CHEST PAIN

Dr Yumnam Bidyalakshmee Devi

Moderator- Dr Javed

Topics covered

1. Introduction 2. Definition 3. Site4. Types5. Pathophysiology of pain6. Referred pain7. Causes of chest pain8. Assessment Of D/D9. Conclusion

Introduction

Introduction

The majority of patients with chest pain referred for a respiratory opinion have either acute pleuritic pain or persistent, well-localized pain.

Cardiac pain rarely presents in this manner, although it should be considered in exertional pain or in the presence of risk factors for ischaemic heart disease.

Within the respiratory system, pain may arise from the parietal pleura, major airways, chest wall, diaphragm, and mediastinum; the lung parenchyma and visceral pleura are insensitive to pain.

Continued

Processes involving the upper parietal pleura cause a pain localized to that part of the chest.

The lower parietal pleura and outer region of the diaphragmatic pleura are innervated by the lower six intercostal nerves, and pain here may be referred to the abdomen.

The central region of the diaphragm is supplied by the phrenic nerve (C 3, 4, 5) and pain may be referred to the ipsilateral shoulder tip . Tracheobronchitis tends to be associated with retrosternal pain.

What is pain? Definition?

• Pain is an unpleasant sensation localised to a part of the body. It is a vital function of the nervous system in providing the body with a warning of potential or actual injury.

• It is both a sensory and emotional experience, affected by psychological factors such as past experiences,beliefs about pain, fear or anxiety.

NociceptorsNociceptors are the specialised sensory receptors responsible for the detection of noxious (unpleasant) stimuli, transforming the stimuli into electrical signals, which are then conducted to the central nervous system.They are the free nerve endings of primary afferent Aδ and C fibres.

Distributed throughout the body (skin, viscera, muscles, joints, meninges) they can be stimulated by mechanical, thermal or chemical stimuli.

Inflammatory mediators (eg bradykinin, serotonin, prostaglandins, cytokines,and H+) are released from damaged tissue and can stimulate nociceptors directly. They can also act to reduce the activation threshold of nociceptors so that the stimulation required to cause activation is less. This process is called primary sensitisation.

Types of pain

A - BETA A-DELTA C Diameter Large Small 2-5μm Smallest <2μmMyelination Highly Thinly Unmyelinated

Conductionvelocity

> 40 ms-1 5-15ms-1 < 2ms-1

Receptoractivationthresholds

Low High and low High

Sensation onstimulation

Light touch,non-noxious

Rapid, sharp,localised pain

Slow, diffuse, dullpain

Characteristics of primary afferent fibres

Ascending pain pathways. DRG dorsal root ganglion, PAG periaqueductal grey matter

Referred pain physiologgy

Definition

• Chest pain can be broadly defined as any discomfort in anterior thorax occurring above the epigastrium and below the mandible.

Site of chest pain

History – quality of pain

History

Causes of acute chest pain include:

• Pulmonary infarction following embolism. • Pneumonia • Pneumothorax • Pericarditis • Pleural infection (empyema, tuberculous) • Autoimmune disease ie. SLE,RA. • Musculoskeletal -Fractured rib

chronic chest pain Causes include: • Malignant pleural disease or chest wall infiltration • Benign musculoskeletal pain • Pleural infection (empyema, tuberculous) • Benign asbestos-related pleural disease • Autoimmune disease (e.g. SLE, RA) • Recurrent pulmonary infarction (emboli, vasculitis)

continued

Pain from malignant chest wall infiltration is often ‘boring’ in character and may disturb sleep; it is frequently not related to respiration. Causes• include 1° lung cancer, 2° pleural malignancy,

mesothelioma, and rib or sternal involvement from malignancy (including myeloma and leukaemia)

• Chronic thromboembolic disease tends to present with breathlessness;when chest pain occurs, it is usually episodic, rather than persistent.

Consideration of

assessment of patient

with chest pain

ASSESSMENT

• It is essential to obtain a thorough assessment that includes:

• Characteristics of pain, including location, duration, radiation, quality and accompanying symptoms.

• Carefully observe for associated symptoms:Heavy pressure or squeezing in the chest area, episodic or exertional triggers, diaphoresis, N&V, weakness, anxiety and palpitations.

• Chest pain with diaphoresis is the most common presentation with an acute MI. Often the patient will describe the pain by using the “Levine Sign” – placing a clenched fist over the sternum.

* chest discomfort be due to an acute,potentially life threatening condition, that warrant urgent evaluation and management.

1. Acute coronary syndrome (Acute MI/Unstable angina)

2. Aortic dissection

3. Tension Pneumothorax

4. Pulmonary embolism

5. Esophageal rupture

Acute coronary syndrome

• Onset/duration -Sudden onset of unrentling pain

• Quality -Tearing or ripping, knifelike

• Location -anterior chest often radiating to back

• Associated features -hypertension,underlying connective tissue disease,loss of peripheral pulse

Myocardial ischemia

• Onset/duration – stable angina –percipitated by Exertion,cold and stress

2-10 min. unstable angina- increasing pattern or at rest MI- >30 min.

• Quality –Pressure,tightness,heaviness,squeezing,burning

• Location –retrosternal,often radiated to jaw,neck,arm,shoulder,epigastrium

• Associated features -S4 gallop

Pulmonary embolism

• Onset/duration -sudden onset

• Quality -pleuritic

• Location -often lateral,on the side of embolism

• Associated features -dyspnoea,tachypnoea,hypotension,tachycardia

Sign Pathology

1. Westermark sign Area of peripheral oligemia

2. Palla's sign/knuckle sign Enlarged Right descending pulmonary artery

3. Hampton's hump Peripheral wedge shaped opacity with convexity towards the hilum

4. Melting sign Infarct shows rapid clearing in contrast to pneumonic consolidation

5. Fleishner's sign Elevated hemidiaphgram

PULMONARY EMBOLISM: Plain x- ray sign

PALLA'S SIGN

Spontaneous Pneumothorax

• Onset/duration -sudden onset

• Quality -pleuritic

• Location -lateral to side of pneumothorax

• Associated features -dyspnoea,decreased breath sounds on the side of pneumothorax

• Could the chest discomfort be due to chronic conditions likely to lead serious complications

1. Stable angina

2. Aortic stenosis

3. Pulmonary hypertension

1. Angina pain

ANGINA

Aortic stenosis

• Onset/duration -gradual in onset

• Quality -feel tight or squeezed,get worse with activity

• Location -reaches into arm,neck or jaw

• Associated features -SOB specially on exertion,become easily tired,palpitations,fainting,weakness,dizziness with activity,weak and delayed pulse and murmur

AORTIC STENOSIS

Pulmonary hypertension

• Onset/duration -variable,often exertional

• Quality -pressure

• Location -substernal

• Associated features -dyspnoea,sign of increse venous pressure

• Could the chest discomfort be due to an acute condition that warrant specific treatment

1. Pericarditis

2.Pneumonia/pleuritis

3.Herpes zoster

Pericarditis

• Onset/duration -variable hours to days,often episodic

• Quality -pleuritic,sharp

• Location -retrosternal or towards cardiac apex

• Associated features -may be relieved by sitting up and leaning forward, pericardial friction rub

Pneumonia/pleuritis

• Onset/duration -variable

• Quality -pleuritic

• Location -unilateral,often localised

• Associated features -dyspnoea,cough,fever,rales

Herpes zoster

• Shingles can present as acute chest pain. The pain is usually burning and unilateral, following the dermatomes.

• Chest pain from Shingles can occur before the onset of vesicles thus making a reliable diagnosis difficult.

Could the chest discomfort be due to another treatable chronic conditions

1. Esophageal reflux

2.Esophageal spasm

3.Peptic ulcer disease

4.Gall bladder disease

5.Cervical disc disease 6.Arhritis of shoulder or spine

7.Costochondritis

8. Anxiety

Esophageal reflux

• Onset/duration -10 to 60 min

• Quality -burning

• Location -substernal

• Associated features -worsened by postprandial recumbency, relieved by antacids

ESOPHAGEAL REFLUX

Esophageal spasm

• Onset/duration -2 to 30 min

• Quality -pressure,tihgtness,burning

• Location -retrosternal

• Associated features -can closely mimic angina

Peptic ulcer disease

• Onset/duration -prolonged, 60 to 90 min after meals

• Quality -burning

• Location -epigastric,substernal

• Associated features -relieved with food or antacids

Gall bladder disease

• Onset/duration - prolonged

• Quality -aching,colicky

• Location -epigastric,right upper quadrant,shoulder(murphy sign)

• Associated features -may follow meal

Psychological

• Onset/duration -variable,may be fleeting or prolonged

• Quality -variable, often menifest as tightness,dyspnoea with feeling of panic or doom.

• Location -variable,often retrosternal• Associated features -situational factors may

percipitate symptoms, h/o panic attacks or depression

APPROACH TO CHEST PAIN BY ATS

Approach to chest pain

Conclusion

• Chest pain is a common presenting problem and has many causes, of which many can be life threatening.

• Cardiac and noncardiac causes must be considered.

• A thorough assessment is vital in order to distinguish all the potential causes and determine the appropriate intervention in a timely manner.