Diagnostic approach to chest pain

1. Diagnostic approach to chest pain

3. differential diagnosis of chest pain • CHEST WALL PAIN  Musculoskeletal pain : • often insidious and persistent, lasting for hours to weeks • sharp and localized to a specific area • positional or exacerbated by deep breathing, turning, or arm movement • F > M

4. GASTROINTESTINAL CAUSES • The heart and esophagus share similar neurologic innervation • Esophageal disease may cause symptoms thought "classical" for myocardial ischemia • Any patient at risk for CAD who presents with anginal-quality chest pain should have myocardial ischemia ruled out before being given a gastroenterologic diagnosis

5. Gastroesophageal reflux disease  • Squeezing or burning, • Located substernally and radiating to the back, neck, jaw or arms, • Lasting anywhere from minutes to hours, • Resolving either spontaneously or with antacids. • It may occur after meals, awaken patients from sleep, and be exacerbated by emotional stress. • After cardiac disease has been ruled out, a trial of acid suppression may assist in the diagnosis of GERD

6. Abnormal motility patterns and achalasia: chest pain is associated with dysphagia • Esophageal rupture, • Foreign bodies  • Medication-induced esophagitis 

7. PULMONARY CAUSES OF CHEST PAIN  • Pulmonary vessels, • Lung parenchyma, • Pleural tissue

8. Acute pulmonary thromboembolism • Dyspnea ; • Pleuriticchest pain ; • Cough ; • Hemoptysis ; • Tachypnea • Tachycardia BE AWARE OF RISK FACTORS

9. Pulmonary hypertension • PRIMARY • SECONDARY

10. Lung parenchyma  • Infection ( Pneumonia ) • Cancer • Chronic diseases

11. Pneumothorax : sudden onset of pleuritic chest pain and respiratory distress • Pleuritis

12. PSYCHOGENIC/PSYCHOSOMATIC CAUSES one-third of patients presenting to the emergency department for chest pain have a psychiatric disorder, approximately one-half of patients with noncardiac chest pain have various psychiatric diagnoses Diagnosis is established after R/O organic causes

13. PAIN REFERRED TO THE CHEST  • Gallbladder or liver disease • Herniated thoracic disc

14. CARDIAC CAUSES • MYOCARDIUM • EPICARDIUM • VALVULAR DISEASE • AORTA

15. Coronary heart disease  • Stable angina pectoris, • Unstable angina, non-ST elevation myocardial infarction, • ST elevation myocardial infarction

17. chest heaviness, pressure, tightness or burning

18. Pain quality (pleuritic, positional, sharp, reproducible with palpation or squeezing, tightness, pressure, constriction, strangling, burning, heart burn, fullness in the chest, a band-like sensation) • Region or location of pain: Ischemic pain is often a diffuse discomfort that is difficult to localize. Pain that localizes to a small area on the chest is more likely of chest wall or pleural origin rather than visceral

20. Radiation may provide a clue to other etiologies of chest pain. • Acute cholecystitiscan present with right shoulder pain, although concomitant right upper quadrant or epigastric pain is more typical than chest discomfort. • Chest pain that radiates between the scapulae may be due to aortic dissection. • The pain of pericarditis typically radiates to one or both trapezius ridges.

21. TIMEThe pain associated with a pneumothorax or a vascular event such as aortic dissection or acute pulmonary embolism classically has an abrupt onset with the greatest intensity of pain at the beginning. • The onset of ischemic pain is more often gradual with an increasing intensity over time. • A crescendo pattern of pain can also be caused by esophageal disease

22. DURATIONChest discomfort that lasts only for seconds or pain that is constant over weeks is not due to ischemia. • A span of years without progression makes it more likely that the origin of pain is functional. • The pain from myocardial ischemia generally lasts for a few minutes; it may be more prolonged in the setting of a myocardial infarction

23. Provocative factors exertion , emotional stress , cold , meals • Palliation Pain that responds to sublingual nitroglycerin is frequently thought to have a cardiac etiology or to be due to esophageal spasm. • Associated symptoms Nausea , vomiting, diaphoresis , dyspnea,… • Risk factor of atherosclerosis

24. The term "atypical" chest pain should be avoided; it increases the risk of misdiagnosing

25. Aortic dissection  • Sudden, severe, and often migratory chest pain occurs in most but not all patients with dissection of the ascending or descending aorta, • Diagnosis often requires a high index of suspicion • It is most common in men older than age 60. • The pain typically is cataclysmic in onset, and is often described as a "ripping" or "tearing" sensation. • Pain is commonly felt in the anterior or posterior chest, or in the neck, throat, or jaw. • Hypertension is the most important risk factor;

28. Valvular heart disease  • Aortic stenosis should be considered whenever a patient presents with progressive angina, dyspnea, and/or syncope • Patients with mitral stenosis infrequently experience chest pain. The pain often resembles angina and, it is most commonly the result of pulmonary hypertension and right ventricular hypertrophy, may be due to underlying coronary artery disease

29. Pulmonic stenosis is a relatively common congenital defect, but a rare cause of chest pain in primary care practice • Aortic regurgitation

30. Pericarditis • The major clinical manifestations of acute pericarditis are chest pain (usually pleuritic), and pericardial friction rub • Fairly pain is sudden onset and occurs over the anterior chest. • It is usually sharp and exacerbated by inspiration. • The pain may decrease in intensity when the patient sits up and can radiate, especially to the trapezius ridge

31. Myocarditis • Myocarditis may present with both cardiac and systemic symptoms. • When chest pain occurs, it is usually associated with concomitant pericarditis although evidence of infarction may be seen. • Systemic symptoms include fever, myalgias, and muscle tenderness

32. Cardiac syndrome X  • Asyndrome of angina-like, non-gastrointestinal chest pain associated with normal coronary arteries; • It is most commonly seen in premenopausal women . • The pain is typical of angina in approximately one-half of patients and may be precipitated by exertion, although it also occurs at rest. • The pain also often has characteristics nonspecific for CAD; it is more severe, prolonged, and is variably relieved with nitrates  • The diagnosis is one of exclusion

33. EMERGENCY RESPONSE TO CHEST PAIN IN THE OFFICE —  • Chest pain due to myocardial infarction, pulmonary embolus, aortic dissection, or tension pneumothorax may result in sudden death. • Any patient with a recent onset of chest pain, especially when the symptoms are ongoing, who may be potentially unstable based upon history, appearance, or vital signs, should be transported immediately to an emergency

34. evaluation • History (description of chest pain, associated symptoms and risk factors) • Physical examination, • Electrocardiogram or chest radiograph