1. Chest Pain

2. Causes of Chest Pain
• Central chest pain
• Peripheral chest pain

3. Central chest pain
• Anxiety emotion (may also cause peripheral
chest pain)
• Cardiac cause
- Myocardial ischaemia (angina)
- Myocardial infarction
- Myocarditis
- Pericarditis
- Mitral valve prolapse syndrome

4. • Aortic
-Aortic dissection
-Aortic Aneurysm
• oesophageal
- Oesophagitis
- Oesophageal spasm
- Mallory-weiss syndrome
• Massive pulmonary embolism
• Mediastinal
- Tracheitis
- malignancy

5. Pheripheral chest pain
• lungs / pleura.
- pulmonary
infarct - malignancy
- pneumonia - TB
- pneumothorax - connective tissue
d/s

6. • Musculoskeletal
- osteoarthritis
- Rib fracture/ injury
- intercostal m/s injury
- costochondritis (Tietze's syndrome)
- Epidemic myalgia (Bornholm d/s)

7. • Neurologial
- PID
- Herpes zoster
- Thoraeic outlet syndrome

8. Enquire about chest pain
• Site of origin of pain
• Duration
• Radiation
• Character of the pain & severity
• Pattern of onset
• Aggravating factor relieving factor
• Associated features

9. Site of origin of pain
Angina - Pain is characteristics central &
retrosternal diffuse
- because of the derivation of nerve
supply to the heart & mediasinum
Pleural or lung d/s musculo skeletal and
Anxiety
- Peripheral localised

10. Radiation
ischaemic pain - radiate to neck, jaw &
upper & even lower arms
- sometime only at the site of
radiation or in the back
Non Cardiac chest pain
- other or no radiation

11. Character
Ishaemic cardiac Pain
• typically dull, constricting choking or heavy
& is usually described as squeezing,
crushing, burning or aching .
• The sensation can be described as
breathlessness or like indigestion

12. • patient typicaly use characteristic hand
gesture (eg. open hand or clenched fist)
when describing ischaemic pain.
Non cardiac pain
- sharp , stabbing , pricking or knife-like

13. Aggravating Factor
Angina - Exertion
- Emotion, excitement
- Cold weather
- Exercise after meal.
Pleural, pericardial pain
- breathing coughing or movement
Musculoskeletal pain
- Specific movement
(bending, stretching, turning)

14. Relieving Factor
Angina - Rest
- Glyceryl trinitrate
- warm up before exercise
Non cardiac pain
- Not relieved by rest
- Slow or no response to nitrate

15. Pattern of onset
MI - typically take several minutes or even
longer to develop.
Angina -build up gradually in proportion
to the intensity of exertion
Aortic dissection, PE, Pneumothorax
-very sudden onset

16. Associated features
MI, PE, Aortic dissection
- Accompanied by autonomic
disturbance including sweating,
nausea and vomiting
MI,Angina
- Breathlessness due to
pulmonary congestion arising
from transient ischaemic left
ventricular dysfunction
Non cardiac pain
- Respiratory , GI, locomotor or
psychological

17. Severity Of Angina
• Canadian Cardiovascular Society:
functional classification of stable angina
Grade 1 - Ordinary physical activity such
as walking and climbing stairs,
does not cause angina. Angina
with strenous or rapid or
prolonged exertion at work or
recreation

18. Grade 2 - Slight limitation of ordinary activity.
Walking or climbing stairs rapidly,
walking uphill, walking or stair
climbing after meals in cold ,in
wind, or when under emotional
stress, or only during the few hours
after awakening.

19. Grade 3 - Marked limitation of ordinary
physical activity . Walking
one to two blocks on the level
and climbing less than one
flight in normal condition.

20. • Grade 4 – Inability to carry on any
physical activity without
discomfort anginal
syndrome may be present
at rest.

21. Questions –To assess the severity of
angina
• How far can you walk on the flat before
experiencing discomfort ?
• Do you get discomfort climbing stairs or
hills ?
• Do you experience discomfort gardening,
making the bed or during other household
chores?

22. • Does sexual intercourse produce
discomfort ?
• Is the discomfort influenced by
meals ?
• Is it influenced by cold weather ?

23. Types of cardiac pain
Type Cause Characteristic
Angina Coronary stenosis (rarely Precipitated by
aortic stenosis hypertrophic exertion, eased by rest
cardiomyopathy ) Characteristic
distribution
Myocardial Coronary occlusion Similar sites to
infarct angina ,more severe
,persists at rest.
Pericarditic pain Pericarditis Sharp, raw or stabbing
Varies with movement
or breathing
Aortic pain Dissection of the aorta Severe ,sudden onset ,
radiates to the back

24. Differential diagnosis
Psycological aspects of chest
pain
• very common
• considered if there are features of
anxiety or neurosis
• lacks a predictable relationship with
exercise

25. Psycological aspects of chest
pain
• Psychological and organic features can be
coexist
• responsible for the death of close friend or
relative
• Anxiety may amplify the effects of organic
disease (create a confusing picture)

26. Musculosketal Chest Pain
• Common problem
• Very variable in site and intensity
• Pain may vary with posture or
movement of the upper body
• Sometimes accompanied by local
tenderness over a rib or costal
cartilage

27. Musculosketal Chest Pain
• Numerous causes of chest wall pain
- arthritis
- Costochondritis
- intercostal muscle injury
- coxsackie viral infection
(epidemic myalgia or Bornholm
disease)
• Many minor soft tissue injury are
related to everyday activities such as

28. Differential diagnosis:angina vs
oesophageal pain
Angina Oesophageal pain
• Usually precipitated • Canbe worsened by
by exertion exertion, but often
present at other times
• Not rapidly relieved
• Rapidly relieved by by rest
rest
• Retrosternal or
• Restrosternal and epigastric, sometimes
radiates to arm and
radiates to arm or
jaw
back

29. Differential diagnosis:angina vs
oesophageal pain
Angina Oesophageal pain
• seldom wakes • Often wakes patient
patient from sleep from sleep
• No relation to • Sometimes related
heartburn (but to heartbum
patients often have
'wind')
• Rapidly relieved by • Often relieved by
nitrates nitrates
• Typical duration • Variable duration
2-10 minutes

30. Differential diagnosis:angina vs
myocardial infarction
Angina Myocardial infarction
Site: retrosternal, radiates As for angina
to arm, epigastrium, neck
Precipitated by exercise or Often no obvious
emotion precipitant
Relieved by rest, nitrates Not relieved by rest,
nitrates

31. Differential diagnosis:angina vs
myocardial infarction
Angina Myocardial infarction
• Mild/moderate • Usually severe (may be
severity silent')
• Anxiety absent or • Severe
mild
• No increased
sympathetic • Increased sympathetic
activity
activation
• No nausea or
vomiting • Nausea and vomiting are

32. Characteristics of percarditic pain
Site • -Retrosternal, may radiate
to left shoulder or back
Prodrome • -May be preceded by a viral
illness
Onset • -No obvious initial
recipitating factor; tends to
fluctuate in intensity

33. Characteristics of percarditic pain
Nature • May be stabbing or
'raw'-'like sandpaper'.
Often described as
sharp,rarely as tight
or heavy
Made worse by • Changes in posture,
respiration
Helped by
• Analgesics,
especially
Accompanied
by NSAIDs
• Pericardial rub

34. Characteristics of pain caused by
dissection of aortic aneurysm
Site • Often first felt between
shoulder blades, and/or
retrosternally
Onset • Usually sudden
Nature
• Very severe pain, often
described as 'tearing' in
nature

35. Characteristics of pain caused by
dissection of aortic aneurysm
Relieved by • Tends to persist. Patients
often restless with pain
Accompanied by • Hypertension, asymmetric
pulses, unexpected
bradycardia, early diastolic
murmur. syncope, focal
neurological symptoms and
signs