THE PPT seminar CHEST PAIN (1) (2).pptx

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1. CHEST PAIN PRESENTED BY- DR . RAJVARDHAN SINGH SISODIA ] GUIDED BY Dr.Kumar Girendra Sir (HOD & Prof.) Dr.Ishani Deshmukh Mam ( Asso . Prof.) Dr.Sunil Mukati Sir ( Asso.Prof .) Dr.Sudarshan Gupta Sir (AP) Dr.Ankit Agrawal Sir (AP) Dr.Sameer Vaidya Sir (AP) Dr.Azinkya Joshi Sir (AP)

2. CHEST PAIN A GENERAL TERM FOR ANY DISCOMFORT OR ACHING PAIN IN THORAX . IT CAN BE CARDIAC OR NON CARDIAC RELATED

3. VARIOUS CAUSES OF CHEST PAIN SOURCE:HARRISON’S 21 ST EDITION

4. PLEUROPULMONARY DISORDERS Pleurisy Infection Pulmonary embolism Spontaneous pneumothorax Sickle cell disease Familial Mediterranean fever Malignancy (e.g., mesothelioma) Pulmonary hypertension GASTROINTESTINAL DISORDERS Reflux esophagitis Esophageal motility disorders Cholecystitis Peptic ulcer disease Pancreatitis Disorders of intestinal motility SOURCE: MURRAY AND NADELS TEXTBOOK OF RESPIRATORY MEDICINE

5. INFLAMMATION OR TRAUMA OF THE CHEST WALL Rib fracture Muscle injury (myalgia) Infection Malignancy Herpes zoster infection CARDIOVASCULAR DISORDERS Angina pectoris Variant angina Myocardial infarction Aortic valve disease Mitral valve prolapse Hypertrophic cardiomyopathy Pericarditis Cocaine toxicity DISORDERS OF THE AORTA Aortic dissection

6. SOURCE:HARRISON’S 21ST EDITION

7. SOURCE: MURRAY AND NADELS TEXTBOOK OF RESPIRATORY MEDICINE

8. SITES OF REFERRED PAIN IN CHEST SOURCE: MURRAY AND NADELS TEXTBOOK OF RESPIRATORY MEDICINE

9. PLEURISY Pleurisy results from inflammation of the parietal pleura . Pleuritic pain is conveyed by somatic nerves. The parietal pleura that lines interior of the rib cage and covers the outer portion of each hemidiaphragm innervated by the neighboring intercostal nerves ; when pain fibers in these regions are stimulated, pleuritic pain is localized to the cutaneous distributions of the involved neurons over the chest wall. In contrast, the parietal pleura that lines the central region of each hemidiaphragm I innervated by fibers that travel with the phrenic nerves ; when this portion of the diaphragm is stimulated (e.g., by contiguous inflammation), the resulting pain is referred to the ipsilateral shoulder or neck . .

10. This pain referral arises because visceral afferent input carried by the phrenic nerve converges with somatic input carried by the supraclavicular nerves that innervate the skin of the shoulder (i.e., viscerosomatic convergence , visceral pain leading to referred sensations). Pain may be variously described as “ sharp,” “dull,” “achy,” “burning,” or simply a “catch.” There is a distinct relationship to breathing movements, and taking a deep breath typically aggravates pleuritic pain . Coughing and sneezing can cause intense distress. Movements of the trunk, such as bending, stooping, or turning in bed, worsen pleuritic pain, so patients often prefer the body position in which motion of the affected region is least.

11. D/D OF PLEURITIC PAIN An immediate onset of pleuritic pain suggests traumatic injuries or spontaneous pneumothorax . A sudden onset, often associated with dyspnea and tachypnea, characterizes pulmonary embolism . A slower but still acute onset over minutes to a few hours often heralds the development of community-acquired bacterial (typically pneumococcal) pneumonia, especially when accompanied by fever and chills . Recurrent acute pleuritic pain is a feature of familial Mediterranean fever . G radual onset over days or weeks, often associated with features of chronic illness, such as low-grade fever, weakness, and weight loss, suggests tuberculosis or malignancy

12. PULMONARY HYPERTENSION Persons with pulmonary hypertension may experience crushing or constricting substernal pain t hat at times radiates to the neck or arms, thus resembling the pain of myocardial ischemia. Pain from pulmonary hypertension has been reported in patients with conditions that are acute (e.g., multiple or massive pulmonary emboli) and chronic (e.g., Eisenmenger syndrome). In primary pulmonary hypertension, chest pain may be related to either (1) right ventricular ischemia because coronary blood flow is unable to meet the metabolic needs of the overloaded right ventricular muscle mass (2) compression of the left main coronary artery by the dilated pulmonary artery trunk.

13. Pleuritic ,Sudden onset with dyspnea Massive pulmonary emboli cause Severe and persistent substernal pain due to Distention of the pulmonary artery. Smaller emboli lead to pulmonary infarction can cause lateral pleuritic chest pain Hemodynamically significant pulmonary emboli may cause hypotension, syncope, and signs of right-sided heart failure. PULMONARY EMBOLISM

14. Clinical manifestation Symptoms Unexplaned dyspnea - Present in 90% Chest pain - 66% of patients with PE Cough Sudden onset Signs Tachycardia > 100 beats per minute Tachypnea > 20 breaths per minute Hypoxia < 95% on RA (no other cause) Lower extremity swellings Jugular venous distension Hemoptysis

15. PRIMARY SPONTANEOUS PNEUMOTHORAX CHEST PAIN : Sharp, unilateral Sudden onset with dyspnea Occurs in the absence of underlying lung disease. Typically results from apical pleural blebs. Risk factors: male sex, smoking, family history and marfan's syndrome. Symptoms are sudden in onset and dyspnea may be mild. Simple aspiration may be adequate treatment for an initial primary spontaneous Ptx . Recurrence typically requires thoracoscopic intervention.

16. Tietze syndrome, or idiopathic costochondritis Anterior chest-wall pain, aggravated by movement and deep breathing. Dull-achy, localized Reproducing the chest pain syndrome by direct pressure over the involved costochondral junction or the relief of pain after local infiltration with lidocaine, is a helpful diagnostic maneuver . Injuries to the ribs (fracture) and thoracic cage muscles (strain, tears, or hematoma) are common causes of localized chest pain INFLAMMATION OR TRAUMA OF CHEST WALL

17. Begin approximately 60 minutes after injection or inhalation of the substance and last for 120 minutes. The pain is most frequently substernal in location and pressure-like in character ; it may be accompanied by shortness of breath and diaphoresis Cocaine-induced chest pain is due to the combined effects of - 1] I ncrease in myocardial oxygen demand owing to an increase in heart rate and in systolic and mean arterial pressures and 2] Decrease in myocardial oxygen supply due to vasoconstriction of the epicardial coronary arteries. Nitroglycerin and calcium-channel blocking drugs (e.g., verapamil) constitute the treatments of choice COCAINE TOXICITY

18. Diffuse esophageal spasm Neuromuscular motor disorder of the esophagus. Age: more common in 50- 60 yrs old individuals. Pain is retrosternal ; can be burning, squeezing, or aching in quality; often radiates to the back, arms, and jaw. Pain as a result of dysphagia, and regurgitation of gastric contents, can last for minutes or hours, can be relieved by TNG, which also relaxes esophageal smooth muscle Reflux esophagitis Mucosal irritation:- failure of the lower esophageal sphincter to prevent regurgitation of highly acidic gastric contents. Heartburn and regurgitation occur after meals or ingestion of coffee or after postural changes .

19. PSYCHOGENIC CHEST DISCOMFORT Recurrent chest pain . Difficult to separate from angina pectoris, particularly when it occurs in patients with multiple risk factors for CAD or in otherwise asymptomatic patients of CAD. Most common psychogenic cause of chest discomfort : anxiety. Quality of Pain: sharp or stabbing, localized to the left infra mammary area(sharply circumscribed), extremely short duration (<1 min). At times, pain can persist for many hours. Associated symptoms- air hunger, circumoral paresthesias , globus hystericus, and multiple somatic complaints- suggest a neurasthenic personality .

20. PERICARDITIS ▪ Inflammation of pericardium due to infectious or non infectious cause. Visceral surface of the pericardium is insensitive to pain, as is most of the parietal surface. Therefore, noninfectious causes of pericarditis (e.g., uremia) usually cause little or no pain. In contrast, infectious pericarditis almost always involves the surrounding pleura, so patients typically experience pleuritic pain.

21. Clinical features Chest pain: Positional, Sharp and penetrating in quality. Pleuritic Either side; gradual onset; pain referred to trapezius . Cardinal diagnostic feature because of pleural association is, worsening by changes in body position ( relieved by leaning forward ); during deep inspiration. Central diaphragm receives its sensory supply from the phrenic nerve (C3 to C5 segments of the spinal cord), pain from infectious pericarditis is frequently felt in the shoulders and neck

22. ANGINA PECTORIS Chest pain or discomfort ("tightness," "pressure," "burning," "heaviness," "aching," "strangling," or "compression.") of cardiac origin. Results from a temporary imbalance between myocardial oxygen supply and demand. Angina pectoris should be considered a symptom and not a specific disease. Location: Retrosternal, tends to radiate to the neck, jaw, teeth, arms, or shoulders,

23. Classically, the discomfort is induced by exercise, emotion, after meals or cold weather or spontaneously at rest Walk-through phenomenon :- Occasionally, angina will dissipate despite continued exercise. Warm up phenomenon:- chest discomfort will not occur when a second exercise effort is undertaken that previously produced. Due to opening of functioning coronary arterial collaterals during the initial myocardial ischemia. [Ischemic preconditioning] The pain of acute myocardial infarction is similar in location to that of angina pectoris but is typically much more severe in intensity, is not relieved by rest or nitroglycerin and is frequently associated with profuse sweating, nausea, dyspnea, and profound weakness

24. ISCHEMIC PAIN Location and radiation Location: Retrosterna l or slightly to the left of the midline. Ischemic chest pain radiate to neck, jaw, teeth, arms, or shoulders, One or two clenched fists held by the patient over the sternal area ( Levine sign ) is much more indicative of ischemic pain. Highly localized pain are unlikely angina episode .

25. MECHANISM OF CARDIAC PAIN Ischemic episode stimulate chemo sensitive and mechano receptive receptor . Stimulate release of adenosine, bradykinin that activate the sensory ends of sympathetic and vagal afferent fiber. Afferent fibers traverse the nerves that connect to the upper 5 thoracic sympathetic ganglia of spinal cord. Within spinal cord, cardiac sympathetic afferent impulse may converge with impulses from somatic thoracic structure i.e T1 –T5 DERMATOME ( basis for referred cardiac pain] Impulse are transmitted to the thalamus . Cardiac afferent fiber synapse in nucleus tractus solitarius of medulla and then descend to the upper cervical spinothalamic tract, this contributes to anginal pain experienced in neck and jaw.

26. Aortic Dissection 85% have chest pain[substernal] or back pain(commonly interscapular region) . Sudden onset, "Ripping" or "tearing" in 50% Acute aortic syndrome involving ascending aorta tend to cause pain in midline of anterior chest Descending aortic syndrome present with pain in back Asymmetric pulse.

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