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Approach to Chest Pain

CVS Pulmonary GIT MSK Misc
Pericardium Pleura Esophagus Rib Fracture Herpes Zoster
- Pericarditis - Pleuritis - GERD Costochondritis (Shingles)
Myocardium - Pneumothorax - Esophagitis Psychiatric
- HF Airways & Alveoli - Eso. Spasm - Panic Attack
- Myocarditis - Asthma Stomach - Somatization
- CM - COPD - Gastritis
Endocardium - Pneumonia - PUD
- Endocarditis Vessels
Valves - PE
- AS, MS, - Pul. HT
- AR, MR, Lung Cancers
Arterial Diseases
- Atherosclerosis (large arteries ➝
cholesterol plaque in tunica intima)
- Monckeberg Sclerosis (medium
arteries ➝ dystrophic calcification
in tunica media)
- Arteriolosclerosis (small arteries ➝
hyaline or hyperplastic)
Vessels (Aorta)
- Aortic dissection
- Aortic Aneurysm
- Subclavian Steel Syndrome
- HTN
- ACS/IHD
Conduction System
- Tachycardia
- Bradycardia
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CVS Chest Pain

Association CF Ix & Rx
HF High output Failure ➝ A2T2P LVF CXR ➝ ABCDE
V Systolic (S3)  Orthopnea Gross ➝ Nutmeg app.
C=  Eccentric hypertrophy (series)  PND Sx relief & ↓ Mortality:
P  Dilated CM (ABCCD)  PEd (HF cells in lungs)  Hydralazine with nitrate
Diastolic (S4) RVF  ↓ Mortality ➝ A + B
 Concentric septal hypertrophy  ↑ JVP  ↓ Sx ➝ C
 Hypertrophic (young sudden death)  Hepatomegaly (Nutmeg) AHA Classification:
Infiltrative CM (P LEASH) Pedal edema A. ACEi, ARB
B. β blockers, K sparing
C. Diuretics (loop & thiazide)
D. Neprilysin inhibitors
Tamponade Fluid compresses all 4 chambers ➝ ↓ CO Pulsus Paradoxus (Pea COAT) Echocardiogram
Equilibrium of diastolic pressure in all Beck’s Triad  Pericardial effusion
chambers ↑ JVP, muffled HS, ↓ BP  (Echo free zone around
heart)
ECG
 Low voltage QRS
 Electrical alternans
Rx ➝ Pericardiocentesis
Pericarditis Causes ➝ SC2AR2 I2N pericardium Pericardial friction rub, fever ECG: (PericarditiS)
Chest Pain  PR depression
 Worse on inspiration  Saddle-shaped (concave) ST
 Relieved by sitting forward elevation in all leads
Rx:
 NSAIDs + Colchicine
 Steroids (glucocorticoids)
 Dialysis
Myocarditis Major Cause of SCD in Adults (< 40 years): Chest pain, SOB, fever Complications:
 Viral (PACHH) Characteristic:  Dilated CM (Coxsackie B)
 Parasitic (T. cruzi, T. gondii)  Persistent tachycardia out of  Heart block, HF, SCD
 Others (CO, doxorubicin, Kawasaki) proportion to fever.  Mural thrombus with systemic
Sudden Deaths in Young: emboli
 HOCM
 Long QT syndrome
 Brugada ➝ Pseudo RBBB w ST
Endocarditi Rheumatic Fever Rheumatic ➝ JONES Criteria Rheumatic Fever
s  Immune-mediated (hypersensitivity II) Infective  Histology
o M protein with Myosin  Fever >1wk + New Murmur o Aschoff bodies
 Cause  FROM JANE o Anitschkow cells
o Pharyngeal infection. with group A  Vascular + Immuno. o Wavy, rod-like Nucleus
β hemolytic streptococci  Tricuspid (drugs)  ECG ➝ Prolonged PR
o Mitral > Aortic > Tricuspid Non-bacterial thrombotic  Titers
Infective  Asymptomatic till embolism o ↑ ASO
 Asso. ➝ PG2 C2D o ↑ Anti-DNase B
 Types ➝ Acute & Subacute  Rx: Penicillin
Non-bacterial thrombotic Infective
 Hypercoagulable state  Ix: blood culture + Echo
o Pancreatic adenocarcinoma  Rx: antibiotics
o SLE (Libman-Sacks)
Arterial Atherosclerosis Atherosclerosis (A CoPy Cat Willis) Monckeberg: Pipestem app in X ray
Diseases  Cholesterol plaque accumulation within  Pathogenesis: Atheroma Atherosclerosis
vessel walls (PDGF)  Obstructive plaque (ischemia,
 Intima involved in large arteries  Location: Abdominal aorta > infarct, peripheral vascular
Mönckeberg Arteriosclerosis Coronary A > Popliteal A > disease)
 Dystrophic calcification w/in vessel walls Carotid A > Circle of Willis  Plaque rupture causes
 Media involved in medium arteries  RF: AGE, Cig, DM, HT, ↑ LDL thrombus or Cholesterol
 Lumen unaffected thus vascular  Sx: angina, claudication Emboli Syndrome (vascular
stiffening without obstruction. occlusion)
Arteriolosclerosis  Aneurysm and rupture
 Response to ↑ pressure in small arteries
 Hyaline ➝ pink amorphous deposits in
arterial wall
 Hyperplastic ➝ “Onion-skin” app.
Traumatic Aortic Dissection (intimal tear ➝ false lumen) Aortic Dissection AD CXR: wide mediastinum.
Aortic  Hypertension  Tearing, sudden chest pain TAA AAA
Rupture  Bicuspid Aortic valves, radiating to back Chest & back pain Back pain
 Inherited CT disorder (Marfan or  Markedly unequal BP in arms. Hoarse voice + Pulsatile
Danlos-Ehlers Syndrome)  Result in organ ischemia, SOB (Lt recurrent mass (Bruit)
TAA (cystic medial degeneration) aortic rupture, death. laryngeal N) Resistant
 Same as above (HT, Bicuspid, CT dx) Stanford A Stanford B hypotension
 3o Syphilis (endarteritis of vasa Ascending Descending Aorta CXR: wide CT: dilated
vasorum) Aorta (AR / (Below left SCA) mediastinum aortic wall
AAA (transmural degeneration) tamponade Location: Infrarenal
 Tobacco use (smoking) ) ascending aorta location
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 Age, Male, Family Hx Rx: surgery βB ➝ Vasodilator (Root dilation, AR)

Subclavian Etiology: Axillary artery Imaging:

Steel  Atherosclerosis,  Claudication,  Reduced contrast uptake in
Syndrome  Takayasu arteritis,  Ipsilateral limb ischemia, areas distal to stenosis and
(SSS)  Prior thoracic (aortic) surgery.  Asymmetric SBP b/w UL (>15) ipsilateral vertebral artery.
Patho:  Sx ↑ w activity of affected limb.
 Lt SCA stenosis ➝ retrograde blood Vertebrobasilar insufficiency
flow from Rt to Lt vertebral artery.  Dizziness, diplopia, vertigo

Aortic Dissection:
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Valvular Defects
Valvular Auscultation Unique
Murmur Classic Cause Heart Failure ↑ Murmur Intensity
Disease Location Feature
Holosystolic crescendo- Radiation to Diastolic: Concentric ↑ Preload (Passive leg raise) ↓
AS 2nd R ICS Dystrophic calcification Afterload
decrescendo carotids hypertrophy (S4)
High pulse Systolic: Eccentric ↑ Preload (Passive leg raise) ↑
AR Diastolic decrescendo Erb’s point Multiple Afterload (Hand grip)
pressure hypertrophy (S3)
↑ Preload (Passive leg raise) ↓
MS Diastolic decrescendo Cardiac apex Opening snap Rheumatic heart disease Low output Afterload
Systolic: Eccentric ↑ Preload (Passive leg raise) ↑
MR Holosystolic murmur Cardiac apex Radiate to axilla MVP Afterload (Hand grip)
hypertrophy (S3)
↑ with Inspiration
↑ with IVDU ➝ Infective
TR Holosystolic murmur 4th L ICS Right-sided ↑ Preload (Passive leg raise) ↑
inspiration endocarditis Afterload (Hand grip)
Mid-systolic ↓ Preload (Valsalva)
MVP Late-systolic crescendo Cardiac apex Multiple MR ➝ Systolic Later click with ↑ Afterload
click
Systolic crescendo- Left lower sternal Inherited mutations in ↓ Preload (Valsalva) ↓
HOCM Young patient Septal hypertrophy (S4) Afterload
decrescendo border sarcomere

Congenital Heart Diseases

# Disease Principle Problem Unique Features CXR Associations
Acyanotic (Later Cyanosis ➝ Left to Right Shunt)
Harsh holosystolic murmur & LLSB
Defect in membranous part of ventricular
(MR @ apex) Down Syndrome
1 VSD* (MC) septum Self-resolves
↑ murmur due to ↑ afterload Maternal Diabetes
(Endocardial cushion)
↓ murmur due to ↑ size/severity
Defect in intra-atrial septum
Wide, fixed split S2 Down Syndrome
Septum primum occurs with other
2 ASD Paradoxical embolism - Fetal Alcohol
murmurs
(Cryptogenic shock) Syndrome
Septum secundum is MC
Failed fusion of septum primum and ASD
3 PFO - -
secundum Paradoxical embolism
Premature:
Prematurity
Indomethacin ➝
Rubella (1st trimester)
Close PDA
Impaired closure of ductus arteriosus Continuous machine-like murmur Fetal alcohol
4 PDA Cyanotic CHD:
(Derived from 6th left aortic arch) wide pulse pressure (like AR) syndrome
PGE1 (Alprostadil) ➝ Fetal hydantoin
Maintain PDA syndrome

CoA + PDA ➝ aSx

CoA + NO PDA:
Juxtaductal narrowing
(Aortic isthmus i.e., between ductus
6 CoA
arteriosus and left subclavian artery)
Chronic L to R shunting ➝ Pul. HT ➝ RVH
5 Eisenmenger (RVP > LVP) ➝ R to L shunting
(Shunt Reversal)
Cyanotic (Early Cyanosis ➝ Right to Left Shunt)
Persistent Incomplete aorticopulmonary septum
1 Truncus
formation ➝ single vessel
Arteriosus
Failed spiralling of aorticopulmonary
2 TGA septum ➝ aorta and pulmonary artery
switched locations
No functional tricuspid valve,
3 Tricuspid Atresia
hypoplastic RV
4 ToF Deviation of infundibular septum
Berry aneurysm
1. Harsh systolic murmur at CXR: notched ribs
(↑ rupture in SAH)
Rx: PGE
multiple locations (LSB) Bicuspid aortic valve
(PDA maintains BP to
2. Differential cyanosis Turner syndrome
lower limb)
3. Brachial-femoral delay Williams syndrome
Lower extremity claudication
Heart failure
Cyanosis (systemic) & clubbing
Differential cyanosis & clubbing if - -
Eisenmenger with PDA
(Cyanosis in lower limb NOT UL)
Minimal cyanosis initially ---- DiGeorge Syndrome
Severe cyanosis at birth
Two parallel circuits, requires ASD, Egg-on-a-string Maternal diabetes
PFO, VSD, and/or PDA for survival
Severe cyanosis at birth Ebstein Anomaly
↓ Pulmonary markings
Requires ASD, PFO, VSD, &/or PDA (Lithium)
Tet spells Boot-shaped heart DiGeorge syndrome*
PROVE (pulmonic stenosis, Down syndrome
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overriding aorta, RVH, VSD) Maternal alcohol use

Pulmonary veins drain into right heart
5 TAPVR Pulmonary hypertension Snowman sign ----
circulation
Aorticopulmonary Septum problem (failure of Neural Crest Cell migration) ➝ Truncus Arteriosus (1), TGA (2), ToF (4)

CoA PDA
Differential Cyanosis Differential Cyanosis
Normal BP and pulse in lower limb ↓ BP and ↓ pulse in lower limb
- Breastfeeding causes SOB in CHD (classic as baby is NOT breathing through mouth).