CHEST

DISCOMFORT
PGI JHON PAULO L. LAYUG
Chest Discomfort*
● Three categories:
1. Myocardial ischemia
2. Other cardiopulmonary
causes (pericardial
disease, aortic
emergencies, and
pulmonary conditions)
3. Non-cardiopulmonary
causes
CAUSES OF DISCOMFORT*
TYPICAL CLINICAL FEATURES
OF MAJOR CAUSES OF ACUTE
CHEST DISCOMFORT
CARDIOPULMONARY
CARDIOPULMONARY
CARDIOPULMONARY
NON-CARDIOPULMONARY
NON-CARDIOPULMONARY
NON-CARDIOPULMONARY
CARDIOPULMONARY CAUSES
 CARDIAC
CONDITIONS
 MYOCARDIAL ISCHEMIA/INJURY
● ANGINA PECTORIS
➔ Myocardial ischemia causing chest discomfort
➔ Primary clinical concern in patients presenting with
chest symptoms
● Precipitated by:
➔ Imbalance between myocardial oxygen requirements
and myocardial oxygen supply, resulting in insufficient
delivery of oxygen to meet the heart’s metabolic
demands
 MYOCARDIAL ISCHEMIA/INJURY*
● MYOCARDIAL O2 CONSUMPTION ELEVATED BY:
❏ Increases in heart rate
❏ Ventricular wall stress
❏ Myocardial contractility
● MYOCARDIAL O2 SUPPLY IS DETERMINED BY:
❏ Coronary blood flow
❏ Coronary arterial oxygen content
 ISCHEMIC HEART DISEASE*
❖ STABLE IHD*
● STABLE ANGINA
➔ characterized by ischemic episodes that are typically
precipitated by a superimposed increase in oxygen
demand during physical exertion and relieved upon
resting.
 ISCHEMIC HEART DISEASE
❖ UNSTABLE IHD*
● UNSTABLE ANGINA
➔ Marked by ischemic symptoms at rest, with minimal activity,
or in an accelerating pattern
➔ No detectable myocardial injury
● NSTEMI
➔ Evidence of myocardial necrosis
● STEMI
➔ When the coronary thrombus is acutely and completely
occlusive, transmural myocardial ischemia
➔ ST-segment elevation on the ECG + myocardial necrosis
 ACUTE CORONARY SYNDROME
● Encompasses unstable angina, NSTEMI, and STEMI
● Ischemia precipitated by acute coronary atherothrombosis.
CHARACTERISTICS OF ISCHEMIC CHEST
DISCOMFORT

Heberden initially described angina as a sense

of “strangling and anxiety.”
MECHANISMS
OF PAIN*
 MECHANISMS OF PAIN*
● This pain usually radiates into the left neck area and down the left arm.
● Visceral pain whose specific underlying mechanisms for pain generation
are not entirely understood.
● Myocardial ischemia leads to acidosis and loss of normal ATP
sodium-potassium pump and membrane integrity.
● Release of substances such as adenosine, lactate, serotonin, bradykinin,
histamine, and reactive oxygen species stimulate chemo-sensitive
receptors.
● Stimulation of afferent sympathetic fibres in the upper thoracic
spinothalamic tract leads to chest and arm pain symptoms
● Stimulation of vagal afferent fibres leads to excitation of cervical
spinothalamic tracts which may result in neck and/or jaw pain symptoms.
Resources:
https://www.researchgate.net/figure/Schematic-presentation-of-mechanisms-and-pathways-involved-in-cardiac-chest-painIschemic_fig2_3
42872592
OTHER CARDIOPULMONARY
CAUSES
 PERICARDIAL AND OTHER MYOCARDIAL
DISEASES
● PERICARDITIS
➔ Inflammation of the pericardium due to infectious or
noninfectious causes can be responsible for acute or chronic
chest discomfort.
➔ The visceral surface and most of the parietal surface of the
pericardium are insensitive to pain.
➔ Pain: arise principally from associated pleural inflammation
PERICARDITIS*
 PERICARDIAL AND OTHER MYOCARDIAL
DISEASES*
● MYOCARDIAL DISEASES
❏ Takotsubo (stress-related) cardiomyopathy
➔ symptoms often start abruptly with chest pain and
shortness of breath.
➔ Triggers: emotional or physical stressful event
➔ Mimic acute MI (ECG abnormalities, including
ST-segment elevation, and elevated biomarkers of
myocardial injury)
 DISEASES OF AORTA
● ACUTE AORTIC SYNDROMES
❏ AORTIC DISSECTION
➔ Less common cause of chest discomfort*
➔ Tear in the aortic intima, resulting in separation of
the media and creation of a separate “false” lumen.
❏ PENETRATING ULCERS
➔ Ulceration of an aortic atheromatous plaque that
extends through the intima and into the aortic
media, with the potential to initiate an intramedial
dissection or rupture into the adventitia.
 DISEASES OF AORTA
● ACUTE AORTIC SYNDROMES
❏ INTRAMURAL HEMATOMA
➔ Aortic wall hematoma with no demonstrable
intimal flap, no radiologically apparent intimal tear,
and no false lumen.
➔ Can occur due to either rupture of the vasa vasorum
or, less commonly, a penetrating ulcer.
 ACUTE AORTIC SYNDROME

● ASCENDING AORTA ● DESCENDING AORTA

➔ pain in the midline of ➔ pain in the back
the anterior chest
 DISEASES OF AORTA
● AORTIC ANEURYSMS
➔ Most often asymptomatic
❏ THORACIC AORTIC ANEURYSMS
➔ can cause chest pain and other symptoms by
compressing adjacent structures.
➔ This pain tends to be steady, deep, and
occasionally severe.
● AORTITIS
➔ Noninfectious or infectious etiology, in the absence of
aortic dissection is a rare cause of chest or back
discomfort.
PULMONARY
CONDITIONS
 PULMONARY EMBOLISM
● Can produce dyspnea and chest discomfort that is sudden in
onset
● Pleuritic in pattern*
● Chest discomfort associated with pulmonary embolism may
result from:
❏ Involvement of the pleural surface of the lung adjacent to a
resultant pulmonary infarction
❏ Distention of the pulmonary artery
❏ Right ventricular wall stress and/or subendocardial
ischemia related to acute pulmonary hypertension
 PULMONARY EMBOLISM
● MASSIVE PULMONARY EMBOLI
➔ Cause severe substernal pain that may mimic an MI
➔ Attributed to the second and third of these potential
mechanisms
➔ May also be associated with syncope, hypotension, and
signs of right heart failure
 PNEUMOTHORAX
● PRIMARY SPONTANEOUS PNEUMOTHORAX
➔ Rare cause of chest discomfort (United States of 7 per
100,000 among men and <2 per 100,000 among women)
➔ Risk factors: male sex, smoking, family history, and
Marfan syndrome.
➔ Symptoms: sudden in onset, and dyspnea may be mild;
thus, presentation to medical attention is sometimes
delayed.
 PNEUMOTHORAX
● SECONDARY SPONTANEOUS PNEUMOTHORAX
➔ Underlying lung disorders: chronic obstructive pulmonary
disease, asthma, or cystic fibrosis
➔ Symptoms that are more severe
● TENSION PNEUMOTHORAX
➔ Medical emergency caused by trapped intrathoracic air
that precipitates hemodynamic collapse
Other Pulmonary
Parenchymal, Pleural, or
Vascular
Disease
 OTHER PULMONARY CONDITIONS
● PNEUMONIA AND MALIGNANCY
➔ Can produce chest pain due to the involvement of the
pleura or surrounding structures
● PLEURISY
➔ Knifelike pain that is worsened by inspiration or coughing
● CHRONIC PULMONARY HYPERTENSION
➔ Chest pain similar to angina in its characteristics (right
ventricular myocardial ischemia in some cases)
● REACTIVE AIRWAYS DISEASES
➔ Can cause chest tightness associated with breathlessness
rather than pleurisy
PULMONARY CONDITIONS
NON-CARIOPULMONARY
CAUSES
GASTROINTESTINAL
CONDITIONS*
 ESOPHAGEAL DISORDERS
● ACID REFLUX
➔ Often causes a burning discomfort
● ESOPHAGEAL SPASM
➔ Intense, squeezing discomfort that is retrosternal in
location
➔ Like angina, may be relieved by nitroglycerin or
dihydropyridine calcium channel antagonists
● ESOPHAGEAL INJURY
❏ Mallory-Weiss tear
❏ Esophageal rupture (Boerhaave syndrome)
➔ Severe vomiting
 PEPTIC ULCER DISEASE
● Most commonly epigastric in location but can radiate into the
chest
 HEPATOBILIARY DISORDERS
● CHOLECYSTITIS AND BILIARY COLIC
➔ May mimic acute cardiopulmonary diseases
● Pain usually localizes to the right upper quadrant of the
abdomen, it is variable and may be felt in the epigastrium and
radiate to the back and lower chest.
● Referred to the scapula or may in rare cases be felt in the
shoulder, suggesting diaphragmatic irritation
● The pain is steady, usually lasts several hours, and subsides
spontaneously, without symptoms between attacks.
 PANCREATIC DISEASE
● PANCREATITIS
➔ Pain typically aching epigastric pain that radiates to the
back
NON-CARDIOPULMONARY
Musculoskeletal
and Other Causes*
 MUSCULOSKELETAL AND OTHER CAUSES
● COSTOCHONDRITIS
➔ Causing tenderness of the costochondral junctions
(Tietze’s syndrome) is relatively common
● CERVICAL RADICULITIS
➔ Prolonged or constant aching discomfort in the upper
chest and limbs.
➔ Pain exacerbated by motion of the neck
● BRACHIAL PLEXUS INJURY
➔ Occasionally, chest pain can be caused by compression of
the brachial plexus by the cervical ribs
 MUSCULOSKELETAL AND OTHER CAUSES
● TENDINITIS OR BURSITIS
➔ Involving the left shoulder may mimic the radiation of
angina
● HERPES ZOSTER
➔ Pain in a dermatomal distribution can also be caused by
cramping of intercostal muscles
NON-CARDIOPULMONARY
Emotional and
Psychiatric Conditions
 EMOTIONAL AND PSYCHIATRIC CONDITIONS
● As many as 10% of patients who present to EDs with acute
chest discomfort have a panic disorder or related condition.
● The symptoms may include chest tightness or aching that is
associated with a sense of anxiety and difficulty in breathing.
● The symptoms may be prolonged or fleeting.
PSYCHOLOGICAL
APPROACH TO THE PATIENT
CONSIDERATIONS IN THE ASSESSMENT OF THE
PATIENT WITH CHEST DISCOMFORT*
HISTORY*
 QUALITY OF PAIN*
● PRESSURE OR TIGHTNESS*
❏ Myocardial ischemic pain
● PLEURITIC DISCOMFORT
➔ Suggestive of a process involving the pleura
❏ Pericarditis
❏ Pulmonary embolism
❏ Pulmonary parenchymal processes
● STEADY SEVERE PRESSURE OR ACHING (Less frequently)*
❏ Pericarditis
❏ Massive pulmonary embolism
 QUALITY OF PAIN
● “TEARING” or “RIPPING” PAIN or “KNIFELIKE” PAIN
❏ Acute Aortic Dissection
● BURNING PAIN
❏ Acid Reflux
❏ Peptic Ulcer Disease
❏ MI
● SEVERE SQUEEZING
❏ Esophageal spasm
 LOCATION OF DISCOMFORT
● Substernal location with radiation to the neck, jaw, shoulder, or
arms.
❏ MI
● Retrosternal
❏ Esophageal pain
● Abdomen or epigastrium with possible radiation to the chest
❏ MI (Angina)
● Severe pain radiating to the back, particularly between the
shoulder blades
❏ Acute Aortic Syndrome
● Radiation to the trapezius ridge
❏ Pericardial
 PATTERN
● Usually builds over minutes and is exacerbated by activity
and mitigated by rest
❏ Myocardial ischemic discomfort
● Pain that reaches its peak intensity immediately
❏ Aortic dissection
❏ Pulmonary embolism
❏ Spontaneous pneumothorax
 Provoking and Alleviating Factors
● Prefer to rest, sit, or stop walking
❏ MI
● “warm-up angina”
➔ Some patients experience relief from angina as they
continue at the same or even a greater level of exertion
● Alterations in the intensity of pain with changes in position
or movement of the upper extremities and neck
❏ MSK
● Worse in the supine position and relieved by sitting upright
and leaning forward
❏ Pericarditis
 Provoking and Alleviating Factors
● Exacerbated by alcohol, some foods, or by a reclined position,
relief can occur with sitting
❏ GERD
● Exacerbation by eating
❏ PUD
➔ symptomatic 60–90 min after meals
❏ Cholecystitis
❏ Pancreatitis
❏ Severe coronary atherosclerosis
➔ After eating can trigger postprandial angina
(redistribution of blood flow to the splanchnic vasculature)
 Provoking and Alleviating Factors
● Acid-reducing therapies
❏ Acid reflux
❏ PUD
● Nitroglycerin*
❏ MI (not specific and sensitive)
❏ Esophageal Spasm
 ASSOCIATED SYMPTOMS
● Diaphoresis, dyspnea, nausea, fatigue, faintness, and
eructations
❏ MI
● Sudden onset of significant respiratory distress
❏ Pulmonary Embolism
❏ Spontaneous Pneumothorax
● Hemoptysis
❏ Pulmonary Embolism
❏ Severe HF
➔ blood-tinged frothy sputum*
 ASSOCIATED SYMPTOMS
● Syncope or pre-syncope
❏ Pulmonary embolism
❏ Aortic Dissection
● Nausea and vomiting
❏ Gastrointestinal d/o
❏ Inferior MI
➔ Activation of the vagal reflex or stimulation of left
ventricular receptors as part of the Bezold-Jarisch
reflex
 PAST MEDICAL HISTORY
● Useful in assessing the patient for risk factors for coronary
atherosclerosis and venous thromboembolism as well as for
conditions that may predispose the patient to specific
disorders. *
● A careful history may elicit clues about depression or prior
panic attacks.
How to distinguish anginal chest pain from other causes?
How to distinguish anginal chest pain from other causes?
 PHYSICAL
EXAMINATION
 GENERAL
● Anxious, uncomfortable, pale, cyanotic, or diaphoretic
❏ MI or other acute cardiopulmonary disorders
● Levine’s sign
➔ Massaging or clutching their chests may describe their
pain with a clenched fist held against the sternum
● Body Habitus
➔ Marfan syndrome or the prototypical young, tall, thin man
with spontaneous
➔ pneumothorax.
 VITAL SIGNS
● Significant tachycardia and hypotension
❏ Acute MI with cardiogenic shock
❏ Massive pulmonary embolism
❏ Pericarditis with tamponade
❏ Tension pneumothorax
● Severe hypertension but may be associated with profound
hypotension (due to coronary arterial compromise or
dissection into the pericardium)
❏ Acute Aortic emergencies
 VITAL SIGNS
● Sinus Tachycardia
❏ Submassive pulmonary embolism
● Tachypnea and hypoxemia
❏ Pulmonary cause
● Low-grade fever
❏ Infection
❏ MI
❏ thromboembolism
 PULMONARY EXAMINATION
● Examination of the lungs may localize a primary pulmonary
cause of chest discomfort:
❏ Pneumonia
❏ Asthma
❏ Pneumothorax
● Left ventricular dysfunction from severe ischemia/infarction as
well as acute valvular complications of MI or aortic dissection
can lead to pulmonary edema, which is an indicator of high
risk
 CARDIAC EXAMINATION
● Jugular venous pulse is often normal in patients with
❏ Acute myocardial ischemia
❏ Pericardial tamponade
❏ Acute right ventricular dysfunction
● Cardiac auscultation: 3rd or, more commonly, a 4th heart
sound
❏ Myocardial systolic or diastolic dysfunction
● Murmurs of mitral regurgitation or a ventricular-septal defect
❏ mechanical complications of STEMI
 CARDIAC EXAMINATION
● Murmur of aortic insufficiency
❏ Complication of proximal aortic dissection
● Other murmurs
❏ Cardiac disorders contributory to ischemia (e.g., aortic
stenosis or hypertrophic cardiomyopathy)
● Pericardial friction rubs
❏ Pericardial inflammation
 ABDOMINAL EXAMINATION
● Vascular pulse deficits
❏ Chronic atherosclerosis, which increases the likelihood
of coronary artery disease
● Acute limb ischemia with loss of the pulse and pallor,
particularly in the upper extremities
❏ Catastrophic consequences of aortic dissection
● Unilateral lower-extremity swelling
❏ Venous thromboembolism*
 MUSCULOSKELETAL EXAMINATION
● Localized swelling, redness, or marked localized tenderness
❏ Pain arising from the costochondral and chondrosternal
articulations*
● Although palpation of the chest wall often elicits pain in
patients with various musculoskeletal conditions, it should be
appreciated that chest wall tenderness does not exclude
myocardial ischemia.
● Sensory deficits in the upper extremities
❏ Cervical disk disease
ELECTROCARDIOGRAPHY
 ELECTROCARDIOGRAPHY
● Professional society guidelines recommend that an ECG be
obtained within 10 min of presentation
● Primary goal of identifying patients with ST-segment
elevation diagnostic of MI who are candidates for immediate
interventions to restore flow in the occluded coronary artery.
● ST-segment depression and symmetric T-waveinversions at
least 0.2 mV in depth
➔ useful for detecting myocardial ischemia in the absence of
STEMI
➔ Indicative of higher risk of death or recurrent ischemia
 ELECTROCARDIOGRAPHY
● ACS
➔ Serial performance of ECGs (every 30–60 min) is
recommended
● Ischemia
➔ ECG with right-sided lead placement and a nondiagnostic
standard 12-lead ECG*
 ELECTROCARDIOGRAPHY
● Abnormalities of the ST segment and T wave
❏ Pulmonary embolism
❏ Ventricular hypertrophy
❏ Acute and chronic pericarditis
❏ Myocarditis
❏ Electrolyte imbalance
❏ Metabolic disorders
● Nonspecific ST and T-wave abnormalities
❏ Hyperventilation associated with panic disorder
 ELECTROCARDIOGRAPHY
● Sinus tachycardia, rightward shift of the ECG axis,
manifesting as an S-wave in lead I, with a Q-wave and
T-wave in lead III
❏ Pulmonary Embolism
● ST-segment elevation + diffuse lead involvement not
corresponding to a specific coronary anatomic distribution
and PR-segment depression
❏ Pericarditis from Acute MI
CHEST RADIOGRAPHY
 CHEST RADIOGRAPHY
● Plain radiography of the chest is performed routinely
➔ Acute chest discomfort and selectively when individuals
who are being evaluated as outpatients have subacute or
chronic pain
● Useful in identifying pulmonary processes
❏ Pneumonia
❏ Pneumothorax
● Findings are often unremarkable in patients with ACS, but
pulmonary edema may be evident.
 CHEST RADIOGRAPHY
● Widening of the mediastinum
❏ Aortic dissection
● Hampton’s hump or Westermark’s sign
❏ Pulmonary embolism
● Pericardial calcification
❏ Chronic pericarditis
CARDIAC BIOMARKERS
 CARDIAC BIOMARKERS
● CARDIAC TROPONIN
➔ Preferred biomarker for the diagnosis of MI
➔ Measured in all patients with suspected ACS at
presentation and repeated in 3–6 h
● Testing after 6 h is required only when there is uncertainty
regarding the onset of pain or when stuttering symptoms have
occurred.
● It is not necessary or advisable to measure troponin in patients
without suspicion of ACS unless this test is being used
specifically for risk stratification (e.g., in pulmonary embolism
or heart failure).
 CARDIAC BIOMARKERS
● The greater negative predictive value of a negative troponin
result with current-generation assays is an advantage in the
evaluation of chest pain in the ED.
● In patients presenting >2 h after symptom onset, a
concentration of cardiac troponin below the limit of detection
using a high-sensitivity assay may be sufficient to exclude MI
with a negative predictive value >99% at the time of hospital
presentation.
 CARDIAC BIOMARKERS
● Observation of a change in cardiac troponin concentration between
serial samples is useful in discriminating acute causes of
myocardial injury from chronic elevation due to underlying
structural heart disease, end-stage renal disease, or interfering
antibodies.
● D-dimer test
➔ To aid in exclusion of pulmonary embolism
● B-type natriuretic peptide
➔ Useful when considered in conjunction with the clinical history
and examination for the diagnosis of heart failure
➔ Provide prognostic information among patients with ACS and
those with pulmonary embolism.
INTEGRATIVE
DECISION-AIDS
PROVOCATIVE TESTING
FOR ISCHEMIA
 EXERCISE ELECTROCARDIOGRAPHY (“STRESS
TESTING”)
● Commonly employed for completion of risk stratification of
patients who have undergone an initial evaluation that has
not revealed a specific cause of chest discomfort and has
identified them as being at low or selectively intermediate risk
of ACS.
● Safe in patients without high-risk findings after 8–12 h of
observation and can assist in refining their prognostic
assessment.
● Contraindication: Ongoing chest pain
 PHARMACOLOGIC STRESS TESTING WITH
NUCLEAR PERFUSION IMAGING OR
ECHOCARDIOGRAPHY
● Patients who are unable to exercise
● Resting myocardial perfusion images
➔ Persistent pain and nondiagnostic ECG and biomarker
data
➔ Absence of any perfusion abnormality substantially
reduces the likelihood of coronary artery disease*
OTHER NONINVASIVE
STUDIES
 ECHOCARDIOGRAPHY
● Not necessarily routine in patients with chest discomfort
● Patients with an uncertain diagnosis, particularly those with
nondiagnostic ST elevation, ongoing symptoms, or
hemodynamic instability, detection of abnormal regional
wall motion provides evidence of possible ischemic
dysfunction.
● Diagnostic in patients with mechanical complications of MI or
in patients with pericardial tamponade.
● TRANSTHORACIC ECHOCARDIOGRAPHY
➔ poorly sensitive for aortic dissection, although an intimal
flap may sometimes be detected in the ascending aorta.
 CT ANGIOGRAPHY*
● CORONARY CT ANGIOGRAPHY
➔ Sensitive technique for detection of obstructive coronary
disease, particularly in the proximal third of the major
epicardial coronary arteries.
● CT appears to enhance the speed to disposition of patients
with a low-intermediate probability for ACS
➔ Its major strength being the negative predictive value of
a finding of no significant disease
 CT ANGIOGRAPHY
● CONTRAST-ENHANCED CT
➔ Can detect focal areas of myocardial injury in the acute
setting.
● CT ANGIOGRAPHY
➔ Can exclude aortic dissection, pericardial effusion, and
pulmonary embolism.
● Balancing factors in the consideration of the emerging role of
coronary CT angiography in low-risk patients are radiation
exposure and additional testing prompted by nondiagnostic
abnormal results.
 MRI
● CARDIAC MAGNETIC RESONANCE (CMR) IMAGING
➔ Evolving, versatile technique for structural and functional
evaluation of the heart and the vasculature of the chest
➔ Can be performed as a modality for pharmacologic stress
perfusion imaging
 MRI*
● CARDIAC MAGNETIC RESONANCE (CMR) IMAGING
➔ Can be a useful modality for cardiac structural evaluation
of patients with elevated cardiac troponin levels in the
absence of definite coronary artery disease
 MRI
● GADOLINIUM-ENHANCED CMR
➔ Can provide early detection of MI, defining areas of
myocardial necrosis accurately, and can delineate patterns
of myocardial disease that are often useful in
discriminating ischemic from non-ischemic myocardial
injury.
 MRI
● MRI also permits highly accurate assessment for aortic
dissection but is infrequently used as the first test because CT
and transesophageal echocardiography are usually more
practical.
CRITICAL PATHWAYS
FOR ACUTE CHEST
DISCOMFORT
 CRITICAL PATHWAYS FOR ACUTE CHEST
DISCOMFORT*
1 2 3

● Rapid ● Accurate ● Through more efficient

identification identification of and systematic
● Triage low-risk patients accelerated diagnostic
● Treatment of who can be safely protocols, safe
high-risk observed in units reduction in costs
cardiopulmonary with less intensive associated with overuse
conditions (e.g., monitoring, undergo of testing and
STEMI) early exercise unnecessary
testing, or be hospitalizations
discharged home
OUTPATIENT
EVALUATION OF CHEST
DISCOMFORT
 OUTPATIENT EVALUATION OF CHEST
DISCOMFORT*
● Pretest probability of an acute cardiopulmonary cause is significantly
lower.
● Therefore, testing paradigms are less intense, with an emphasis on
the history, physical examination, and ECG.
● Moreover, decision-aids developed for settings with a high
prevalence of significant cardiopulmonary disease have lower
positive predictive value when applied in the practitioner’s office.
● However, in general, if the level of clinical suspicion of ACS is
sufficiently high to consider troponin testing, the patient should be
referred to the ED for evaluation.
 Resources
● HARRISON 20TH EDITION
● https://www.researchgate.net/figure/Schematic-presentation
-of-mechanisms-and-pathways-involved-in-cardiac-chest-pa
inIschemic_fig2_342872592
 THANK YOU SO
MUCH! GODBLESS!