APPROACH TO THE PATİENT WITH CHEST PAIN

1. APPROACH TO THE PATİENT WITH CHEST PAIN IN PRIMARY CARE

2. Learning objectives • Understand a diagnostic approach to chest pain and • How to reduce potential damage to myocardium by implementing rapid evaluation Guldal Izbirak, MD, Assoc Prof of Family Medicine

3. Know the evaluation of CP and • How to best implement the primary treatment of CP • Identify the risks and the need to educate patients to reduce their risks Guldal Izbirak, MD, Assoc Prof of Family Medicine

4. Be familiar with the DD of CP and • How to best rule in and out the more life-threatining problems Guldal Izbirak, MD, Assoc Prof of Family Medicine

5. Introduction • Chest pain is one of the most common medical symptoms. It must always be considered because it may be the first signal of serious, potentially lethal disease. Guldal Izbirak, MD, Assoc Prof of Family Medicine

6. What Lies in the Chest? • Skin • Muscles • Bones • Joints • Heartand Vessels • Lungs and Airways • Esophagus • Nerves

7. Pathophysiology • The heart, lungs, esophagus, and great vessels provide afferent visceral input through the same thoracic autonomic ganglia. • A painful stimulus in these organs is typically perceived as originating in the chest, but because afferent nerve fibers overlap in the dorsal ganglia, thoracic pain may be felt (as referred pain) anywhere between the umbilicus and the ear, including the upper extremities. Guldal Izbirak, MD, Assoc Prof of Family Medicine

8. Painful stimuli from thoracic organs can cause discomfort described as pressure, tearing, gas with the urge to eructate, indigestion, burning, aching, stabbing, and sometimes sharp needle-like pain • When the sensation is visceral in origin, many patients deny they are having pain and insist it is merely “discomfort.” Guldal Izbirak, MD, Assoc Prof of Family Medicine

10. Aetiology Emotional & psychiatric Anxiety or depression, hyperventilation

11. Causes of chest pain Some disorders are immediately life threatening: • Acute coronary syndromes (acute MI/unstable angina) • Thoracic aortic dissection • Tension pneumothorax • Esophageal rupture • Pulmonary embolism (PE) Guldal Izbirak, MD, Assoc Prof of Family Medicine

12. Overall, the most common causes are • Chest wall disorders %38 (ie, those involving muscle %20 muscle pain, rib %2 rib fracture, or cartilage %13 chostochondritis) • Pleural disorders • GI disorders% 20 (eg, esophageal reflux or spasm % 13, ulcer disease % 1-2, cholelithiasis % 1) • Idiopathic • CV disorders: Acute coronary syndromes % 2-3 AMI / % 3 US AP and stable angina % 10, others < % 1 Guldal Izbirak, MD, Assoc Prof of Family Medicine

13. Risk factors for CAD (most common cause ofcardiovascular CP) • Should be elicited from the history • Increased Age • Male gender • Hypertension • Diabetes • Dyslipidemia • Smoking • PMH or FH of CAD • Obesity • Substance abuse Guldal Izbirak, MD, Assoc Prof of Family Medicine

14. H&PE • A careful medical history is the first step. • Then, a thorough physical examination and, when indicated, one or two laboratory tests, an ECG and chest x-ray, completes the baseline information necessary to decide what to do next; watch and wait, • proceed with management, • or refer for specialized evaluation. Guldal Izbirak, MD, Assoc Prof of Family Medicine

15. History of present illness • Attributes of pain • Location/Radiation • Quality/Quantity • Timing/Duration/Frequency • Aggravating/Relieving Factors • Associated Symptoms (e.g. Breathlessness, cough, hemoptysis, nausea) Guldal Izbirak, MD, Assoc Prof of Family Medicine

16. PMH, Drug History, Smoking history, • Family History (Coronary Artery disease) • Review of Systems Guldal Izbirak, MD, Assoc Prof of Family Medicine

17. It is worth that noting that cardiac causes of chest pain are often accompanied by shortness of breath; but in contrast to many respiratory causes of chest pain and dyspnea, and with the exception of pericarditis, the pain of heart disease does not vary with breathing. Guldal Izbirak, MD, Assoc Prof of Family Medicine

18. Physical Examination • General appearance (distress, sweating, pallor, fever) • BP in both arms, pulses, JVP, apex beat, heart sounds • Lung fields, local tenderness, pain on movement of chest • Examination of the lungs • Upper abdominal examination • Swelling or tenderness of legs Guldal Izbirak, MD, Assoc Prof of Family Medicine

19. Neck is inspected for venous distention and hepatojugular reflux, and the venous wave forms are noted. • The neck is palpated for carotid pulses, lymphadenopathy, or thyroid abnormality. • The carotid arteries are auscultated for bruit.

20. Palpate the chest and the spinous processes of vertebrae (local tenderness, fractures, symptomes of spinal diseases • Crepitus associated with rib fracture, localized pain, signs of trauma. • Hyperesthesia, particularly when associated with a rash, is often due to herpes zoster

21. Lungs are percussed and auscultated for presence and symmetry of breath sounds, signs of congestion (dry or wet rales, rhonchi), consolidation (pectorilloquy), pleural friction rubs, and effusion (decreased breath sounds, dullness to percussion).

22. Cardiac & Pulmonary Auscultation • Cardiac murmurs, 3rd & 4th heart sounds, pericardial rubs, • Intensityof breathsounds, • Pleuralfriction, rubpleurisy, • Evidence of pneumothorax (absence of respiratory sounds, vocal fremitus), pulmonary embolism, pneumonia or pleurisy

23. The chest is inspected for skin lesions of trauma or herpes zoster infection and palpated for crepitance (suggesting subcutaneous air) and tenderness. • The abdomen is palpated for tenderness, organomegaly, and masses or tenderness, particularly in the epigastric and right upper quadrant regions.

24. The legs are examined for arterial pulses, adequacy of perfusion, edema, varicose veins, and signs of DVT (eg, swelling, erythema, tenderness). Guldal Izbirak, MD, Assoc Prof of Family Medicine

25. Red flags: Certain findings raise suspicion of a more serious etiology of chest pain: •  Abnormal vital signs (tachycardia, bradycardia, tachypnea, hypotension) • Signs of hypoperfusion (eg, confusion, ashen color, diaphoresis) • Shortness of breath • Asymmetric breath sounds or pulses • New heart murmurs • Pulsus paradoxus > 10 mm Hg - abnormally large decrease in systolic blood pressure and pulse wave amplitude during inspiration. • The paradox in pulsus paradoxus is that, on clinical examination, one can detect beats on cardiac oscultationduring inspiration that cannot be palpated at the radial pulse. It results from an accentuated decrease of the blood pressure, which leads to the (radial) pulse not being palpable. Guldal Izbirak, MD, Assoc Prof of Family Medicine

26. Cardiovascular causes ofchest pain • Cardiac ischaemia (lack of oxygen supply to the heart muscle the myocardium; the myocardial infarction, angina pectoris • The pericardium; pericarditis • The aorta; dissecting aneursym Guldal Izbirak, MD, Assoc Prof of Family Medicine

27. Guldal Izbirak, MD, Assoc Prof of Family Medicine

28. Clinical picture of patient with CAD in primary care • Emergent • Acute coronary syndrome (AMI with or without ST elevation) • Unstable angina • Nonemergent • Stable angina • asymptomatic Guldal Izbirak, MD, Assoc Prof of Family Medicine

29. AP • Quality/Quantity Pain is usually described as an intense “pressure”, “squeezing”, or “constriction”, Location originating underneath or to the left of sternum. Radiation May radiate to one/both arms, neck, or jaw. Timing/Duration/FrequencyIt seldom lasts more than 15 minutes Guldal Izbirak, MD, Assoc Prof of Family Medicine

30. AP • Aggravating/Relieving FactorsThus angina characteristically develops with exertion and it is relieved by rest; • excitement, • cold, • emotional stress, • sexual intercourse or • ingestion of food. Guldal Izbirak, MD, Assoc Prof of Family Medicine

31. AP • It is relieved with seconds or occasionally minutes by glycerly trinitrate (nitroglycerin)and the response to this can be used as a diagnostic test. • Associated SymptomsIt is often associated with breathlessness due to temporary left ventricular dysfunction, or palpitations. Guldal Izbirak, MD, Assoc Prof of Family Medicine

32. AP • Cardiac ischemiae may be related to exercise when it causes the pain called angina “angin d’effort” • “unstable ”angina should be used to describe unstable patterns (prolonged pain, occurring at rest, increasing frequency, etc) Guldal Izbirak, MD, Assoc Prof of Family Medicine

33. Stable AP Severity of effort can be variable / It should be consistent every time • Severe Effort • Running • Climbing several steps • Walking upward • Daily activities • Walking • Climbing one step • Mild Effort • Activities at home Guldal Izbirak, MD, Assoc Prof of Family Medicine

34. DD of AP and UAP is based on history AP : nonemergent Follow up and treatment can be organized by FP Aspirine, nitrates, bete-blocker 7 Ca-Channel bloker, statines UAP: emergent Should be referred to for observation and hospitalization Guldal Izbirak, MD, Assoc Prof of Family Medicine

35. MI • Definition: death or necrosis of heart muscle, occurs when occlusion of a coronary artery causes irreversible ischemia • Coronary artery occlusion can also cause sudden death, so the term “heart attack” is usually used to encompass both myocardial infarction and sudden death. Guldal Izbirak, MD, Assoc Prof of Family Medicine

36. MI • Quality/Quantity Constricting or crushing pain or intense dull ache Timing/Duration/Frequency Pain due to a heart attack is similar in nature to angina but it usually lasts with several hours and the diagnosis of infarction is unlikely if the pain settles within 30 minutes. Pain lasting longer than 48 hours is unlikely to be due to infarction. It is lasting>1/2h. Guldal Izbirak, MD, Assoc Prof of Family Medicine

37. MI • Location/Radiation Similar in location and radiation to that of angina but in contrast, tends to be much more severe, Aggravating/Relieving Factors is not relieved by GTN. Glyceryl trinitrate is ineffective and powerful analgesics such as morphine are needed for pain relief. • Associated Symptoms Important distinguishing features are accompanying dyspnea, profuse sweating, nausea, vomiting and profound weakness. Guldal Izbirak, MD, Assoc Prof of Family Medicine

38. Clinical Decision Rule for Identifying Patients with Chest Pain Caused by CAD Guldal Izbirak, MD, Assoc Prof of Family Medicine

39. Algorithm for the evaluation of patients with chest pain in the primary care setting. (ECG = electrocardiography.) http://www.aafp.org/afp/2011/0301/p603.htmlPoint-of-Care Guides Guldal Izbirak, MD, Assoc Prof of Family Medicine

40. Pericarditis • Pericardial pain, which is due to inflammation involving the parietal pericardium, Quality/Quantity feels like stabbing, burning or cutting Aggravating/Relieving Factors is made worse by coughing, swallowing, deep breathing, or lying down; diminished by leaning forward.It is not relieved by nitroglycerin. • Timing/Duration/Frequency Pericardial pain can last for hours or days. Guldal Izbirak, MD, Assoc Prof of Family Medicine

41. Location/Radiation It is less variable in character, position, and referral area than myocardial ischemic pain. • Associated Symptoms May be associated with fever, breathlessness. Signs pericardial rub, tamponade • Diagnosis History of pain, pericardial friction rub, ECHO,serial chest x-ray(effusion) • Lab ESR, Leukocytosis Guldal Izbirak, MD, Assoc Prof of Family Medicine

42. Dissecting Aneursym • A tear in the aortic intima through which blood surfes into the aortic wall, stripping the media from the adventitia. • Quality/Quantity Pain from dissection of the aortais usually very severe and of a tearing or rending character.Location/Radiation It is sudden interscapular back pain or pain similar to MI ± radiation through to back or down into the abdomen. Associated Symptoms Often the patient is very unwell and shocked. Guldal Izbirak, MD, Assoc Prof of Family Medicine

43. Non-cardiovascular causes of chest pain arise in; • The pleura • The oesophagus • The chest wall Guldal Izbirak, MD, Assoc Prof of Family Medicine

44. Pleuritic pain • Pleuritic pain is usually sharply restricted to the ipsilateral chest wall or shoulder. Pain, usually well localized, may be variously described as “sharp”, “dull”, “achy”, sometimes “burning”, but whatever its designation, it is worsened and thus prevents deep inspiration. Also coughing and sneezing. Guldal Izbirak, MD, Assoc Prof of Family Medicine

45. Aggravation by breathing causes patients to seek, find, and remain in the body position that most restricts movement of the affected region. Implies inflammation or irritation of the pleura. Causes are chest infection. Guldal Izbirak, MD, Assoc Prof of Family Medicine

46. Pulmonary Embolism • Venous thrombi (usually from a DVT) pass into the pulmonary circulation and block blood flow to the lungs. • Fatal in ~1:10 cases. • Risk factors: Immobility(long flight or bus journey, post-op), smoking, COC pills, pregnancy or puerperium, past and/or family history of DVT or PE Guldal Izbirak, MD, Assoc Prof of Family Medicine

47. Symptoms chest pain, bloody sputum, acute breathlessness, • Signs pleuritic pain,hemoptysis, hypotension, tachycardia, cyanosis, tachypnoea, syncope, pleural rub, ↑ JVP • Screening Postero-anterior and lateral chest x-rays. • Therapy Give oxygen as soon as possible. • Consult pulmologist. Guldal Izbirak, MD, Assoc Prof of Family Medicine

48. Pneumothorax • Def: Air in the pleural cavity. >1/2 cases are due to trauma of some kind-the rest are spontaneous. • Symp/Signs: Sudden onset of chest pain and/or increased breathlessness ± pallor, sweating and tachycardia, hypotension, shock • Physical examination:  or absent breath sounds and chest movement, diminished vibration(vocal fremitus), hyperresonance by percussion • Refer for Chest X-Ray. Guldal Izbirak, MD, Assoc Prof of Family Medicine

49. Oesophageal pain • Quality/Quantity May be very similar to cardiac pain. Reflux or spasm.Reflux pain is burning in nature Timing/ Duration/ Frequency occurs shortly after meal. Location a substernal pressure-type pain, which may last 2 t0 5 minutes, similar to angina. Radiation It usually radiates to the back rather than to the arms. Guldal Izbirak, MD, Assoc Prof of Family Medicine

50. Aggravating/Relieving FactorsNot associated with exertion. Relieved by antacids. • Relieved by GTN but less rapidly than angina. • Suspect if related to food or alcohol ingestion or occurs in bed on lying flat. Guldal Izbirak, MD, Assoc Prof of Family Medicine