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Introduction . Chest Pain Diseases of heart aorta lungs pleura mediastinum oesophagus stomach abdominal viscera muscul
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1. Acute Chest Pain in Emergency Room Dr Chaitanya Vemuri
Post Graduate Student
2. Introduction Chest Pain
Diseases of heart
aorta
lungs
pleura
mediastinum
oesophagus
stomach
abdominal viscera
musculoskeletal
psychological
3. Approach
History
Clinical Examination
Differential Diagnosis
Investigations
4. History
Onset of pain ( abrupt / gradual )
Site of pain (substernal, chest wall, diffuse, localized)
Quality of Pain ( squeezing, catching, burning, dull ache )
Radiation ( shoulder, jaw, back )
Provocation / Palliation ( activities that provoke pain or alleviate pain )
Timing ( constant / episodic, duration of episodes )
5. Clinical examination
ECG
Chest X ray
2D Echocardiography
Special Investigations
6. Aim in Emergency Room
Immediate recognition and exclusion of life-threatening causes of chest pain
7. Acute Coronary Syndrome
Aortic Dissection
Pulmonary Embolism
Pneumothorax
Mediastinitis
Pericardial Tamponade
8. Case 1 A 58 year old male
Smoker
k/c/o Systemic Hypertension
Dyslipidemia
Diabetes mellitus type 2
c/o left sided chest pain since last 30 minutes
squeezing pain
gradual onset
radiating to jaw and left arm
associated with dyspnea, sweating and vomiting
On ex : Pul : 90 / min BP : 150 / 90 mm Hg RR : 20 /min
CVS : S1+,S2+, No murmurs RS : Clear
9. Acute Coronary Syndrome History
Left sided or Substernal chest pressure or tightness
Onset is gradual
Pain radiating to shoulder, jaw
Pain increasing on exertion
Atypical symptoms – dyspnea, weakness in elderly and diabetics
10. Acute Coronary Syndrome Clinical Examination
Nonspecific
Signs of Heart failure
Acute LVF
Bradycardia / Heart block / Hypotension
11. Acute Coronary Syndrome Investigations
ECG
Cardiac Enzymes
2D Echocardiogram
12. Acute coronary syndrome refers to any constellation of clinical symptoms that are compatible with acute myocardial ischemia and encompasses acute myocardial infarction.
- STEMI,
- NSTEMI,
- Unstable Angina
13. Anterior wall ischemia
14. Evolution of MI
15. Acute anterolateral wall ischemia
16. Acute lateral wall ischemia
17. Acute myocardial infarction
18. Acute anterior wall stemi
19. Acute anteroseptal MI with RBBB
20. Acute inferior wall MI
21. Acute inferior wall MI
22. Posterior wall MI
23. Cardiac Enzymes In patients with negative cardiac enzymes within 6 hrs of onset of pain , another sample should be drawn within 6 – 12 hrs
Troponin I & Troponin T : Preferred Biomarker
Increase in 3-12 hrs after the onset of MI
Peak at 24-48 hrs
Return to baseline over 5 -14 days
24. Cardiac Enzymes
CK-MB : >95% Sensitivity & Specificity for myocardial injury when measured 24-36 hrs after the onset of chest pain
Increase within 3-12 hrs of chest pain
Peak at 24 hrs
Return to baseline after 48-72 hrs
CKMB : CK > 2.5 – Suggests myocardial source but not diagnostic
25. 2D Echocardiogram
Look for Regional wall motion abnormality
LV function
RV function
Mitral Regurgitation
26. Management Oxygen Inhalation
Morphine – pain relief
Antiplatelets
Statins
Betablockers
ACEI /ARB
IV/ SC Heparin / Thrombolysis / PCI
+/- Diuretics
28. Case 2 70 year old male
k/c/o Systemic Hypertension
c/o Sudden onset Chest pain
tearing in nature
along the back
29. Aortic Dissection History
Sudden onset of sharp, tearing or ripping pain
Maximal severity at onset
Often begins in chest / can begin in back
30. Aortic Dissection Clinical Examination
Absent upper extremity or carotid pulse
Discrepancy in Systolic BP > 20 mm Hg between right and left upper limb
Aortic Regurgitation
30 % Neurological findings
31. Aortic Dissection Investigations
ECG : 15 % - Ischemic changes
30 % - Non specific ST –T changes
CXR : Wide mediastinum /
Loss of Normal Aortic Knob Contour – 76 %
Normal – 10 %
32. Chest X Ray
33. 2D Echocardiogram
35. Case 3 A 50 Year old female # neck of femur s/p surgery
on prolonged bed rest
swelling of left lower limb since 1 week
sudden onset dyspnea since 4 hrs
associated sharp catchy chest pain on right side
On ex : Tachypnea
Pulse : 110 / min BP : 110/60 mm Hg
Chest : Clear ; CVS : S1+S2+ No murmurs
36. Pulmonary Embolism – The Great Masquerader History
Risk Factors : Prolonged Immoblization
Deep Vein Thrombosis
Malignancy
Central Venous Instrumentation<3m
Pleuritic chest pain
Dyspnea ( dominant feature )
Sudden in onset
37. Pulmonary Embolism Clinical Examination
Symptoms & Signs – highly non specific & variable and also common in those with and without PE
No finding is specific
Extremity – may be normal
Tachypnea – common
Tachycardia
Jugular venous distension
Non specific focal rales
Absent breath sounds
Loud P2
38. Pulmonary Embolism
Massive Pul Embolism : Acute RV failure
Jugular venous distension
RV S3
Parasternal Lift
Rarely Circulatory Collapse
39. Pulmonary Embolism Blood Tests :
D-dimer : A Useful Rule-out Test
Sensitivity > 80% for DVT
Sensitivity > 95% for PE
Not specific for PE
Levels increase in MI,Pneumonia,Sepsis
Cardiac Biomarkers : Elevated S.Troponin
( RV microinfarct )
Elevated S.BNP / NT-ProBNP
( myocardial strech )
40. Pulmonary Embolism ECG : usually abnormal ; nonspecific
Sinus Tachycardia
S1Q3T3
T wave inversion in V1-V4
Signs of Right heart strain
- Right axis deviation
- RBBB
- Right atrial enlargement
41. Pulmonary Embolism
42. Chest X Ray
43. Chest X Ray
44. Chest X Ray
45. Echocardiography Not of diagnostic value
Useful to rule out mimics of PE : Acute MI
Pericardial Tamponade
Aortic Dissection
Mc Connell’s Sign
Specific Appearance of RV
Hypokinesia of RV free wall with normal motion of RV apex
46. Diagnostic modalities
MDCT Chest with Contrast + Pulmonary angiogram – Principal imaging for the diagnosis of PE
Ventilation Perfusion Scan – 2nd line investigation
Pulmonary Angiography – Gold standard
47. CT-PA
48. Case 4
A 50 year old male
k/c/o COPD – Emphysema
Sudden onset Right Chest Pain – Sharp , Catchy
With predominant Dyspnea
On Ex : Pul 100 /min BP : 110/60mmHg RR: 40/min
Deviation of trachea to left side
Hyperresonance - Rt side of chest
Diminished Breath sounds - Right side of chest
49. Pneumothorax Can occur
Following trauma
Following pulmonary procedures
Primary Spontaneous pneumothorax
Secondary pneumothorax – COPD
- Asthma
- Cystic Fibrosis
50. History
Sudden onset pleuritic chest pain
Dyspnea as dominant feature
Clinical Examination
Tachypnea
Shift of mediastinum to contralateral side
Ipsilateral diminished or absent breath sounds
51. Chest X Ray
52. Case 5 46 year old male
c/o
Sudden onset diffuse chest discomfort / pain
Dyspnea – predominantly
On ex :
Tachypnea
Hyperresonance on percussion bilaterally
b/l diminished breath sounds
53. D/D
54. Case 6 A 30 year old male
Alcoholic
Post alcohol consumption
Devoleped severe retching and vomitings
Followed by excruciating retrosternal chest pain
Also upper abdominal pain
On Ex : Tachypnea
Cyanosis
Fever
Hypotension – Shock
55. Mediastinitis – Esophageal Rupture Occurs in
Alcoholics
Patients with gastric or duodenal ulcer
Spontaneous perforation of esophagus after vomiting
- Boerhaave’s Syndrome
Spontaneous esophageal rupture can also occur in :
Caustic ingestion
Pill esophagitis
Barett’s ulcer
following dilatation of esophageal strictures
56. Clinical examination
Non specific findings – early in course of illness
Subcutaneous emphysema – not specific
Hamman’s crunch – mediastinum
Pleural effusion
57. Chest X Ray
58. CT Chest
59. Cardiac Tamponade History
Sharp anterior chest pain made worse by lying down
Pain relieved by sitting forward
Pain aggravated by inspiration
Dyspnea : common
60. Clinical examination
Sinus tachycardia
Elevated JVP ( Preserved X descent
Absent Y descent )
Pulsus Paradoxsus
Hypotension
Muffled heart sounds
61. ECG Low voltage complexes
Electrical alternans
Diffuse PR segment
depressions and or
ST segment elevations
62. Echocardiography
Diastolic collapse of right ventricle and right atrium
Diastolic collapse of left ventricle – more specific
63. Echocardiography
64. Common causes of Chest Pain in ER – Not Of Immediate Threat To Life
65. Chest Pain – cardiac CAD – Chronic Stable Angina
Variant angina
Cocaine precipating ACS
Valvular heart disease : AS / MS / PS
Pericarditis
Myocarditis
Stress induced Cardiomyopathy
Cardiac Syndrome X
Pheochromocytoma
66. Variant angina Vasospastic Angina / Prinzmetal Angina
Spontaneous episodes of angina in association with ST segment elevation in ECG
Patients : Young females with epicardial disease
Chest pain often occurs at rest than in exertion
Predominantly in morning
Chest pain associated with ST elevation in ECG
67. Variant Angina
ECG : ST segment Elevation
Stress testing : often normal
except when epicardial disease +
Coronary Angiogram : often proximal plaque
68. Cardiac Syndrome X
Angina pectoris with normal coronary arteries
Chest pain episodes often with exertion
Chest pain is associated with ST segment depression in ECG
69. Cardiac Syndrome X
ECG : Normal / ST Segment Depression
Stress Testing : ST Segment depression
Coronary Angiography : normal epicardial vessels;
no vasospasm
70. Pericarditis Retrosternal and left precordial pain
Radiate to left shoulder, neck
Aggravated by inspiration , movement, swallowing
More in supine position
Relieved in sitting and leaning forward position
h/o fever +
On ex : Pericardial frictional rub
72. Case 7 A 55 year old female
No co morbidities
Lost her husband 3 days ago – RTA
Devoleped sudden onset left sided chest pain
On Ex : Pul : 80 / min
BP : 100 / 70 mm Hg
RR : 20 / min
Chest : clear
CVS : S1 + S2+ ESM +
73. ECG
74. Investigations Cardiac Enzymes : Trop I : 0.4
CK-MB : 35
2D ECHO : Apical Ballooning of left ventricle in
end systole
Severe Akinesia of distal portion of LV
Reduced EF
CAG : Normal Coronaries
75. Tako – Tsubo Cardiomyopathy Apical Ballooning Syndrome
Elderly females
After severe emotional upset
Reversible within 3 – 7 days
Normal Coronaries
Mech : unknown
catecholamines acting on epicardial
coronaries
76. 2D Echocardiogram
77. Left Ventriculogram
78. Chest pain – Gastrointestinal
Any patient at risk for CAD who presents with anginal quality chest pain -
r/o myocardial ischemia before being given gastrointestinal diagnosis
79. GERD Chest pain can mimic angina pectoris
Squeezing / Burning pain - Substernal - Radiating - to back
Lasting minutes to hours
Resolving spontaneously or with antacids
Reflux symptoms : dyspepsia / regurgitation / acid taste
ECG / Cardiac enzymes / ECHO – R/O ACS
Diagnosis : Oesophageal manometry / OGDscopy
80. Mallory Weiss Syndrome h/o non bloody vomiting and retching followed by hemetemesis chest discomfort – epigastric / in back
Incidence increases with age
Associated with alcoholics and hiatus hernia
Mallory-Weiss syndrome is characterized by longitudinal mucosal lacerations – proximal stomach and distal oesophagus
Diagnosis : OGDscopy
81. Mallory Weiss Tear
82. Esophageal chest pain Pain provoked by swallowing
Pain provoked by postural changes
Pain palliated by antacids
Inconsistent relationship with exercise
Substernal chest pain which doesn’t radiate
Frequent episodes
Nocturnal pain
Pain associated with heartburn, acid taste in mouth
83. Others…. Achalasia cardia
Oesophageal spasm
Nut cracker esophagus
Medication induced esophagitis
Radiating visceral pain – Peptic ulcer disease
Cholecystitis
Biliary Colic
Pancreatitis
Appendicitis
84. Pulmonary Causes
Pneumonia – pleuritic pain
Lung Cancer – dull aching pain
Sarcoidosis
Pleurisy
Empyema
Empyema necessitans
85. Musculoskeletal Chest pain
Insidious onset
Recent repetitive unaccustomed activity
Pain : localized or diffuse
Positional component
Persistant – prolonged ( hours – days )
86. COSTOCHONDRITIS : Multiple areas of tenderness in upper costal cartilages at costochondral junctions NO SWELLING
TIETZE’S SYNDROME : Painful nonsuppurative localized swelling of costosternal, sternoclavicular, costochondral joints
87. Associated conditions Chronic low back ache, young individual : Ankylosing Spondylitis
Ocular Inflammation : Ankylosing Spondylitis
Behcets Syndrome
Diffuse musculoskeletal pain / sleep disturbance : Fibromyalgia
Peripheral joint pain and swelling : RA
Skin lesion : Psoriatic Arthritis
88. Neuropathic Pain
Herpes zoster
Radiculopathy
89. Psychological Causes
Panic attack
Panic disorder
DSM –IV PC
90. Treat Chest Pain with Respect
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