Approach to Chest Pain and

Angina

Dr .Rachmat Setiarsa, SpJP

Chest Pain
• Common complaint in ED
– 5% of all ED visits or 5 million visits per year
• Chest pain is the second most common ED complaint
Patients with chest pain present with a wide
spectrum of signs and symptoms
• It is up to the clinician to recognize the life-
threatening causes of chest pain
• Wide range of etiologies
– Cardiac, Pulmonary, GI, Musculoskeletal
• Accurate diagnosis remains a challenge !!!!!
The challenges:

• Patients presenting with chest pain who have life

threatening underlying disease often look well on
initial presentation
• It is estimated that 8-10% of patients presenting with
ACS are discharged mistakenly from the ED
• These patients have 30 day mortality of 2%
Challenges cont:

• Missed MI is the most common cause for litigation

stemming from ED treatment
• Higher awards are recovered in medical malpractice
lawsuits for missed MI than for any other condition
Cayley 2005
As a general rule any chest pain is ischemic in origin
until proven otherwise!
 Chest Pain That Can Kill
• Acute Coronary Syndromes
• Pulmonary Embolism
• Aortic Dissection
• Esophageal Rupture
• Pneumothorax
• Pneumonia
• Various others: Pulmonary HTN, Myocarditis,
Tamponade
 CHEST PAIN

• there are a lot of importment data of the pain:

– localisation
– radiation
– onset of the pain
– the type (press, smart,cutting)
– dinamic of the pain (continouosly, ongoing, undulaiting)
– answer to the medical therapy
Chest Pain

• Visceral
– Often referred
– Aching, heaviness, discomfort
– Difficult to localize pain
• Somatic
– Sharp, easily localized
Categorizing Chest Pain

1. Chest Wall Pain

• Sharp, Precisely localized
• Reproducible: Palpation, movement
2. Pleuritic or Respiratory CP
• Somatic pain, Sharp
• Worse with breathing/coughing
3. Visceral CP
• Poorly localized, aching, heaviness
 Chest pain
1. Chest wall 2. Pleuritic
• Costosternal synd • Pulmonary Embolism
• Costochrondritis • Pneumonia
• Precordial catch synd • Spontaneous pneumo
• Slipping Rib Synd • Pericarditis
• Xiphodynia • Pleurisy
• Radicular Synd
• Intercostal Nerve
• Fibromyalgia
 Chest Pain

3. Visceral Pain: • Aortic Dissection

• Typical Exertional • Pericarditis
Angina • Esophageal Reflux or
• Atypical Angina spasm
• Unstable Angina • Esophageal Rupture
• Acute Myocardial • Mitral Valve Prolapse
Infarction (AMI)
Differential Diagnoses
Acute myocardial infarction, Acute coronary ischemia, Aortic
Cardiovascular dissection, Cardiac tamponade, Unstable angina, Coronary spasm,
Prinzmetal's angina, Cocaine induced, Pericarditis,
Myocarditis, Valvular heart disease, Aortic stenosis, Mitral valve
prolapse, Hypertrophic cardiomyopathy
Pulmonary embolus, Tension pneumothorax,
Pulmonary Pneumothorax, Mediastinitis,
Pneumonia, Pleuritis, Tumor, Pneumomediastinum
Esophageal rupture (Boerhaave), Esophageal tear (Mallory-
Gastrointestinal Weiss), Cholecystitis, Pancreatitis, Esophageal spasm, Esophageal
reflux, Peptic ulcer, Biliary colic
Muscle strain, Rib
Musculoskeletal fracture, Arthritis, Tumor, Costochondritis, Nonspecific chest wall pain
Spinal root compression, Thoracic outlet, Herpes zoster, Postherpetic
Neurologic neuralgia
Psychologic, Hyperventilation
Other
“Classic” Angina

• Location: central chest

• Quality: squeezing, pressure, heaviness
• Radiation: arm(s), neck, jaw
• Associated symptoms: dyspnea, diaphoresis, nausea
• Eliciting factors: exertion
• Relieving factors: rest, nitroglycerin
 History – typical descriptions
• Pleuritic Pain = Pain
worse on inspiration
– Sharp, stabbing
– Localised
– Worse on inspiration,
coughing
– May be worse on sitting up
or leaning forward
– Not related to exertion
• Oesophageal pain
• Usually “Burning” but may
be dull ache
• Worse after meals
• Worse on lying down
• Relieved by antacid
• Oesophageal spasm may
be relieved by GTN
 Typical vs. Atypical Chest Pain
Typical Typical
• Characterized as
discomfort/pressure rather than
pain
• Time duration >2 mins
• Provoked by activity/exercise
• Radiation (i.e. arms, jaw)
• Does not change with
respiration/position
• Associated with
diaphoresis/nausea
• Relieved by rest/nitroglycerin
Atypical
• Pain that can be localized with
one finger
• Constant pain lasting for days
• Fleeting pains lasting for a few
seconds
• Pain reproduced by
movement/palpation
Assessment

• Pre- and post test probability

• Pre test probability influenced by factors such as:
– History of previous coronary disease
– Angina, AMI, coronary angiogram or angioplasty, coronary
surgery
– History of cardiac risk factors
– Smoking, Hypertension, High Cholesterol, Diabetes
Mellitus
– Diagnostic approach to Acute Coronary Syndromes is often
a ‘risk assessment’ rather than a ‘diagnosis’
 Classification of chest pain

• Typical angina
1. Substernal chest discomfort with characterstic quality and duration
2. Provoked by exertion or emotional stress
3. Relieved by rest or NTG

• Atypical angina
Meets 2 of the above characteristics

• Noncardiac chest pain

Meets one or none of the typical characteristics
History and Physical

You next ask about risk factors…

To increase pre-test probability
• Lipids, DM, HTN, smoking, and Fam. Hx
• Plus a past hx of PVD, or Stroke
 Pre-test likelihood of CAD
Nonanginal
Atypical angina Typical angina
chest pain
Age M F M F M F

35 3-35 1-19 8-59 2-39 30-88 10-78

45 9-47 2-22 21-70 5-43 51-92 20-79

55 23-59 4-25 45-79 10-47 80-95 38-82

65 49-69 9-29 71-86 20-51 93-97 56-84

Estimated 10-Year CHD Risk in
55-Year-Old Adults According to Levels of Various Risk
Factors
Framingham Heart Study

40 37
Estimated 10-Year Rate (%)

35
30 25 27
25 20 Men
20
13 Women
15
8
10 5 5
5
0
A B C D
A B C D
Blood Pressure (mm Hg) 120/80 140/90 140/90 140/90
Total Cholesterol (mg/dL) 200 240 240 240
HDL Cholesterol (mg/dL) 50 50 40 40
Diabetes No No Yes Yes
Cigarettes No No No Yes
mm Hg = millimeters of mercury
mg/dL = milligrams per deciliter of blood

Source: Circulation 1998;97:1837-1847.

Is the DIAGNOSIS established after the Hx/Px
and initial tests?

Does the pt fit into one of the following?

1. Noncardiac c/p and low pretest prob…
• No further testing needed.
• Pt does not have angina

2. Diagnosis of angina is established (high pretest prob)

• No further diagnostic testing needed.
• Pt needs risk stratification for prognosis
3. Diagnosis is still not clear…(intermediate pretest prob)
• Consider the following tests to make a diagnosis…
 Diagnosis of CAD
You decide to classify his chest pain as atypical, and
estimate his pre-test probability of CAD as
intermediate ( 65%)
Nonanginal chest pain Atypical angina Typical angina

Age M F M F M F

Is this high enough to give

35 3-35 1-19 8-59 2-39 30-88 10-78
him a diagnosis of CAD and
start treatment? 45 9-47 2-22 21-70 5-43 51-92 20-79

55 23-59 4-25 45-79 10-47 80-95 38-82

65 49-69 9-29 71-86 20-51 93-97 56-84

How would you confirm the diagnosis?

Diagnostic Tests for CAD

– ECG Exercise Stress Testing (GXT)

– Stress test plus imaging (nuclear or echo)
– Pharmacologic testing (dipyridamole-MIBI, or
Dobutamine-MIBI/Echo)
– Angiography (gold standard test)

What test is the most appropriate for him?

DIAGNOSTIC Tests
ACC/AHA Guidelines Circ. 1999; 99:2829-48

Exercise ECG (GXT) for diagnosis

– Class I
• Pts with intermediate pretest prob. (with normal ECG)
– Class IIa and IIb
• Suspected vasospastic angina
• Pts with high or low pretest prob of CAD
– Class III
• Baseline ECG abn. (LBBB, paced ECG, WPW, >1mm ST
depression)

Click here to see the ACC/AHA classification system

Diagnostic Tests

Stress imaging studies (nuclear or echo)

– Class I
• Pts with intermediate pretest prob. and abnormal ECG
– Class II
• Pts with low or high pretest prob. and abn. ECG
Pts unable to exercise…
use pharmacological stress
– Dypyridamole sestamibi or
– Dobutamine echo/sestamibi
 Test Characteristics of
Non-invasive testing

Diagnostic
test
Sn Sp LR + LR -

Exercise Test 68 77 3 0.42

Nuclear Stress 88 77 3.8 0.16

Stress Echo 76 88 6.3 0.27

…for occlusive CAD

2D ECHO

What about rest ECHO in the diagnosis of chest pain or

CAD?
Class I
• Pts with signs of AS or HOCM
• Pts with findings of CHF
– Class III
• Pts with none of the above findings
• i.e. routine echo is not indicated in the dx of angina
Angiography (Gold standard)

How about angiography for diagnosis?

– Class I
• Pts who have survived sudden cardiac death
– Class II
• Pts with uncertain dx after noninvasive tests
• Pts who cannot undergo noninvasive tests
– Class III
• Pts who “want to know” but are low prob.
 Summary
1. Start with the Hx and P/E
• estimate the pre-test probability of CAD

2. Decide whether the patient needs testing

• to make a diagnosis of CAD or
• the diagnosis established clinically, but need
testing to determine prognosis.
TERIMA KASIH