introduction chest pain to the primary care physician represents an immediate challenge. the correct...

INTRODUCTION chest pain to the primary care physician represents an immediate challenge. The correct diagnosis is most often derived from detailed history (pain description; associated symptoms; and risk factors) that is supported by specific physical findings, an ECG, and/or chest x-ray. Chest pain accounts for approximately 6million annual visits to emergency departments (ED) in (US), making chest pain the 2d most common complaint.

EPIDEMIOLOGY IN PRIMARY CARE POPULATIONS A prospective study of 399 episodes of chest pain in patients seen in multiple outpatient centers over a one-year period noted the following prevalences of various causes of chest pain.

Approximately 60 percent of chest pain diagnoses were not "organic" in origin (ie, not due to cardiac, gastrointestinal, or pulmonary disease). Musculoskeletal chest pain accounted for 36 percent of all diagnoses (of which costochondritis accounted for 13 percent) followed by reflux esophagitis. Stable angina pectoris was responsible for 11 percent of chest pain episodes; unstable angina or myocardial infarction occurred in only 1.5 percen.

CARDIAC CAUSES OF CHEST PAIN Coronary heart disease Aortic dissection Valvular heart disease Pericarditis Myocarditis Stress-induced cardiomyopathy Cardiac syndrome X Pheochromocytoma

GASTROINTESTINAL CAUSES OF CHEST PAIN Gastroesophageal reflux disease Esophageal hyperalgesia Abnormal motility patterns and achalasia Esophageal rupture, mediastinitis, and foreign bodies Medication-induced esophagitis Other gastrointestinal causes of chest pain,peptic ulcer disease, cholecystitis or biliary colic, pancreatitis, kidney stones or even appendicitis Other gastrointestinal causes of chest pain

PULMONARY CAUSES OF CHEST PAIN Pulmonary vasculature- Acute pulmonary thromboembolism- Pulmonary hypertension and cor pulmonale Pulmonary vasculature- Acute pulmonary thromboembolism- Pulmonary hypertension and cor pulmonale Lung parenchyma- Pneumonia- Cancer- Sarcoidosis Pleura and pleural space- Pneumothorax- Pleuritis/serositis- Pleural effusion Pleura and pleural space- Pneumothorax- Pleuritis/serositis- Pleural effusion Mediastinal disease

PSYCHOGENIC/PSYCHOSOMATIC CAUSES OF CHEST PAIN Chest pain may be a presenting symptom of panic disorder, depression, and hypochondriasis, as well as cardiac, cancer, or other phobias.

Life-threatening conditions Acute coronary syndrome Aortic dissection Pulmonary embolism Tension pneumothorax Pericardial tamponade Mediastinitis (eg, Esophageal rupture)

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The ascending aortic arch is dilated, displacing the trachea to the right (black arrow). A left lower lobe density is suggestive of a pleural effusion. Surgery revealed a dilated ascending aorta with a dissection

Acute Aortic Dissection

Left panel: A left-sided, simple pneumothorax is seen on this PA chest radiograph (large white arrows). Right panel: On the expiratory film, the pneumothorax is larger and more easily seen (small white arrows).

Chest film from a patient with Boerhaave's syndrome reveals air under both diaphragmatic leaflets.

Cardiomegaly due to a massive pericardial effusion. At least 200 mL of pericardial fluid must accumulate before the cardiac silhouette enlarges.

Apical 4 chamber view from a 2-D echocardiogram shows a large pericardial effusion surrounding the heart. The heart has a swinging motion during the cardiac cycle and there is slight compression of the right atrium early in diastole, suggesting early tamponade

diastolic collapse of the right atrium and ventricle, a result of tamponade.

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General approach Onset of pain (eg, abrupt or gradual) Provocation/Palliation (which activities provoke pain; which alleviate pain) Quality of pain (eg, sharp, squeezing, pleuritic) Radiation (eg, shoulder, jaw, back) Site of pain (eg, substernal, chest wall, diffuse, localized) Timing (eg, constant or episodic, duration of episodes, when pain began)

Comorbidities: hypertension, diabetes mellitus, peripheral vascular disease, malignancy Recent events: trauma, major surgery or medical procedures (eg, endoscopy), periods of immobilization (eg, long plane ride) Other factors: cocaine use, cigarette use, family history.

EMERGENCY RESPONSE TO CHEST PAIN IN THE OFFICE 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 department in an ambulance equipped with a defibrillator.

intravenous access, placement of a cardiac monitor, and supplemental oxygen if breathlessness, hypoxemia, or signs of heart failure or shock are present. A 12-lead electrocardiogram within 10 minutes after presentation. Chest Radiography blood sample for cardiac enzyme measurement. Biomarkers, cardiac troponin (T or I; cTnT or cTnI); creatine kinase MB isoenzyme (CK-MB) is less sensitive. [8] acute coronary syndrome (ACS) 325 mg aspirin, Sublingual nitroglycerin.nitroglycerin

EVALUATION The office evaluation of new onset chest pain in stable individuals should begin with the consideration of imminently life-threatening causes (including acute coronary syndrome, pulmonary embolus, aortic dissection, pneumothorax, and esophageal rupture).

This is usually accomplished using clinical judgement, along with ECG testing, and less frequently exercise testing, other noninvasive testing, or invasive angiography.

Description of chest pain A thorough description of the pain is an essential first step in the diagnosis of chest pain.

Several studies suggest that a diagnosis of "nonspecific" chest pain carries risk of increased mortality, especially due to ischemic heart disease. Thus, a diagnosis of nonspecific chest pain should be made cautiously and may indicate the need for vigilant follow-up.

Quality of the pain The patient with myocardial ischemia often denies feeling chest "pain." More typical descriptions include squeezing, tightness, pressure, constriction, strangling, burning, heart burn, fullness in the chest, a band-like sensation, knot in the center of the chest, lump in the throat, heavy weight on chest, and toothache (when there is radiation to the lower jaw)

Acute chest pain with a classically ripping or tearing quality may be helpful in diagnosing acute aortic dissection. Pulmonary embolism presents with pleuritic chest pain in only 40 to 48 percent of patients. The chest pain of myocarditis can be pleuritic, but it can also mimic that of myocardial ischemia.

Region or location of pain Patients who indicated larger areas of discomfort were more likely to have an ischemic etiology of pain than patients who indicated smaller areas of discomfort.

Radiation The pain of myocardial ischemia may radiate to the neck, throat, lower jaw, teeth, upper extremity, or shoulder. 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. Cervical radiculopathy may present with chest, upper back or upper extremity pain.

timing The 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. "Functional" or nontraumatic musculoskeletal chest pain might have a much more vague onset.

Provocation Discomfort that reliably occurs with eating is suggestive of upper gastrointestinal disease. Postprandial chest pain may be due to gastrointestinal or cardiac disease; in the latter case it can be a marker of severe myocardial ischemia (eg, left main or three-vessel CHD. Chest discomfort provoked by exertion is a classic symptom of angina, although esophageal pain can present similarly.

Other factors that may provoke ischemic pain include cold, emotional stress, meals, or sexual intercourse. Pain made worse by swallowing is likely of esophageal origin. Truly pleuritic chest pain is worsened by respiration and may be exacerbated when lying down.

Palliation Pain that responds to sublingual nitroglycerin is frequently thought to have a cardiac etiology or to be due to esophageal spasm.nitroglycerin The pain of pericarditis typically improves with sitting up and leaning forward. On the other hand, pain that abates with cessation of activity strongly suggests an ischemic origin.

Severity The severity of pain is not a useful predictor of the presence of CHD. As many as one-third of myocardial infarctions may go unnoticed by the patient.

Associated symptoms Belching, a bad taste in the mouth, and difficult or painful swallowing are suggestive of esophageal disease, although belching and indigestion also may be seen with myocardial ischemia. Vomiting may occur in the setting of myocardial ischemia (particularly transmural myocardial infarction), in addition to gastrointestinal problems such as peptic ulcer disease, cholecystitis, and pancreatitis.

Diaphoresis, Dyspnea, Cough,Palpitations Syncope The patient with myocardial ischemia may describe presyncope. However, syncope associated with chest pain should raise a concern for aortic dissection, a hemodynamically significant pulmonary embolus, a ruptured abdominal aortic aneurysm, or critical aortic stenosis.

Psychiatric symptoms Symptoms of panic disorder, generalized anxiety, depression, or somatization may occur in patients with chest pain. Constitutional symptoms The elderly in particular may describe profound fatigue as the presenting complaint of myocardial infarction.

Symptoms associated with coronary heart disease in women In a report of 515 women with an acute MI, only 57 percent reported acute chest pain; the other presenting symptoms were shortness of breath (58 percent), weakness (55 percent), and fatigue (43 percent.

Risk factors The presence of hyperlipidemia, left ventricular hypertrophy, or a family history of premature CHD increase the risk for myocardial ischemia. Hypertension is a risk factor for both CHD and aortic dissection. A recent infection, especially viral, may precede an episode of pericarditis or myocarditis. Cigarette smoking is a nonspecific risk factor for serious pathology; it is associated with CHD, thromboembolism, aortic dissection, pneumothorax, and pneumonia.

Physical examination The focused physical examination is used to support or disprove hypotheses generated by the history. The general appearance,A full set of vital signs,complete cardiac examination Examination of Cardiovascular System

ALGORITHM FOR THE APPROACH TO THE DIAGNOSIS OF CHEST PAIN Step 1 (Evaluate need for emergent care ) Consider potentially life-threatening causes of chest pain. Patients in whom an acute coronary syndrome (acute myocardial infarction or unstable angina) is suspected should receive emergent care. critical noncoronary diagnosis such as pulmonary embolus, pneumothorax, aortic dissection, esophageal rupture, or acute abdomen.

Step 2 (Emergent care not needed) In patients in whom a diagnosis of stable CHD appears likely based on symptoms that are suggestive of angina and/or a history of cardiac risk factors.

Step 3 (Symptoms consistent with stable angina ) Evaluate the patient for CHD. outpatient management, admitting the patient to the hospital, especially if symptoms are progressive, Consider other causes of anginal chest pain, such as cardiac syndrome X and pulmonary hypertension.

Step 4 (Evaluation for CHD was negative ) Evaluate the patient for gastrointestinal disease. This evaluation may initially involve a trial of acid suppression.

Step 5 (Symptoms not suggestive of angina) Step 5a For patients who are felt not to have an ischemic etiology for chest pain but who have significant risk factors for CHD, consider arranging for an evaluation for CHD. Step 5b If symptoms suggest a musculoskeletal etiology, a trial of an NSAID is appropriate. Step 5c If symptoms suggest a gastrointestinal etiology, evaluate the patient for gastrointestinal disease.

Step 5d If symptoms suggest a psychogenic etiology, evaluate the patient for a psychosocial source of chest pain. Step 5e Consider chest anatomy as a guide to other less common causes of non-life-threatening chest pain including (zoster, breast disease,pericarditis, lung parenchyma, vasculature, or pleura.

Step 6 (Persistent chest pain ) If chest pain persists and evaluations for CHD (as in step 5a), musculoskeletal pain (as in step 5b), gastrointestinal pain (as in step 5c), psychogenic pain (as in step 5d), and other causes (as in step 5e) have not all been performed, those evaluations should now be undertaken.

Step 7 (Diagnostic evaluations negative ) Patient likely has chronic idiopathic chest pain. Since this is known to cause significant disability, consider referral to a pain management center or medical symptom reduction program.

Algorithm for the initial diagnostic approach to a patient with chest pain

Algorithm for the evaluation and management of patients suspected of having ACS.

Options for transporting STEMI patients and initial reperfusion treatment

THANKS FOR ALL

introduction chest pain to the primary care physician represents an immediate challenge. the correct...

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