Approach to a patient Approach to a patient with chest pain with chest pain

presenting in primary presenting in primary care settingcare setting

DR Ihab Suliman MBBS,MRCP,Diplomate

certification Board of Nuclear Cardiology(USA)

Chest PainChest Pain

Common presentation.Trivial to life-threatening causes.Key to diagnosis is history NOT

INVESTIGATIONS.

Negative baseline investigations DO NOT ruleout serious conditions

Life-threateningLife-threatening Causes ofCauses ofChest PainChest Pain

Myocardial infarction(ACS).Thoracic aortic dissection.Pulmonary embolus.Tension pneumothorax.Oesophageal rupture.

Investigations

ECG most important But history is more important.

20% of patients having an MI will have a normal ECG initally.

Negative cardiac enzymes in A&E are not helpful.

CXR useful to rule out other causes like pneumonia.

26 yr old thin man with sudden onset of severe L sided 26 yr old thin man with sudden onset of severe L sided sharp chest pain ,tachypnoeic. sharp chest pain ,tachypnoeic.

Right Pneumothorax

65 year old man(H/O DM,HTN) presented with a 1 hour history of 65 year old man(H/O DM,HTN) presented with a 1 hour history of severe central crushing chest pain. He is sweaty, clammy and has severe central crushing chest pain. He is sweaty, clammy and has

vomited twice .vomited twice .

65 year old man(H/O DM,HTN) presented with a 1 hour history of 65 year old man(H/O DM,HTN) presented with a 1 hour history of severe central crushing chest pain. He is sweaty, clammy and has severe central crushing chest pain. He is sweaty, clammy and has

vomited twice .vomited twice .

Anterior (extensive) Myocardial infarction.

Why ?

Male 65 years.

H/O DM+HTN( remember INTERHEART study)

Crushing chest pain.

Associated sweaty,clammy,vomiting.

70 years old male with long history of untreated 70 years old male with long history of untreated HTN,nonsmoker came complaining of chest pain migrated HTN,nonsmoker came complaining of chest pain migrated

to interscapular region & became severe(tearing),SBP to interscapular region & became severe(tearing),SBP 200,ECG mild inferior changes200,ECG mild inferior changes

Most likely diagnosis is? AMI?PE?Esophagear Rupture ?Aortic Dissection

Aortic DissectionAortic Dissection•Severe, sharp, “tearing” posterior chest pain or Severe, sharp, “tearing” posterior chest pain or back pain (occurs in 74-90% of pts)back pain (occurs in 74-90% of pts)

•Pain may be associated with syncope, CVA, MI, or CHFPain may be associated with syncope, CVA, MI, or CHF

–Painless dissection relatively uncommon 15%Painless dissection relatively uncommon 15%

•Chest pain is more common with Type A dissectionsChest pain is more common with Type A dissections

•Back or abdominal pain is more common with Type Back or abdominal pain is more common with Type B dissectionsB dissections

Physical ExaminationPhysical Examination •Pulse deficitPulse deficit

–Weak or absent carotid, brachial, or Weak or absent carotid, brachial, or femoral pulses femoral pulses

–these patients have a higher rate of these patients have a higher rate of mortalitymortality

•Acute Aortic InsufficiencyAcute Aortic Insufficiency

–Diastolic decrescendo murmurDiastolic decrescendo murmur

–Best heard along the right sternal Best heard along the right sternal borderborder

TEE of Aortic Dissection & CT aortaTEE of Aortic Dissection & CT aorta

40 years old male finished cardiac evaluation last week40 years old male finished cardiac evaluation last week for insurance (every thing is for insurance (every thing is

normal) .ate a heavy meal with friends (celebrating).followed by severe vomiting then chest normal) .ate a heavy meal with friends (celebrating).followed by severe vomiting then chest pain.vomitus contains streaks of fresh blood.pain.vomitus contains streaks of fresh blood.

Likely diagnosis?ACS?PE?Aortic DissectionEsophageal submucosal tear(mallory weiss

syndrome).

A 26 year old woman presented 1 week post A 26 year old woman presented 1 week post delivery of her first baby. She has sharp L sided delivery of her first baby. She has sharp L sided

chest pain and she is short of breath.chest pain and she is short of breath.

Pulmonary EmbolismWhy ?Young femalePegnancy hypercoagulable stateOccurrence one week post partum

50 years old female with chronic renal failure,chest 50 years old female with chronic renal failure,chest pain & dizzinesspain & dizziness

she is hypertensive on lisinoprilshe is hypertensive on lisinopril

Hyperkalemia,tall tented T-wave & bradycardia.

Why ?Chronic renal failurePatient on lisinopril

26 Old army officer had flu last week,felt chest pain while driving his 26 Old army officer had flu last week,felt chest pain while driving his car,pain increased by deep breath,he has no history of DM or car,pain increased by deep breath,he has no history of DM or

HTN,nonsmoker,lipid profile LDL 2.0 MMMOL/HTN,nonsmoker,lipid profile LDL 2.0 MMMOL/LL

Acute Pericarditis

26 Old army officer had flu last week,felt chest pain 26 Old army officer had flu last week,felt chest pain while driving his car,pain increased by deep breath,ECG while driving his car,pain increased by deep breath,ECG

after 5 daysafter 5 days..

Resolved Pericardtis.

Diagnostic limitationsHistory:

25% have ‘atypical’ histories

ECG:

55% of pts with AMI have a normal 1ST 12-lead ECG

Convential Cardiac Markers:

Normal for the first 3- 4 hours

Take home points•History 90%

•ECG: if ST elevated act fast

•Risk factor reduction

•Never ignore chest pain