Chest pain dr kmh

Chest PainChest Pain

Causes of Chest Pain Causes of Chest Pain

• Central chest painCentral chest pain

• Peripheral chest pain Peripheral chest pain

Central chest pain Central chest pain

• Anxiety emotion (may also cause Anxiety emotion (may also cause peripheral chest pain)peripheral chest pain)

• Cardiac cause Cardiac cause

- Myocardial ischaemia (angina)- Myocardial ischaemia (angina)

- Myocardial infarction- Myocardial infarction

- Myocarditis - Myocarditis

- Pericarditis - Pericarditis

- Mitral valve prolapse syndrome- Mitral valve prolapse syndrome

• Aortic Aortic -Aortic dissection -Aortic dissection

-Aortic Aneurysm -Aortic Aneurysm • oesophageal oesophageal

- Oesophagitis- Oesophagitis- Oesophageal spasm- Oesophageal spasm- Mallory-weiss syndrome- Mallory-weiss syndrome

• Massive pulmonary embolismMassive pulmonary embolism• Mediastinal Mediastinal

- Tracheitis - Tracheitis - malignancy - malignancy

Pheripheral chest painPheripheral chest pain

• lungs / pleuralungs / pleura..

- pulmonary - pulmonary infarct infarct

- pneumonia- pneumonia

- - pneumothoraxpneumothorax

- malignancymalignancy

- TBTB

- connective connective tissue d/stissue d/s

• Musculoskeletal Musculoskeletal

- osteoarthritis- osteoarthritis

- Rib fracture/ injury- Rib fracture/ injury

- intercostal m/s injury- intercostal m/s injury

- costochondritis (Tietze's syndrome)- costochondritis (Tietze's syndrome)

- Epidemic myalgia (Bornholm d/s)- Epidemic myalgia (Bornholm d/s)

• NeurologialNeurologial

- PID- PID

- Herpes zoster- Herpes zoster

- Thoraeic outlet syndrome- Thoraeic outlet syndrome

Enquire about chest painEnquire about chest pain

• Site of origin of painSite of origin of pain

• Duration Duration

• Radiation Radiation

• Character of the pain & severityCharacter of the pain & severity

• Pattern of onsetPattern of onset

• Aggravating factor relieving factorAggravating factor relieving factor

• Associated featuresAssociated features

Site of origin of painSite of origin of pain

AnginaAngina - Pain is characteristics central - Pain is characteristics central & & retrosternal diffuse retrosternal diffuse

- because of the derivation of - because of the derivation of nerve nerve supply to the heart & supply to the heart & mediasinum mediasinum

Pleural or lung d/s musculo skeletal and Pleural or lung d/s musculo skeletal and Anxiety Anxiety

- Peripheral localised- Peripheral localised

RadiationRadiation

ischaemic painischaemic pain - radiate to neck, jaw & - radiate to neck, jaw & upper & even lower arms upper & even lower arms

- sometime only at the site of - sometime only at the site of radiation or in the backradiation or in the back

Non Cardiac chest painNon Cardiac chest pain

- other or no radiation- other or no radiation

CharacterCharacter

Ishaemic cardiac PainIshaemic cardiac Pain

• typically dull, constricting choking or typically dull, constricting choking or heavy & is usually described as heavy & is usually described as squeezing, crushing, burning or squeezing, crushing, burning or aching .aching .

• The sensation can be described as The sensation can be described as breathlessness or like indigestion breathlessness or like indigestion

• patient typicaly use characteristic patient typicaly use characteristic hand gesture (eg. open hand or hand gesture (eg. open hand or clenched fist) when describing clenched fist) when describing ischaemic pain.ischaemic pain.

Non cardiac painNon cardiac pain

- sharp , stabbing , pricking or knife-- sharp , stabbing , pricking or knife-like like

Aggravating FactorAggravating Factor Angina Angina - Exertion - Exertion

- Emotion, excitement - Emotion, excitement

- Cold weather- Cold weather

- Exercise after meal.- Exercise after meal.

Pleural, pericardial painPleural, pericardial pain

- breathing coughing or movement - breathing coughing or movement

Musculoskeletal painMusculoskeletal pain

- Specific movement - Specific movement

(bending, stretching, turning)(bending, stretching, turning)

AnginaAngina - Rest - Rest

- Glyceryl trinitrate- Glyceryl trinitrate

- warm up before exercise - warm up before exercise

Non cardiac painNon cardiac pain

- Not relieved by rest - Not relieved by rest

- Slow or no response to - Slow or no response to nitrate nitrate

Relieving FactorRelieving Factor

Pattern of onsetPattern of onset

MIMI - typically take several minutes - typically take several minutes or even or even longer to develop. longer to develop.

AnginaAngina -build up gradually in -build up gradually in proportion proportion to the intensity of to the intensity of exertionexertion

Aortic dissection, PE, PneumothoraxAortic dissection, PE, Pneumothorax

-very sudden onset-very sudden onset

Associated featuresAssociated featuresMI, PE, Aortic dissectionMI, PE, Aortic dissection

- Accompanied by autonomic - Accompanied by autonomic disturbance including sweating, disturbance including sweating,

nausea and vomiting nausea and vomiting MI,AnginaMI,Angina

- Breathlessness due to - Breathlessness due to pulmonary congestion arising pulmonary congestion arising

from transient ischaemic left from transient ischaemic left ventricular dysfunction ventricular dysfunction

Non cardiac painNon cardiac pain - Respiratory , GI, locomotor or - Respiratory , GI, locomotor or psychological psychological

Severity Of AnginaSeverity Of Angina

• Canadian Cardiovascular Society: Canadian Cardiovascular Society: functional classification of stable anginafunctional classification of stable angina

Grade 1Grade 1 - Ordinary physical activity - Ordinary physical activity such such as walking and climbing as walking and climbing stairs, stairs, does not cause angina. does not cause angina. Angina Angina with strenous or rapid or with strenous or rapid or

prolonged exertion at work prolonged exertion at work or or recreationrecreation

Grade 2Grade 2 - Slight limitation of ordinary - Slight limitation of ordinary activity. activity. Walking or climbing Walking or climbing stairs rapidly, stairs rapidly, walking uphill, walking uphill, walking or stair walking or stair climbing after climbing after meals in cold ,in wind, or meals in cold ,in wind, or when when under emotional stress, or only under emotional stress, or only during the few hours after awakening. during the few hours after awakening.

Grade 3Grade 3 - Marked limitation of - Marked limitation of ordinary ordinary

physical activity . physical activity . Walking Walking one to two blocks one to two blocks on the level on the level and climbing and climbing less than one less than one flight in flight in normal condition. normal condition.

•Grade 4Grade 4 – Inability to carry on – Inability to carry on any any physical activity physical activity without without discomfort discomfort anginal anginal syndrome syndrome may be present may be present at rest. at rest.

QuestionsQuestions – –To assess the severity of To assess the severity of angina angina

• How far can you walk on the flat How far can you walk on the flat before experiencing discomfort ? before experiencing discomfort ?

• Do you get discomfort climbing stairs Do you get discomfort climbing stairs or hills ?or hills ?

• Do you experience discomfort Do you experience discomfort gardening, making the bed or during gardening, making the bed or during other household chores?other household chores?

•Does sexual intercourse Does sexual intercourse produce discomfort ?produce discomfort ?

•Is the discomfort influenced by Is the discomfort influenced by meals ?meals ?

•Is it influenced by cold Is it influenced by cold weather ? weather ?

Types of cardiac painTypes of cardiac pain Type Type CauseCause Characteristic Characteristic

AnginaAngina Coronary stenosis (rarely Coronary stenosis (rarely aortic stenosis aortic stenosis hypertrophic hypertrophic cardiomyopathy )cardiomyopathy )

Precipitated by Precipitated by exertion, eased by exertion, eased by rest rest

Characteristic Characteristic distribution distribution

Myocardial Myocardial infarct infarct

Coronary occlusion Coronary occlusion Similar sites to Similar sites to angina ,more severe angina ,more severe ,persists at rest.,persists at rest.

Pericarditic Pericarditic painpain

PericarditisPericarditis Sharp, raw or Sharp, raw or stabbingstabbing

Varies with Varies with movement or movement or breathing breathing

Aortic painAortic pain Dissection of the aorta Dissection of the aorta Severe ,sudden Severe ,sudden onset , radiates to onset , radiates to

the backthe back

Differential diagnosisDifferential diagnosis

Psycological aspects of chest Psycological aspects of chest painpain

•very common very common

•considered if there are features considered if there are features of anxiety or neurosis of anxiety or neurosis

• lacks a predictable relationship lacks a predictable relationship with exercisewith exercise

Psycological aspects of chest Psycological aspects of chest painpain

• Psychological and organic features Psychological and organic features can be coexistcan be coexist

• responsible for the death of close responsible for the death of close friend or relativefriend or relative

• Anxiety may amplify the effects of Anxiety may amplify the effects of organic disease (create a confusing organic disease (create a confusing picture)picture)

Musculosketal Chest PainMusculosketal Chest Pain

•Common problemCommon problem

•Very variable in site and intensityVery variable in site and intensity

•Pain may vary with posture or Pain may vary with posture or movement of the upper bodymovement of the upper body

•Sometimes accompanied by local Sometimes accompanied by local tenderness over a rib or costal tenderness over a rib or costal cartilagecartilage

Musculosketal Chest PainMusculosketal Chest Pain

•Numerous causes of chest wall Numerous causes of chest wall painpain

- arthritis- arthritis- Costochondritis- Costochondritis- intercostal muscle injury- intercostal muscle injury- coxsackie viral infection - coxsackie viral infection

(epidemic (epidemic myalgia or Bornholm myalgia or Bornholm disease)disease)

•Many minor soft tissue injury are Many minor soft tissue injury are related to everyday activities such related to everyday activities such as driving, manual work and sport.as driving, manual work and sport.

Differential diagnosis:angina vs Differential diagnosis:angina vs oesophageal painoesophageal pain

AnginaAngina

• Usually Usually precipitated by precipitated by exertionexertion

• Rapidly relieved by Rapidly relieved by restrest

• Restrosternal and Restrosternal and radiates to arm radiates to arm and jawand jaw

Oesophageal painOesophageal pain

• Canbe worsened by Canbe worsened by exertion, but often exertion, but often present at other present at other timestimes

• Not rapidly relieved Not rapidly relieved by restby rest

• Retrosternal or Retrosternal or epigastric, epigastric, sometimes radiates sometimes radiates to arm or backto arm or back

Differential diagnosis:angina Differential diagnosis:angina vs oesophageal painvs oesophageal painAnginaAngina• seldom wakes seldom wakes

patient from sleeppatient from sleep• No relation to No relation to

heartburn (but heartburn (but patients often have patients often have

'wind')'wind')• Rapidly relieved byRapidly relieved by nitratesnitrates• Typical duration Typical duration 2-10 minutes2-10 minutes

Oesophageal painOesophageal pain• Often wakes Often wakes

patient from sleeppatient from sleep• Sometimes Sometimes

related to related to heartbumheartbum

• Often relieved by Often relieved by nitratesnitrates

• Variable durationVariable duration

Differential diagnosis:angina vs Differential diagnosis:angina vs myocardial infarctionmyocardial infarction

AnginaAngina

Site: retrosternal, Site: retrosternal, radiatesradiates

to arm, epigastrium, to arm, epigastrium, neckneck

Precipitated by exercise Precipitated by exercise oror

emotionemotion

Relieved by rest, Relieved by rest, nitratesnitrates

Myocardial infarctionMyocardial infarction

As for anginaAs for angina

Often no obviousOften no obvious

precipitantprecipitant

Not relieved by rest,Not relieved by rest,

nitratesnitrates

Differential diagnosis:angina Differential diagnosis:angina vs myocardial infarctionvs myocardial infarction

AnginaAngina

• Mild/moderate Mild/moderate severityseverity

• Anxiety absent or mildAnxiety absent or mild

• No increased No increased sympathetic activationsympathetic activation

• No nausea or vomitingNo nausea or vomiting

Myocardial infarctionMyocardial infarction

• Usually severe (may be silent')Usually severe (may be silent')

• SevereSevere

• Increased sympathetic activityIncreased sympathetic activity

• Nausea and vomiting areNausea and vomiting are

commoncommon

Characteristics of percarditic painCharacteristics of percarditic pain

SiteSite

ProdromeProdrome

Onset Onset

• -Retrosternal, may -Retrosternal, may radiate to left shoulder radiate to left shoulder or backor back

• -May be preceded by a -May be preceded by a viral illnessviral illness

• -No obvious initial -No obvious initial recipitating factor; recipitating factor; tends to fluctuate in tends to fluctuate in intensityintensity

Characteristics of percarditic painCharacteristics of percarditic pain

NatureNature

Made worse byMade worse by

Helped byHelped by

Accompanied Accompanied by by

• May be stabbing orMay be stabbing or 'raw'-'like 'raw'-'like

sandpaper'. Often sandpaper'. Often described asdescribed as

sharp,rarely as tight sharp,rarely as tight or heavyor heavy• Changes in posture, Changes in posture, respirationrespiration• Analgesics, Analgesics,

especiallyespecially NSAIDsNSAIDs• Pericardial rubPericardial rub

Characteristics of pain caused by Characteristics of pain caused by dissection of aortic aneurysmdissection of aortic aneurysm

SiteSite

Onset Onset

NatureNature

• Often first felt between Often first felt between shoulder blades, shoulder blades, and/or retrosternallyand/or retrosternally

• Usually suddenUsually sudden

• Very severe pain, Very severe pain, often described as often described as 'tearing' in nature'tearing' in nature

Characteristics of pain caused Characteristics of pain caused by dissection of aortic by dissection of aortic aneurysmaneurysm

Relieved byRelieved by

Accompanied Accompanied byby

• Tends to persist. Patients Tends to persist. Patients often restless with painoften restless with pain

• Hypertension, Hypertension, asymmetric pulses, asymmetric pulses, unexpected bradycardia, unexpected bradycardia, early diastolic murmur. early diastolic murmur. syncope, focal syncope, focal neurological symptoms neurological symptoms and signsand signs