Differential diagnosis of chest pain

This presentation includes important differential diagnosis of chest pain

1. بسم الله الرحمن الرحیم

2. Differential Diagnosis of Chest Pain

3. Common Causes of Chest Pain Cardiac Aortic Esophageal • Angina pectoris Dissecting aneurysm Reflux oesophagitis • Myocardial infarction Lung and pleura (respiratory) Diffuse esophageal spasm • Myocardial infarction • Pleurisy Musculoskeletal Mitral valve prolapse • Pneumothorax Hyper adrenergic state Pericarditis • Pulmonary embolism Cocaine intoxication Hypertrophic Cardiomyopathy Intra-abdominal conditions Anxiety • Aortic stenosis/regurgitation

4. Respiratory chest pain Respiratory chest pain most commonly arises from parietal pleura (including the diaphragmatic pleura), chest wall and the mediastinal structures . Lung parenchyma and visceral pleura are insensitive to most painful stimuli. The peripheral part of the diaphragm and costal portion of parietal pleura are innervated by somatic intercostal nerves, thus pain felt in these areas is often localized to cutaneous distribution of involved neurons over the adjacent chest wall. Central portion of diaphragm is innervated by phrenic nerve; therefore central diaphragm irritation is referred to ipsilateral shoulder tip or even the neck.

5. Angina Pectoris Pain is usually retrosternal in location and brought on by exertion. It is relieved by rest and sublingual nitrates. Pain seldom lasts more than 20 minutes. Character of the pain is squeezing, crushing or aching. Pain commonly radiates to left arm and less commonly to right arm, throat, back, chin and epigastrium. Often the pain comes on while walking uphill after a heavy meal ,on a cold winter day .

6. physical signs of myocardial ischemia The presence of one or more of signs during an attack of pain may be suggestive. Rise in blood pressure and heart rate Fourth heart sound Murmur of mitral regurgitation due to papillary muscle dysfunction Dyskinetic segment around the apex Paradoxical splitting of second heart sound Relief of pain by carotid sinus massage (Levine test)

7. investigations Salient investigations include Electrocardiography Echocardiography Exercise testing Coronary angiography.

8. Myocardial Infarction A history of previous episodes of angina pain with recent worsening may be present. The pain of infarction is similar in character and distribution is similar to angina pain. But it is more severe, prolonged (lasts more than 20 minutes), persisting at rest and not responding to nitrates. There may be vomiting, anxiety and a feeling of impending death. One or more of the physical signs of myocardial ischemia may be present (refer above). Other common physical signs include pallor, sweating, cyanosis, hypotension, arrhythmias (most commonly ventricular ectopic beats), pericardial friction rub, signs of congestive heart failure and cardiogenic shock. Salient investigations include serial electrocardiograms and cardiac injury enzymes .

9. Mitral Valve Prolapse • History of non-specific chest pain is atypical. • Physical findings include a mid-systolic click and a late systolic murmur varying with posture and respiration. • Echocardiography can confirm the diagnosis .

10. Pericarditis • Pericardial pain is felt retrosternally to the left of the sternum or in the left or right shoulder. Pain is aggravated by deep breathing and rotating the trunk. It is worse in the lying down position and is relieved by sitting up and leanig forwards . • Physical findings include the characteristic pericardia! friction rub and evidence of pericardial effusion. • Salient investigations include electrocardiography and echocardiography.

11. Dissecting Aneurysm of Aorta • Sudden onset of severe, sharp, stabbing or tearing pain over the anterior chest radiating to the back is the usual history. Dissection is more common in hypertensive males. • Physical findings include asymmetry of brachial, carotid or femoral pulses, inappropriate bradycardia and an early diastolic murmur or aortic regurgitation. Neurological features (hemiparesis, paraparesis , etc.) may develop due to carotid artery or spinal artery involvement. • Salient investigations include chest radiography, echocardiography, CT scanning and aortography.

12. Pleurisy • Can occur due to inflammation, infection, neoplastic infiltration or trauma. • Pleuritic pain is a well-localized pain that is cutting, stabbing or tearing in character. It is often aggravated by coughing, sneezing and deep inspiration . Commonest sites of pleuritic pain are axillae and beneath the breasts. • Characteristic sign is a pleural friction rub.

13. Pneumothorax • History of sudden onset dyspnea and chest pain following strenuous exertion or coughing. More common in tall, thin, young males. • Clinical features may include cyanosis, tachycardia, hypotension and distended neck veins. Respiratory system examination reveals shift of the mediastinum (trachea and apex beat) to the opposite side, reduced chest movements, hyper-resonant percussion note, diminished vocal fremitus and vocal resonance, and markedly reduced to absent breath sounds . • Diagnosis is confirmed by chest radiography.

14. Acute Pulmonary Embolism • Characteristic clinical setting may be obvious, e.g. prolonged immobilization, recent surgery, previous history of thromboembolism or intake of oral contraceptives. • Clinical examination may reveal calf muscles tenderness, tachypnea and tachycardia. Respiratory system examination may show a variety of physical signs like crepitations over the involved area, pleural rub or pleural effusion. Cardiovascular system examination may show evidences of acute right ventricular failure including a right-sided third heart sound, murmur of pulmonary regurgitation or increased intensity of the pulmonary component of second heart sound . However, examination may be entirely normal. • Salient investigations include chest radiography, electrocardiogram, echocardiography, helical CT scan and radionuclide ventilation/perfusion scan.

15. Reflux Oesophagitis • Characteristic history is "heart burn", felt as a burning pain behind the sternum, radiating to the throat. It typically occurs after heavy meals and is brought on by bending, lifting or straining. Pain may occur on lying down in bed at night but relieved by sitting up. Other symptoms of gastro- oesophageal reflux are odynophagia and regurgitation of gastric contents into the mouth. • Salient investigations include oesophagoscopy , barium studies and acid infusion studies. Often, a sliding hiatus hernia predisposes to reflux.

16. Diffuse Esophageal Spasm • Pain can mimic that of angina and is sometimes precipitated by exercise and relieved by nitrates. Usually the pain is related to food or drink intake. Dysphagia is often present. • Salient investigations include esophageal motility studies, barium studies and manometry.

17. Musculoskeletal Pain • Common causes of musculoskeletal pains are: • Intercostal myalgia • Costochondritis ( Tietze's syndrome) • Fracture of the ribs (cough, trauma) • Secondaries in the ribs • lntercostal neuralgias • Pain is usually well localised , variable in intensity and site, varying with posture and movement. • Usually associated with severe local tenderness .

18. Intra-Abdominal Conditions • Intra-abdominal conditions can occasionally present as chest pain. These include the following: • Acute pancreatitis • Acute cholecystitis • Perforated peptic ulcer