l 6.approach to chest pain

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Approach toCHEST PAIN

DR.Bilal Natiq Nuaman,MD

CABM,FICMS,DIM,MBChB

2017

Chest pain—broadly defined as any discomfort in the anterior thorax occurring above the epigastrium and below the mandible—can be one of the most challenging problem managed by the physicians.

The typical patients’ concern with the first bout of chest pain is their apprehension of the onset of cardiac pathology, such as ischemic heart disease (IHD).

Chest discomfort is among the most common reasons for which patients present for medical attention at either an emergency department (ED) or an outpatient clinic.

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CAUSES OF CHEST PAIN

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Any adult male (more than 30 years), or postmenopausal female, complaining of retrosternal pain should be suspected to be having myocardial ischemia, until proved otherwise.

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History takingAsk the patient the following 10 points about chest pain:1. Onset2. Site of pain3. Character (Quality)4. Duration5. Radiation6. Aggravating factor7. Relieving factor8. Local tenderness9. Associated symptoms10. Severity.

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Ischemic Vs

Non Ischemic Chest Pain

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• Chest pain due to ischemic heart disease (IHD) may manifest as:

Angina pectoris :2-10 min., relieved by rest , not associated with

vomiting

Myocardial infarction :>30 min., not relieved by rest , associated with vomiting

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Characteristics of cardiac pain

• Onset. The pain of MI typically takes several minutes or even longer to develop; similarly, angina builds up gradually in proportion to the intensity of exertion.

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• Associated features. The pain of MI, massive pulmonary embolism or aortic dissection is often accompanied by autonomic disturbance, including sweating, nausea and vomiting.

Breathlessness, due to pulmonary congestion arising from transient ischemic left ventricular dysfunction, is often a prominent and occasionally the dominant feature of MI or angina (angina equivalent). Breathlessness may also accompany any of the respiratory causes of chest pain and can be associated with cough, wheeze or other respiratory symptoms.

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Major adverse cardiac events (MACE) 29

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DIFFERENTIAL DIAGNOSIS

• Acute, sudden and severe chest pain described as tearing that

is maximal at onset and radiates to interscapular area raises

the possibility of aortic dissection.

Important diagnostic feature is the inequality in the pulses, e.g. carotid, radial and femoral, and a blood pressure differential of greater than 20 mm Hg

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• Severe chest pain, retrosternal, accompanied by dyspnea, cough, and hemoptysis developing in a patient who has been immobilized or bedridden is suggestive of pulmonary embolism

• Chest discomfort due to pericarditis is typically retrosternal, aggravated by coughing, deep respiration, or change in position; worse in supine, and relieved in sitting upright and leaning forward

• The pain of esophageal spasm is commonly an intense, squeezing discomfort that is retrosternal in location and, like angina, may be relieved by nitroglycerin

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• Pain in a dermatomal distribution can also be caused by herpes zoster

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PULMONARY50%

EXCLUDE75%

3495% CAUSES

• Stable angina NON ischemic chest pain

ECG CXR

DIAGNOSTIC CAUSES

TREADMILL TEST ECHO

DIAGNOSTIC VALVE LESION

CORONARY ABDOMINAL U S

ANGIOGRAPHY , OGD DIAGNOSTIC ABDOMINAL

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THANK YOU

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