenses/by-sa/4.0/legalcode

25. Esophageal Spasm
uIntense substernal pain
u↑ by swallowing
u↓ by NTG/CCB
uManometry

26. Esophageal Tears & Ruptures
Mallory Weiss
uEsophageal tear precipitated
by vomiting
u±Hematemesis
uEsophagogastroduodenoscopy
BoerhaaveSyndrome
uEsophageal rupture
precipitated by vomiting
uSevere pain, ↑ w/ swallowing
uPalpable SC emphysema
uCT: Mediastinal air on chest CT

27. Esophageal Tears & Ruptures

28. Peptic Ulcer Disease
uEpigastric pain
uRelieved by antacids
u±Gastrointestinal bleed
uEsophagogastroduodenoscopy
u±H. pylori test

29. Biliary Disease
uRUQ pain
uNausea/vomiting
u↑ by fatty foods
uRUQ Ultrasound
uLiver Function Tests

30. Pancreatitis
uEpigastric/back
discomfort
u↑ amylase &
lipase
uCT Abdomen
Source: startradiology.com
TheCTscan in a 75-year-old man with acute interstitial
pancreatitis. Source: uptodate.com

31. Miscellaneous
Causes of
Chest Pain
uCostochondritis
uHerpes Zoster
uAnxiety

32. Costochondritis
uLocalized sharp
pain
u↑ with movement
uReproduced by
palpation or
maneuver
Horizontal flexion test for the diagnosis of
costosternalsyndrome. Source: clinicalgate.com

33. Costochondritis
uLocalized sharp
pain
u↑ with movement
uReproduced by
palpation or
maneuver
Crowing rooster maneuver for costochondritis courtesy Ashley Hicks

34. Herpes Zoster
uIntense unilateral pain
uPain may precede
dermatomal rash
uDermatomal rash
uSensory findings
Fisle(https://commons.wikimedia.org/wiki/File:Herpes_zoster_chest.png), „Herpes zoster
chest“, https://creativecommons.org/licenses/by-sa/3.0/legalcode

35. u“Tightness”
uDyspnea
uPalpitations
uOther somatic symptomsLeft picture: health.harvard.edu
Right picture: File:LosAngeles, California. Lockheed Employment. A worried applicant
waiting to be interviewed -NARA -532210.tif

36. Initial
Approach
FOCUSED
HISTORY
TARGETED
EXAM
12-LEAD
ECG
IMAGINGCARDIAC
BIOMARKERS

37. Focused History: Symptom Attributes
OLDCARTS
uOnset
uLocation
uDuration
uCharacter
uAggravating/Alleviating factors
uRadiation
uTime
uSeverity
SOCRATES
uSite
uOnset
uCharacter
uRadiation
uAssociated symptoms
uTime/duration
uExacerbating/relieving factors
uSeverity

38. Targeted Exam
uVital signs, including BP in both arms
uCardiac gallops, murmurs, or rubs
uSigns of vascular disease
ucarotid or femoral bruits
u↓ pulses
uSigns of heart failure
uLung & Abdominal exam
uChest wall exam for reproducibility of
pain
Carotid
Bruit
SandercockPAG,KavvadiaE. Practical Neurology2002;2:221-224.

39. 12-lead ECG
uObtain within in 10min
uCompare with priors & obtain
serial ECGs
uConsider posterior leads (V7–
V9) to check for posterior STEMI
uIf hx conforms with ACS but
standard ECG unrevealing or
ST ↓ V1–V3 (anterior ischemia
vs posterior STEMI and angina
is hard to relieve or R/S wave
ratio >1 in V1–V2
Source: emergencymedic.blogspot.com

40. Imaging
uCoronary CT angiography:
u50% patients with acute chest pain and low to
intermediate likelihood of ACS free of CAD by CT and
have no ACS
u∴good for r/o not r/i
uOther imaging (echo, PECTA, etc.) as indicated based on
history, physical exam and initial testing
Hoffmann et al. Coronary Computed Tomography Angiography for Early Triage of Patients With Acute Chest Pain. JACC. 2009;53:1642)

41. Cardiac biomarkers
Cardiac enzymeStarts PeaksStayselevated
Myoglobin2 hrs24 hrsUsed to R/o
CK–MB6 hrs24 hrs48-72 hrs
TroponinT6 hrsHigh SP & SN7-10 days
TroponinI6 hrsHigh SP & SN7-10days
AST (SGOT)6-10 hrs12-48hrs3-4 hrs
LDH8-12 hrs2-3 days5-10 days

42. Management

43. Management
uPatients with ACS and Aortic Dissection should be referred to the
nearest ED/CathLab/CT Surgery center
uReferral best done by direct phone call to the hospital while
ambulance transport is arranged
uReferral documentation should include the patient’s EKG and other
lab investigations
uTension pneumothorax is an Emergency
uTreatment: Immediate needle decompression
uInsert a large-bore (eg, 14-or 16-gauge) needle into the 2nd intercostal
space in the midclavicular line. Gush of air confirms

44. ED
Management
of Chest Pain

47. Case -1
uCC: Chest pain
u64 year old man presents with 5 hours
of SS chest pressure associated with
SOB, nausea and diaphoresis. Gradual
onset while shoveling the snow.
Improved with rest.
uPMH: HTN, DM
uPhysical Exam:
§Gen: Nontoxic appearing,
apprehensive, mildly diaphoretic
§Vitals: 37.5ºC, RR16, HR 100, BP 160/95
§CVS: RRR, Normal S1, S2, no M/R/G
§Resp: CTAB, easy respirations
§Abd: Soft, NTND
§Ext: No calf tenderness or swelling, no
edema, strong distal pulses

48. Case -1

49. Case -1

50. Case -2
uCC: Stroke
u51 year old woman brought in by
EMS with acute onset of right sided
weakness and aphasia.
uPMH: HTN
uPhysical Exam:
§Gen: Somnolent, diaphoretic
§Vitals: 37.5ºC, RR16, HR 110, BP
180/110
§CVS: Tachy, Normal S1, S2, no M/R/G
§Resp: CTAB, easy respirations
§Abd: Soft, NTND
§Ext: No calf tenderness or swelling, no
edema, weak distal pulses
§Neuro: Right leg/arm 4/5 strength,
+expressive aphasia

51. Case -2

52. Case -2

53. Case -3
uCC: Chest pain
u40 year old woman brought in by
EMS with acute onset pleuritic right
sided chest sharpness associated
with SOB.
uPMH: HTN
uPhysical Exam:
§Gen: Well appearing, mildly
uncomfortable
§Vitals: 38ºC, RR 22, HR 120, BP 150/85
§CVS: RRR, Normal S1, S2, no M/R/G
§Resp: CTAB, easy respirations
§Abd: Soft, NTND
§Ext: No calf tenderness but mild left-
sided swelling, no edema, strong
distal pulses

54. Case -3

55. Case -3

57. Thank you!