Chest pain

Causes
- Cardiac
 MI
 Aortic dissection
- Respiratory
 Pneumonia
 Pulmonary embolism
 Pneumothorax
- Gastrointestinal
 GERD and esophagitis
 Gastritis and peptic ulcer
 Cholelithiasis and cholecystitis  produce substernal pain
- MSK
 Rib fracture
 Costochondritis
- Psychological
 Anxiety
 Panic attack
History
OLD CARTS
- Myocardial pain
 Substernal chest pain
 Radiate to left arm, shoulders or jaw
 Associated with diaphoresis, shortness of breath, nausea and vomiting
- Anginal pain
 Last from 5-15min
 Pain appear with exercise, eating or emotional excitement
 Disappear with rest or nitroglycerin
- Pericardial pain
 Persistent, sharp, severe pain
 Relieved by sitting up
 Aggravated by lying back or coughing
- Pneumothorax
 Sudden onset, sharp, unilateral, pleuritic pain
 Associated with shortness of breath
- GERD
 Burning pain that radiates to sternum
 Worse with food and lying down
 Antacids relieve the pain
- Costochondritis
 Produced with palpation
 Patients are reluctant to take deep breath
Physical examination
- General features
 Hypotension  MI, pericardial tamponade, PE and GI bleeding
 Tachycardia  severe illness, arrhythmias
 Fever  pneumonia
 Crepitus  rib fracture
 Sharp localized tenderness  costochondritis
 - Cardiac exam
 MI  audible S4
 Signs of congestive heart failure  S3 and pulmonary rales
 Pericarditis  friction rub and pulsus paradoxus
 Becks triad  suggest cardiac tamponade seen in pericarditis
 Jugular venous distention
 Muffled heart sounds
 Decreased blood pressure
 Aortic dissection
 Hypotension
 Absence of peripheral pulse
 Murmur of aortic insufficiency
- Respiratory exam
 Pneumonia
 Crackles on inspiration, dullness of percussion, egophony, indicates
consolidation
 Pneumothorax
 Hyperresonance to percussion, tracheal deviation, decrease breath sounds,
decreased tactile and vocal fremitus
 Pulmonary embolism
 Normal auscultation, tachycardia, tachypnea, lower extremity edema
Diagnosis
- ECG  initial test to exclude MI
 Diffuse ST elevation  pericarditis
 Q waves  old or recent MI
 ST depression
- Cardiac markers
 Creatine phosphokinase (CPK)
 MB-CPK rise within 4hrs, and peak within 24hrs
 Troponin  first enzymes to rise
 Remain elevated from 5-14days
 Most sensitive and specific
- In stable patients with suspected cardiac disease, outpatient exercise stress is indicated
 Patients with abnormal ECG, positive exercise stress should go radionuclide
testing, stress echo or coronary angiogram
 If patient cannot exercise then chemical stress test with adenosine or dobutamine
- Echocardiogram
 Detect wall motion abnormality in areas damaged with MI, pericardial effusion,
valvular heart diseases
- Chest Xray
 Detect pneumonia, pneumothorax
 Spiral CT scanning is indicated for abnormal Xray
- D dimer for possible pulmonary embolism
Treatment
- Patients with suspected MI, unstable angina, PE should be hospitalized for evaluation
- Patients with MI
 Stabilize initially with oxygen, nitroglycerin, and morphine
 Give aspirin asap  clopidogrel is alternative for allergic patients
  Beta blockers, ACE inhibitors, heparin, nitrates, thrombolytic are other drugs to
treat MI
 Systolic BP should be maintained at 100-120mmHg (except for previous
hypertensive patients) and heart rate at 60bpm
 Thrombolytic indicattions
 Age <75yrs
 ST segment elevation
 History consistent with acute MI who present within 6hrs of chest pain onset
 Thrombolytic contraindications
 Active internal bleeding
 History of CVA
 Recent surgery
 Intracranial neoplasm
 AV malformation
 Aneurysm
 Bleeding diathesis
 Severe uncontrolled hypertension
 Percutaneous transluminal coronary angioplasty (PTCA) is alternative to
thrombolytic therapy  provide emergent catheterization
 Glycoproteins inhibitors are added to heparin in patients with unstable angina and
non Q wave infarction
- Patients with stable angina are treated with aspirin and sublingual nitroglycerin
 Beta blockers reduce symptoms, and increase anginal threshold
 Long acting nitrates reduce anginal pain
 CCB if symptoms still persistent
 Risk control (hypertension, physical inactivity, dyslipidemia) as long term
management
 LDL < 75-100mg/dl in patients with CAD
- Patients with aortic dissection is emergency and require hospitalization and surgical
consultation
- Pericarditis improve with aspirin and NSAIDs
 Use of steroids in severe cases
- PE require anticoagulation
 Warfarin is started concomitant with heparin
 Once normal INR is reached  stop heparin
- Large pneumothorax is treated with chest tube insertion
- Costochondritis is treated with NSAIDs