Chest pain

CHEST PAIN

5% of all ED visits per year
Differential diagnosis is difficult

CHEST PAIN

ANATOMY
DIFFERENTIAL DIAGNOSIS
BRIEF OVERVIEW OF DISEASE PROCESSES CAUSING CHEST PAIN
APPROACH TO

ANATOMY

In devising a differential diagnosis for chest pain, it becomes essential

ANATOMY

SKIN MUSCLES

ANATOMY

BONES

ANATOMY

PULMONARY SYSTEM

ANATOMY

HEART

ANATOMY

VASCULAR AND GI SYSTEM
AORTA AND ESOPHAGUS

DIFFERENTIAL DIAGNOSIS OF CHEST PAIN

CHEST WALL PAIN
PULMONARY CAUSES
CARDIAC CAUSES
VASCULAR CAUSES
GI CAUSES
OTHER

DD: CHEST PAIN

CHEST WALL PAIN
1 - Skin and sensory nerves

DD: CHEST PAIN

PULMONARY CAUSES
1 - Pulmonary Embolism
2 – Pneumonia
3

DD: CHEST PAIN

CARDIAC CAUSES
- Coronary Heart Disease
*Myocardial Ischemia
*Unstable

DD: CHEST PAIN

Vascular Causes:
-Aortic Dissection

DD: CHEST PAIN

GI CAUSES
-ESOPHAGEAL
*Reflux
* Esophagitis
* Rupture (Boerhaave

DD: CHEST PAIN

PSYCHIATRIC
- PANIC DISORDER
- ANXIETY
- DEPRESSION
-

CHEST PAIN

BRIEF OVERVIEW OF DISEASE PROCESSES CAUSING CHEST PAIN

CHEST WALL PAIN

.

CHEST WALL PAIN

HERPES ZOSTER
-Reactivation of Herpes Varicellae
- Immunocompromised patients

HERPES ZOSTER

Clusters of vesicles (with clear or purulent fluid) grouped on

HERPES ZOSTER

TREATMENT:
* Antivirals: reduce duration of symptoms; incidence of postherpatic

CHEST WALL PAIN

Musculoskeletal Pain
- Usually localized, acute, positional;
- Pain

MUSCULOSKELETAL PAIN

DIAGNOSIS
COSTOCHONDRITIS
TIETZE SYNDROME
XIPHODYNIA
PRECORDIAL CATCH SYNDROME
RIB FRACTURE

CLINICAL FEATURES
Inflammation of costal cartilages +/-

MUSCULOSKELETAL PAIN

Treatment:
Analgesia (NSAIDs)

PULMONARY CAUSES OF CHEST PAIN

.

PULMONARY EMBOLISM

RISK FACTORS: VIRCHOW’S TRIAD
- Hypercoagulability
*Malignancy
*Pregnancy, Early Postpartum,

PULMONARY EMBOLISM (PE)

CLINICAL FEATURES
- Shortness of breath
- Chest pain:

PE: DIAGNOSTIC TESTS

ECG:
-Sinus tachycardia most common
- Often see

PE: S1Q3T3

PE: DIAGNOSTIC TESTS

CHEST X-RAY
- Normal in 25% of cases
-

CXR: Hampton’s Hump and Westermark’s Sign

PE: DIAGNOSTIC TESTS

ABG:
*Look for abnormal PaO2 or A-a gradient
D-Dimer:

PE: DIAGNOSTIC TESTS

VQ SCAN (Ventilation-Perfusion scan)- use in setting of renal

PE: TREATMENT

Initiate Heparin
* Unfractionated Heparin: 80 Units/Kg bolus IV, then

PNEUMONIA

CLINICAL FEATURES
- Cough +/- sputum production
- Fevers/chills
- Pleuritic

PNEUMONIA: DIAGNOSIS

X-Ray
If patient is to be hospitalized:
Consider GBC (to look for

LOCALIZING THE INFILTRATE

IDENTIFYING LOCATION OF INFILTRATES

RUL PNEUMONIA

RUL INFILTRATE

RML INFILTRATE

Notice that right heart border becomes obscured on PA view

RLL PNEUMONIA

RLL infiltrate

PNEUMONIA: TREATMENT

Community- Acquired:
- OUT-PATIENT
*Doxycycline: Low cost option
*

SPONTANEOUS PNEUMOTHORAX

RISK FACTORS:
- Primary
* No underlying lung disease

PNEUMOTHORAX

CLINICAL FEATURES
- Acute pleuritic chest pain: 95%
- Usually pain

TENSION PNEUMOTHORAX

What is wrong with this picture??

TENSION PNEUMOTHORAX

Answer: Chest X-ray should have never been obtained
Tension PTX is

Tension Pneumothorax

Trachea deviates to contralateral side
Mediastinum shifts to contralateral side
Decreased breath

NEEDLE DECOMPRESSION

Insert large bore needle (14 or 16 Gauge) with catheter

SPONTANEOUS PTX

RIGHT SIDED PTX

SPONTANEOUS PTX

TREATMENT:
- If small (<20%), observe with repeated X-rays
-

PLEURITIS/SEROSITIS

Inflammation of pleura that covers lung
Pleuritic chest pain
Causes:
- Viral etiology

COPD/ASTHMA EXACERBATIONS

CLINICAL FEATURES:
- Decrease in O2 saturations
- Shortness of

COPD EXACERBATION: TREATMENT

Oxygen: Must prevent hypoxemia. Watch for hypercapnia with O2

ASTHMA TREATMENT

Oxygen
Inhaled short acting B2 agonists: Albuterol
Anticholinergics: Atrovent
Corticosteroids
Magnesium
Systemic B2 agonists: Terbutaline
Heliox
If

CARDIAC CAUSES OF CHEST PAIN

.

RISK FACTORS FOR CAD

Age
Diabetes
Hypertension
Family History
Tobacco Use
Hypercholesterolemia
Cocaine use

ISCHEMIC CHEST PAIN

EXERTIONAL ANGINA
* BRIEF EPISODES BROUGHT ON BY EXERTION

Angina pectoris

Stable angina pectoris is a clinical syndrome characterized by precordial

Angina pectoris

The chest discomfort may be described by the patient either

The chest discomfort usually lasts up to 20 minutes; a typical

ISCHEMIC CHEST PAIN: DIAGNOSIS

12 LEAD EСG
- Look for ST segment

ACUTE MYOCARDIAL INFARCTION

ACUTE INFERIOR MI
ST ELEVATION II, III, AVF

ACUTE ANTERIOR MI
ST SEGMENT ELEVATION V2-4

EСG CHANGES IN ISCHEMIC HEART DISEASE
ST SEGMENT T WAVE

EСG CHANGES IN ISCHEMIC HEART DISEASE
Q WAVES LBBB

ISCHEMIC CHEST PAIN: DIAGNOSTIC TESTS

CARDIAC ENZYMES
- Myoglobin
* Will rise

ISCHEMIC HEART DISEASE TREATMENT: ACUTE ST SEGMENT ELEVATION MI

- OXYGEN
-

ISCHEMIC HEART DISEASE TREATMENT: NONSTEMI AND UNSTABLE ANGINA

- OXYGEN
-

LOW RISK CARDIAC CHEST PAIN

If low risk chest pain, can consider

VALVULAR HEART DISEASE

AORTIC STENOSIS
*Classic triad: dyspnea, chest pain, and syncope

ACUTE PERICARDITIS

CLINICAL FEATURES
- Acute, stabbing chest pain
- Pleuritic chest

ACUTE PERICARDITIS

COMMON CAUSES
* IDIOPATHIC
* INFECTIOUS
* MALIGNANCY
* UREMIA

ACUTE PERICARDITIS: DIAGNOSTIC TESTS

ECG
*Look for diffuse ST segment elevation and

ACUTE PERICARDITIS

Diffuse ST segment elevation

TAMPONADE

ELECTRICAL ALTERNANS

ACUTE PERICARDITIS

TREATMENT:
- If idiopathic or viral: NSAIDs
- Otherwise treat

MYOCARDITIS

Inflammation of heart muscle
Frequently accompanied by pericarditis
Fever
Tachycardia out of proportion to

VASCULAR CAUSES OF CHEST PAIN

.

AORTIC DISSECTION

RISK FACTORS
- UNCONTROLLED HYPERTENSION
- CONGENITAL HEART DISEASE
-

AORTIC DISSECTION

CLINICAL FEATURES
* Abrupt onset of chest pain or pain

DIAGNOSIS: AORTIC DISSECTION

CXR: Look for widened mediastinum
CT SCAN:
ANGIOGRAPHY
TEE
** suspected dissectons

AORTIC DISSECTION

WIDENED
MEDIASTINUM

AORTIC DISSECTION

TREATMENT:
- ANTIHYPERTENSIVE THERAPY
*Start with beta blockers (smell, labetalol)

GI CAUSES OF CHEST PAIN

.

ESOPHAGEAL CAUSES

REFLUX
ESOPHAGITIS
ESOPHAGEAL PERFORATION
SPASM/MOTILITY DISORDER/

GERD

RISK FACTORS
* High food fat
* Caffeine
* Nicotine, alcohol

GERD

CLINICAL FEATURES
* Burning pain
* Association with sour taste in

ESOPHAGITIS

CLINICAL FEATURES
*Chest pain +Odynophagia (pain with swallowing)
Causes
*Inflammatory process: GERD

ESOPHAGEAL PERFORATION

CAUSES
*Iatrogenic: Endoscopy
* Boerhaave Syndrome: Spontaneous rupture secondary to

ESOPHAGEAL PERFORATION

CLINICAL FEATURES
*Acute persistent chest pain that may radiate to

ESOPHAGEAL PERFORATION

DIAGNOSIS
*x-Ray: May see pleural effusion (usually on left). Also

ESOPHAGEAL MOTILITY DISORDERS

CLINICAL FEATURES:
* Chest pain often induced by ingestion

OTHER GI CAUSES

In appropriate setting, consider PUD, Biliary Disease, and Pancreatitis

PSYCHOLOGIC CAUSES

Diagnosis of exclusion

APPROACH TO THE PATIENT WITH CHEST PAIN

PUTTING IT ALL TOGETHER

INITIAL APPROACH

Like everything else: ABCs
A: Airway
B: Breathing
C: Circulation
IV,

CHEST PAIN: HISTORY

Time and character of onset
Quality
Location
Radiation
Associated symptoms
Aggravating symptoms
Alleviating symptoms
Prior episodes
Severity
Review

CHEST PAIN: HISTORY

TIME AND CHARACTER OF ONSET:
* Abrupt onset with

CHEST PAIN: HISTORY

Quality:
*Pleuritic Pain: PE, Pleurisy, Pneumonia, Pericarditis, PTX
*Esophageal:

CHEST PAIN: HISTORY

RADIATION:
* To neck, jaw, down either arm: consider

CHEST PAIN: HISTORY

AGGRAVATING SYMPTOMS:
* Activity: consider ischemic heart disease
*

CHEST PAIN: HISTORY

ALLEVIATING SYMPTOMS
* Rest/ Cessation of Activity: Ischemic
*

CHEST PAIN: HISTORY

RISK FACTORS
* Hypertension, DM, high cholesterol, tobacco, family

CHEST PAIN: HISTORY

When did the pain start?
What were you doing when

CHEST PAIN: PHYSICAL EXAM

Review vital signs
* Fever: Pericarditis, Pneumonia

CHEST PAIN: PHYSICAL EXAM

CV EXAM
* Assess heart rate
* Listen

CHEST PAIN: ANCILLARY TESTING

LABS: Consider…….
* Baseline labs: CBC, BMP, PT/PTT

CHEST PAIN: ANCILLARY TESTS

IMAGING: CONSIDER……
* x-Ray
- Rib fractures
-