Chest Pain

Wan Mizgin
 Objectives
By the end of the presentation, students will be
able to:
• Define chest pain
• Distinguish between different causes of
chest pain
• Describe appropriate management and
treatment options depending on cause of
the patient’s chest pain

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 Myocardial infarction
Ischemic
Cardiac
Aortic dissection
Non-
Chest ischemic Pericarditis

pain GI
GERD
Esophageal spasm
Noncardiac Pulmonary
Pneumonia
Pulmonary embolism
Anxiety disorder
Others Chest wall syndrome3
 Case 1
• 59 year old male presents to ER with chest pain
for 2 days duration, the pain started gradually and
it is progressively getting worse. Pain radiates to
the back and shoulders and is squeezing in
character. It started when he was resting after
work and it exacerbates with exertion, there is no
relieving factor. Pain is associated with nausea and
sweating, but no any other symptom.
“
• PMH: hypertension for 6 years
• PSH: insignificant
• Medication Hx: antihypertensive???
• No known drug allergy up until now
• Social Hx: smoker, non alcoholic

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 Physical Examination
• Pt. in pain
• Pain not reproducible
• CV: tachycardia, regular rhythm; no murmurs, no
bruits
• Lungs: clear to auscultation

Vitals:
- BP: 90/60 mmHg
- HR: 100 BPM
- SPO2: 92%
- RR: 24 BPM 6
• Typical angina (definite):
1- Substernal chest discomfort with a
Clinical classification
characteristic quality and duration.
2- provoked by exertion or stress.
of chest pain
3- relieved by rest or GTN.
(Diamond, Forrester)
• Atypical angina:
- Meets 2 of above characteristics.
• Noncardiac chest pain: meets 1 or none.
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 Marburg Heart Score
• Age >= 65 years in women, >=55 years in men

• Known clinical vascular disease (e.g. CAD, CVD)

• Chest pain increases with Exercise

• Chest Pain not reproduced with palpation of the

chest wall

• Patient assumes pain is of cardiac etiology

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 Interpretation of the
MHS
If the patient has
• 0-1 points → pt’s CP is not cardiac (almost 100% NPV)
-Treat as non-cardiac CP (look for other causes)
• 2-3 points → pt’s CP may be cardiac
-Consider CAD-related CP (further w/u non-invasive)
-Exercise Stress Testing + Myocardial Perfusion Echocardiography
-CCTA or CMRIA (becoming new first-line test in the US)
• 4-5 points → pt’s CP likely to be cardiac
-Consider CAD-related CP (further w/u invasive)
-Cardiac angiography 9
 Back to our patient…
Our pt. Points

• 59 Y/O • 1

• Hypertension • 1

• Pain worse on exertion. • 1

• Nonreproducible chest pain • 1

• Patients assumes it is his heart • 1

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Management
• Always start with ABC

• Check vital signs

• Send for ECG ASAP

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 Investigations
Cardiac enzymes: CBC: RFT:

• Troponin: 9.95 ng/ml • Urea: 48mg/dL

• WBC: High • Creatinine:
normal<0.5
1.37mg/dL
• Hb: Normal
• CK-MB: 34.72 ng/ml

Normal<5.0 • PLT: Normal

• Myoglobin: 198.38
ng/ml

Normal<80 12
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 Treatment:

• Oxygen
• Aspirin
• Morphine+ antiemetic
• Nitroglycerine
• Send pt. for coronary
angiography
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 Case 2
• A 45 year old female, high school teacher presents to
her cardiologists clinic with intermittent retrosternal

chest pain for 3 months duration. It started gradually

and has been increasing in frequency and intensity
since then. The pain is burning in character and there
is no radiation. It is associated with palpitation and
bitter taste in mouth. It gets worse with some types
of food (coffee, chocolate, spices…etc), with lying
downs especially at night. Pain is relieved with
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taking PPI.
“ • PMH: hypothyroidism,
hyperprolactinemia.
• PSH: C-section, lipoma resection
• Medications: levothyroxine,
cabergoline

NKDA up until now.

• Social Hx: Non- smoker, non- 17
 Physical examination:
• Pt. is not in distress
• Pain not reproducible
• CV: normal rate, regular rhythm, good
volume; no murmurs, no bruits.
• Lungs: clear to auscultation.
• Abdomen: soft, mild tenderness in
epigastric region. Normal bowel sounds.

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“
• Vital signs:
• BP: 120/80 mmHg

• HR: 80 BPM

• SPO2: 99%

• RR: 14 BPM

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Management:

• ABC

• Check vital signs

• Send for ECG ASAP

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Investigations:
Echocardiography report:
• CBC
• Normal cardiac
• Thyroid
chambers
function Test • Normal wall thickness
with good systole
• RBS
• No significant abnormal
• RFT
valve flow

• Lipid profile • Diastolic dysfunction

• Trivial pericardial 22
 Diagnosis of GERD:

• 24 Hour PH monitoring

• Upper endoscopy

• Esophageal manometry: in patients

with normal endoscopy and atypical
symptoms.
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 Treatment:
Lifestyle changes: Pharmacotherapy:
• Weight loss in
overweight/obese patients • Step up therapy

• No eating 2 hours before vs. step down

sleeping
• Eliminate food that increase therapy.
gastric acid production
• PPI
• Elevation of the bed head.
• H2RA

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 Case 3
• A 72-year old elderly gentleman was rushed to the ER

due to in-flight onset of severe chest pain that started a

few minutes before the landing of his long-haul flight

from New Delhi, India. He complains of having a sharp

pain that is associated with shortness of breath and

profuse sweating. There is no radiation, and no

exacerbation/relieving factor.
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• PMH: HTN
• PSH: left knee replacement, six
weeks ago.
• Medication: diuretic
NKDA up until now
• Social Hx: non-smoker, non-
alcoholic
• FH: not significant

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 Physical examination:
• Patient is restless, tachypneic, pale and diaphoretic.

• The pulse is rapid, irregular.

• The JVP is elevated and there is edema, erythema and

tenderness over the left calf.

• There is tachycardia, loud P2 and a right-sided S3. No

murmur or pericardial friction rub is audible.

• On chest auscultation, breath sounds are diminished over

the base of the left lung posteriorly.

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Vital signs:

• PR: 110-120 BPM

• BP: 90/60 mmHg.
• RR: 32 BPM
• SPO2: not given

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 Wells score
• Clinical signs and symptoms of DVT = 3
• An alternative diagnosis is less likely than PE =
3 0-1: low risk
2-6: moderate risk
• Heart rate more than 100 = 1.5 >6: high risk

• Immobilization for 3 or more consecutive days

or surgery in the previous 4 weeks = 1.5
• Previous objectively diagnosed PE or DVT =
1.5
• Hemoptysis = 1
• Malignancy (on treatment, treatment in last 6 29
 Pretest probability of PE
Low Intermediate High
• PE rule out criteria • D-dimer • CTPA
• D-dimer • Normal:
• Normal no exclude
further testing is PE
required • High:
• High CTPA CTPA

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 Best initial Tests
ECG: CXR ABG
• Sinus tachycardia • Most commonly • Hypoxemia
normal • Respiratory
• Nonspecific ST
changes • Rare cases: alkalosis
• Hamptons
• T wave changes
hump
• New right bundle • Watermark
branch block sign
• Rare/ classic
Finding:
• S1Q3T3
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Treatment: depends on hemodynamic
status:
Unstable Stable:
• Thrombolytic therapy: • Anticoagulation
TPA therapy
• C/I for thrombolysis: • C/I:
pulmonary • Inferior vena
embolectomy cava filter

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