The Differential Diagnosis and Management

of Chest Pain in Emergency Department

Mohammad Yusuf Suseno, SpJP(K), FIHA

Cardiologist, Intervensionist
Telogorejo Heart Center, Semarang, Indonesia
Founder SatuHariSatuEKG Telegram Group, Indonesia

IG : @satuharisatuekg
@yusufsusenospjp
 Learning Objective

• To know the differential diagnose of chest pain

• To know which chest pain belong to life threatening and non life
threatening
• To know how to manage chest pain life threatening cases in emergency
department.
Epidemiology
 Epidemiology
Chest pain is one of the most common
complain in emergency medicine
The most common cause of chest pain
in primary care is musculosceletal
condition.
Cardiovascular disease are the most
common cause of chest pain in
emergency setting.
 Epidemiology in ED

Chest discomfort is the third most common reason for visits to

the ED
• Six to 7 million emergency visits each year.
• More than 60% —> hospitalized for further testing.
• Less than 25% —> diagnosed with ACS
• Most common diagnoses are gastrointestinal causes.
• Fewer than 10% are other life‐threatening cardiopulmonary
conditions
Storrow, A; Annals of Emergency Medicine
Volume 35, Issue 5, May 2000, Pages 449–461
 Differential Diagnosis of Chest Pain

• CARDIOVASCULAR • GASTROINTESTINAL
• Ischemia (ACS, CAD) • Cholecystitis
• Pericarditis
• Pancreatitis
• Thoracic aortic dissection
• Hiatal Hernia
• HCM
• Esophageal disease / GERD
• Aorta Stenosis
• Peptic Ulcer Disease
• Stress CM
• Pericarditis
 Differential Diagnosis of Chest Pain

• RESPIRATORY • MUSCULOSCELETAL • OTHER

• Pulmonary Embolism • Costochondritis • Herpes Zoster
• Pneumothorax • Cervical Disk Disease • Disorder of the breast
• Pneumonia • Rib Fracture • Panic attacks / anxiety
• Plural irritation • Intercostal Muscle Cramp • Fibromyalgia
 REMEMBER

• Literally dozens of illnesses cause chest pain.

• Knowing common signs, symptoms and patient presentations
can help you differentiate
• Treat patient as though he is critical, until proved otherwise

If you are ever not sure what kind of chest pain you
are dealing with, treat it as cardiac!
STAT : Chest Pain Discharge Diagnosis from ED
• Gastro intestinal 42 %
• Ischemic Heart Disease 31 %
• Chest Wall Syndrome 28 %
• Pericarditis 4 %
• Pleuritis 2 %
• Pulmonary Emboli 2 %
• Lung Cancer 1.5 %
• Aortic Aneursym/Dissection 1 %
• Aorta Stenosis 1 %
• Herpes Zoster 1 %
Epidemiology
In the emergency department chest pain is the second most common complaint comprising
approximately 5% of all emergency department visits. In evaluating for chest pain, the provider
should always consider life-threatening causes of chest pain. These are listed below with
approximate percent occurrence in patients presenting to the emergency department with chest
pain based on a study by Fruerfaard et al. [2]

Acute coronary syndrome (ACS), 31%

Pulmonary embolism (PE), 2%

Pneumothorax (PTX), unreported

Pericardial tamponade, unreported (pericarditis 4%)

Aortic dissection, 1%

Esophageal perforation, unreported

Other common causes of chest pain with approximate percent occurrence in patients presenting
to the emergency department with chest pain include:

Gastrointestinal reflux disease, 30%

Musculoskeletal causes, 28%

Pneumonia/pleuritis, 2%
 Epidemiology in ED

• Two to 6% of patients presumed non‐ischemic etiology who

are discharged from the ED, later had a missed myocardial
infarction (MI).
• Patients with a missed diagnosis of MI have a 30‐day risk of
death that is double that hospitalized.
• Missed diagnosis of ACS leading cause of malpractice claims.
Storrow, A; Annals of Emergency Medicine
Volume 35, Issue 5, May 2000, Pages 449–461
REMEMBER
REMEMBER
REMEMBER
WHICH Chest Pain Patients SHOULD BE ADMITTED?

• RR > 30
• HR > 130
• BP < 90/60
• SaO2 < 92 % or cyanotic
• Altered level of consciousness
• High temperature > 38.5 C
 Two PARTS of Chest Pain
Chest Pain That Can Kill ….

Non-Life Threatening
Life Threatening
• Muscular
1. Acute Coronary Syndrome
• Skeletal
2. Acute Aortic disssection • Pneumonia

3. Pulmonary Embolism • Simple pneumothorax

• Pericarditis
4. Pericarditis/Tamponade
• GERD
5. Tension pneumothorax • Valvular heart disease
6. Esophageal rupture • Herpes Zoster
• Radiculopathy
 WHAT WE HAVE?

• EXCELLENCE History Taking.

• METICULOUS Physical Exam.
• RAPID ECG Interpretation.
• BASIC Lab
• BASIC X RAY
• Other : Echo, CT Scan, Cath Lab.
 LET’S START WITH
EXCELLENCE HISTORY TAKING
—> MOST Important KEY

“Listen to the patient-he is telling you the diagnosis”(Sir

William Osler).
?
?
?
?
 Contoh Anamnesa :
Px : Dada saya nyeri Dok. Diagnose Sementara ?
Dr : Nyerinya bagaimana Bu?
A. Angina Pectoris
Px : Seperti ditekan.
B. Diseksi Aorta
Dr : Ditekan bagaimana?
Px : Ditekan benda berat. C. Muskuloskeletal Chest Pain
Dr : Lokasinya dimana Bu? D. Psikosomatis Chest Pain.
Px : Di dada kiri.
Dr : Nyerinya pas apa?
Px : Pas Capek Dok.
Dr : Kalau capek makin nyeri?
Px : Iya Dok.
Tip 10: Start with open ended questions and proceeds to probe
questions and then closed questions.
“Terus Bu?”
 Contoh Anamnesa :
Px : Dada saya nyeri Dok. Diagnose Sementara ?
Dr : Iya Bu. Terus?
A. Angina Pectoris
Px : Nyeri seperti ditekan. Di dada kiri.
Dr : Hmm..
B. Diseksi Aorta
Px : Iya Dok. Sakit banget. Seperti ditekan benda beratt. C. Muskuloskeletal Chest Pain
Dr : Terus? D. Psikosomatis Chest Pain.
Px : Terutama kalau pas capek Dok. Capek ngurus
rumah. Ngurus suami yang gajinya nggak naik-naik
padahal kebutuhan banyak. Mana anak-anak ini harus
diajari saya karena online.
Dr : Gitu ya Bu?
Px : Iya Dok. Makin saya capek mikir rumah makin nyeri
rasanya. Pingin istirahat.
History

u “What NEXT?”
u Onset of pain, Provocation/Palliation, Quality of
pain, Radiation, Site of pain,, Timing.
u Ask about prior diagnostic studies
u Ask whether the discomfort is similar to prior
illness
u Associated symptoms
u Risk factors
DIFF DX of CHEST PAIN
CHEST PAIN
CHEST PAIN
History (Onset)

u Starts suddenly severe(3S) : Acute aortic dissection, pneumothorax,

and pulmonary embolism.
u Forceful vomiting preceding symptoms : Rupture Esophagus
u Starts gradually and worsen with exertion : ACS. Sometimes,
discomfort rather than pain. TA pressure, heaviness, tightness,
fullness, or squeezing. Ischemia less likely if : knifelike, sharp, pleuritic,
or positional.
u Acute aortic dissection : the pain as tearing, or ripping.
u PE : painless dyspnea, may worsen with deep inspiration, and may
localized to the chest wall
1. Acute Coronary Syndrome
 “Excellence History Taking” in ACS

• Quality : tighness or heaviness, pressure-oppresive, burning

• Location : substernal, centre or across chest
• Radiates to jaw, neck, back or arm
• Age, previous episodes, cardiac underlying disease : HTN, CAD, angina
• Assosiated symtomp : dypnea, diaphoresis, nause/ vomitting, weakness
• Aggravating factors : activity / exertion, stress, anxiety
• Relieving factor : medication
Specific Details of the Chest Pain History
Helpful in Distinguishing Anginal Chest Pain
Due to Myocardial Infarction from Pain of
Noncardiac Causation
Precipitating and Agravating Factors
 Angina
History

• Quality : sudden, last minutes, varies, • Aggravating factors : stress,

spasmodic, tighness or heaviness, exertion, after eating, laying
burning down,situational / anxiety
• Location : substernal, radiates to jaw, • Relieving factor : rest, decreased
neck, back or arm movement, position, medication
• Age, previous episodes, cardiac
(nitro)
underlying disease : HTN, CAD, angina
• Assosiated symtomp : dypnea,
diaphoresis, hypo or hypertension
Anginal Pain

1.Constricting discomfort in the front of the

chest, or in the neck, shoulders, jaw, or arms
2. Precipitated by physical exertion
3. Relieved by rest or nitroglycerin within
about 5 minutes

• Non-anginal pain: 0-1 of the above

• Atypical anginal pain: 2 of the above
• Typical anginal pain: 3 of the above
 Pearls..
• Sharp and stabbing —> frequently non ischemic pain.
• Chest pain that is worse than previous angina or similar—> ACS
• Crescendo pattern —>ACS.
• Aortic dissection PAIN : described by patients as “severe” or “the worst pain ever”
• Nitroglycerin causes relaxation of esophageal muscle.
• NTG : relief of cardiac pain is rapid, less than 5 min,
• NTG : relief of esophageal pain more than 10 min.
• Recent studies : no association between AMI and relief of chest pain with NTG.
GRACE Study
• 8.4% (1763/20,881) patients with ACS presented WITHOUT
chest pain
• Not initially recognised as ACS in 23.8%
- Dyspnoea 49.3%

- Diaphoresis 26.2%
- Nausea and vomiting 24.3%
- Syncope 19.1%
Seorang laki-laki 47 th, dengan keluhan utama nyeri dada,
PF dalam batas normal
Faktor Risiko : HT.
 Working Dx? ? (Q1)

• A. Angina Pectoris
• B. Muskuloskeletal Chest Pain
• C. GERD
• D. Psikosomatis.
 Usul? (Q2)

• A. Foto Thorax
• B. Treadmill
• C. Endoskopi
• D. Obat.
Treadmill TEST, chest pain +
 Next step? (Q3)

• A. MSCT Cardiac
• B. Echocardiografi
• C. Angiografi koroner
• D. Optimal Medicamentosa.
Hasil Angiografi
 “Meticulous Physical Exam” in ACS
• Usually normal, BUT not exclude diagnosis
• Sign of complication :
• Tachypnea
• Hypotension
• Tachycardia-bradycardia
• Jugular vein distention
• Gallop S3
• Pulmonary rales
• Systolic murmur
Rapid ECG Interpretation in ACS
European Heart Journal doi :10.1093.14 June 2007
 STEMI

Symptom Call to Prehospital ED CCU Cath Lab

Recognition Medical System

yt es
yoc
of M
oss
asi ng L
I ncre

Delay in initiation of Pharmacologic

Reperfusion
Acute Coronary Syndrome

STEMI ECG
 ECG in ACS

•A single ECG detects < 50 % percent of

AMIs.
•Normal or nonspecific ECGs have : 1- 5 %
AMI and 4-23% UA.
•Repeated as frequently as every 10 minutes.
•Prior ECG?
70
71
 ST ELEVASI MI

Text
PATIENT 1
Ny N, 44 th, DM.

Nausea and epigastric
pain since 3 hours.
Stable haemodynamics.
Physical Exam within
normal limits
Pain patterns with myocardial ischemia
Usual distribution of pain with Less common sites of pain with
myocardial ischemia myocardial ischemia

Right side Jaw

Epigastrium Back
What’s Your Diagnosis? (Q4)

• A. GERD
• B. NSTEMI
• C. STEMI
• D UNSTABLE ANGINA

76
RV LEADS..
Your Treatment at ED ? (Q5)

• A. ASPIRIN 300 mg
• B. ASPIRIN 150 mg
• C. Nitrat Sublingual
• D. Oksigen

80
 After Diagnosis 

(while decide for Reperfusion
therapy)
• I.V line
• Aspirin 150-300 mg (kunyah)
• CLOPIDOGREL 300 mg or Ticagrelor
180 mg
• Morfin
• Nitrate
• Heparin 5000 units.
Emergency Medical
Therapy
Reperfusion Time
• Thrombolytics : 12
hours, less than 3
hours is the best!
• Primary PCI : up to 48
hours
• Rescue PCI : limitless
We give them Streptokinase at
Emergency Room.

Door to needle time :

45 minutes.
What Should We Do After This?
(Q6)

• A. Echocardiography
• B. Intensive Monitoring at ICCU
• C. MSCT Cardiac
• D. Angiography

88
 STEMI diagnosis a

EMS or non primary-PCI

Primary-PCI capable center
capable center

Preferably
<60 min
PCI possible <120 min?

Immediate transfer
to PCI center
Primary-PCI Yes No
Preferably
≤90 min
(≤60 min in early presenters) Preferably
Rescue PCI ≤30 min

Immediately
Immediate transfer
No to PCI center
Successful Immediate
fibrinolysis? fibrinolysis
Yes

Preferably 3–24 h

a
The time point the diagnosis is confirmed with patient
Coronary angiography history and ECG ideally within 10 min from the first
medical contact (FMC).
All delays are related to FMC (first medical contact).
 Thrombolysis can fail..

After 45-60min:

-Less than 50% ST-resolution

-Ongoing chest pain
-Arrythmias
-Hemodynamic unstable
AFTER FIBRINOLYTIC..
98
99
100
Q7 A. Failed Trombolytic
B. Succesful Trombolytic
C. Should under go PCI ASAP
D. Don’t have to do angiography 101
102
NSTE-ACS

103
Non STE ACS

NSTEMI ECG
TROPONIN.
 Patient 2.
• Our lady, 70 years old with ACS, Pneumonia and Heart
Failure. Shock.

• High Troponin. Leukocytosis. ST depression at

Anterolateral.

• EF only 22 %.

• Recurrent VT.

• On vasopressor. Dobutamin, Norephineprine.

 Medication..
• Aspilet
• Trimetazidine

• Clopidogrel

• Lidocaine

• Atorvastatin 40

• Dobutamin and Nor

• Antibiotics
Epinefrin.

• Ramipril 1.25

• LMWH
• Bisoprolol 1.25
What should we do? (Q8)
A. Angiography and PCI
B. Optimal medical treatment
C. Send the patient to
Harapan Kita Jakarta
D. Pray harder.
IABP placement
Subtotal RCA
Distal LM and prox LAD
Distal LM
 Distal LM and Lcx

•
Ballon 2.0/15 18 atm
Scoreflex balloon 3.0/15 16 atm
Long stent to LAD 2.75/38
14 atm
Stent 3.0/16
16 atm
Wiring RCA
 First day Third day
• Better
haemodynamics
• Increased Leukocyt until
25.000. Change AB

• Oliguria

• But better
• Increased Creatinin — haemodynamics. IABP
> 3.0 —> stop.
haemodialysis
• Finally going home after 1 month
hospitalisation.
Seorang laki2 usia 55 th, smoker. Sudah sebulan
ini setelah mandi selalu dada rasa tidak nyaman.
Saat jalan jauh agak sesak.
Tensi 155/60. PF lain kesan dBN.

Bacaan EKG? (Q9)

A. Normal Sinus

B. STEMI

C. Early Repolarization

D. LVH
• Macfarlane (2015), mendefinisikan
early repolarization pattern
dengan kriteria:

• 1. Takik atau slurred (gelombang

J) pada akhir QRS komplek
dengan dominasi gelombang R;

• 2. Elevasi J-point ≥ 0,1 mV di 2

atau lebih posisi yang
berhubungan, kecuali V1-V3;

• 3. Durasi QRS < 120 milidetik

 Anda di Puskesmas. Usul?
(Q10)

• A. Beri anti platelet dan NItrat

• B. Kirim ke RS untuk evaluasi lanjutan

• C. Pulangkan ke rumahnya tanpa obat

• D. Sampaikan pada keluarga semua baik-baik saja.

Seorang laki2 usia 55 th, smoker.
Sudah sebulan ini setelah mandi selalu dada rasa
tidak nyaman.
Saat jalan jauh agak sesak.
Tensi 155/60. PF lain kesan dBN.
How to Rule Out ACS in Chest
Pains without Troponin?
2. Acute Aortic Dissection
DEFINITION
 Chest Pain in AORTIC DISSECTION vs MI

• Severe, sudden tearing sensation in the chest, back or

abdomen (may radiate into legs).
• Aortic Dissection pain radiates to back or
• Myocardial Infarction rarely radiates like this
• Aortic Dissection pain is most severe at onset
• Myocardial Infarction pain is typically crescendo in nature
• Some times : neurovascular symptoms
Chest Pain in AAD.
How to Diagnosed AAD?
 X RAY

>8.7 cm

LMW> 5.5 AP POS

LMW>4.95 PA POS
 Classic Triad

1. SEVERE abrupt onset Chest Pain

2. Pulse deficit or difference in upper extremity BP> 20
mmHg
3. Widening Mediastinum on X Ray.
TTE TEE
Let’s Quiz
• A man 40 y.o smoker. Severe chest pain. High CKMB. Shock.
 Working Diagnosis (Q11)?

• A. STEMI
• B. Aortic Dissection
• C. NSTEMI
• D. Unstable Angina
 What will you do(Q12)?

• A. Activate Cath Lab

• B. Anti Platelet
• C. Thrombolytic
• D. Anti coagulant
“A high level of suspicion is required for
successful diagnosis as presenting
symptoms are so variable…”
• Laki-laki 70 tahun. Hipertensi lama.
• Nyeri dada dada tengah depan. Tidak menjalar.
• Tidak ada pulse deficit. TD kanan dan kiri sama.
220/100. HR 120 x/menit
• EKG : Sinus takikardi

Usul ? (Q13)
A. Foto Thorax
B. Cek Troponin
C. Cek CKMB
D. Cek D Dimer
3. Acute Pulmonary Embolism
Pulmonary Embolism, What kind of Chest Pain?

• Onset : sudden pain, pleuritic chest pain, painless dyspnea, may worsen
with deep inspiration, and may localized to the chest wall.
• Location : lateral chest
• Previous hystory of DVT, recent surgery, smoking
• Assosiated symptom : dypnea, diaphoresis, syncope, hypo or
hypertension, cyanosis, hemoptysis
• Aggravating factors : breathing
• Relieving factors : decreased or shallow breathing
“It is critical that high level of suspicion be maintaned”
Diagnosis?(14)
A. Ischemia.
B. PE
C. Cor Pulmonale
D. None
“It is critical that high level of suspicion be maintaned”
Westermark sign has a 14%
T

sensitivity, 92% specificity, 38%

PPV, and 76% NPV
hest_radiograph_and_CT_of_the_Westermark_sign.pptx
 Ha
Hampton Hump and
Palla Sign
Pulmonary Embolism
 Another Quiz (15)
Latihan No. 63, 27 Juni 2020, dr. Emil Parapat, Sp.JP(K)

Pasien perempuan 64th, dikonsulkan krn sesak nafas. Pasien sdh opname 3 hari, sesak tdk berkurang disertai
nyeri dada. Dgn riwayat Ca Hepar dan Leukemia.

A. STEMI B. Early Repolarization C.Pericarditis D.None above

\
4.Pericarditis

Pericarditis
 Pericarditis

• Onset : sudden pain, last hours

• Quality : Sharp / localized
• Location : centre or acrross chest / retrosternal
• Radiates to neck or arm (not always)
• Previous history of URTI / fever
• Assosiated symptomp : dypnea, paradoxical pulse
• Aggravating factors : breathing, movement
• Relieving factors : sitting up or leaning forward, medications
 Pericarditis

• Pericardial friction rub at left lower sternal border, when leaning forward
at the end of expiration

ST elevation in all leads

• Suggest Cardiac Tamponade if :
• Muffled heart sound (1)
• Tachycardia
• Distended neck vein (2)
• Hypotension (3)
• Pulsus paradoxus
• Becks Triad
5. Pneumothorax
 Pneumothorax

• Onset : sudden pain

• Quality : pleuritic, tearing
• Location : lateral chest
• Previous hystory : trauma
• Assosiated symptomp : dypnea, hypo or hypertension
• Aggravating factors : breathing, movement
• Relieving factors : rest or decreased movement, decreased or shallow
breathing
 Pneumothorax

• Decreased excursion on affected

side
• Diminished breath sounds
• Hyperresonant lung

Blue arrow : collaps lung

White arrow : White

visceral pleural line
5. Esophageal Ruptur
Algorithm for Chest Pain in ED
Thank You
 Aortic Dissection

• Onset : sudden pain

• Quality : Sharp, tearing / excruciating
• Location : centre or acrross chest, abdomen
• Radiates to back
• Underlying cardiac disease : HTN, Marfan, ED synd.
• Assosiated symptomp : diaphoresis, syncope, unequal BP, pulsating abdominal
mass, abdominal pain
• Aggravating factors : hurts badly no matter what
• Relieving factors : nothing helps it feel better
 Aortic Dissection

• Pulse defisit or blood pressure differential

• Focal neurological dificits --> compression artery that suplay spinal cord
• Pulsatile sternoclavicular joint
• Murmur aortic regurgitation
• Sign of cardiac tamponade