approach to chest pain
DESCRIPTION
A practical approach to a common problemTRANSCRIPT
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Approach to chest pain
Do not panic
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Pain
Subjective symptom
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Pain sensitive structures Skin Breast Muscles Bones, joints Parietal pleura Myocardium Pericardium Esophagus Aorta- adventitia Nerve roots
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Common causes Cardiac- CAD (angina/MI), pericarditis Vascular- aortic dissection, PE Pulmonary- pleuritis, pneumothorax GI- esophageal reflux/spasm/rupture Skeletal- costochondritis, arthritis Nervous- radicular pain, H. zoster
Tumors, abscesses, muscle cramps etc.
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How to go?
Serious or catastrophic causes Cardiac ischemia Pericarditis Aortic dissection Pulmonary emboli Esophageal rupture
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Back to basics
History & examination
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Myocardial ischemia Pain- described as
heaviness/pressure/squeezing/tightness Onset/worsening with exertion/meals Location- substernal/retrosternal Radiation to arms/jaw/shoulder/back Duration- <20 mins. or >20 mins. Relieved with rest, S/L NTG, morphine Associated with nausea/sweating/sense of doom h/o DM, HT, smoking Family history of CAD
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Other causes Pericarditis- ant. chest/back, pleuritic,
worse when supine and relieved by sitting upright & leaning forward
Aortic dissection- abrupt onset, rapidly worsens, retrosternal, radiates to back, lasts hours, no relief with analgesics
GI causes- UGI symptoms Costochondritis- elicitable pain
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Relevant examination
Vitals- equal pulses, BP, tachypnea Local tenderness or skin lesion LNE (tumor) Crepitations, pleural rub S3/S4, murmur Upper abdominal examination
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Relevant investigation
ECG, trop T stress tests (TMT/ECHO)
Chest X-ray D-dimer CT scan chest
Other X-rays- spine, shoulder
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Treatment of pain Angina- NTG MI- morphine Pericarditis/PE- NSAIDs Aortic dissection/esophegeal rupture-
Surgery Esophageal reflux- PPI/H2RB Zoster- amitriptyline, carbamazepine,
pregabalin, gabapentin Bone/joint/muscle pain- NSAIDs
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Palpitation
Unpleasant awareness offorceful, rapid, irregular
heart beat
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Causes Cardiac Sinus bradycardia Any tachycardia PVC/PAC Sick sinus syndrome Advanced AV block Aortic regurgitation
Non-cardiac Fever Anemia Thyrotoxicosis Pheochromocytoma Drugs Alcohol, CocaineAnxiety/Panic
disorder
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Evaluation History Onset/offset, frequency, rate, rhythm Aggravating/relieving factors, associated symptoms h/o cardiac disease Examination Pulse- rate, rhythm Pallor, e/o hyperthyroidism Cardiac examination Investigation ECG, ECHO, Holter, Hb., TSH Treatment- of underlying etiology