evaluating chest pain

2.  Causes of chest pain that cause immediate threat to
life:
 Acute coronary syndrome
 Aortic dissection
 Pulmonary embolism
 Tension pneumothorax
 Pericardial tamponade
 Mediastinisis ( esophageal rupture)

3. Acute coronary syndrome:
 Leading cause of death in adults
 Results from atherosclerotic plaque rupture &
thrombus formation
 Coronary blood flow is reduced & myocardial
ischemia occurs
 Degree & duration of oxygen supply-demand
mismatch determines whether pt. develops
myocardial ischemia with or without injury

4. Aortic dissection:
 Commonly affects pts with systemic HTN
 Begins as tear in inner layer of aortic wall allowing
blood to track b/w intima & media causing
subsequent obstruction of branches of arteries &
ischemic injury
Pulmonary embolism:
 Occurs when dislodged venous clot migrates through
rt.side of heart & gets lodged at branch pt. of pul.
Arteries
 Occlusion results in pul.HTN, rt.venticular
dysfunction, poor gas exchange, parechymal
infarction
Mediastinitis:
 Common causes include odontogenic infection,
esophageal perforation, iatrogenic complications
of cardiac surgery or upper GI or airway
procedures

5. Pneumothorax:
 Can occur following trauma or pul.procedures
 Also occurs spontaneously in pts with or without
underlying lung disease
 Accumulation of air in pleural space can lead to
tension pneumothorax with compression on
mediastinum causing rapid clinical deterioration &
death
Pericardial tamponade:
 Occurs when there is accumulation of pericardial
fluid under pressure leading to impaired filling
producing picture resembling cardiogenic shock
 Can occur following aortic dissection, thoracic
trauma, acute pericarditis,malignancy,uremia etc

6. Common conditions:
Cardiac causes:
 Acute heart failure
 Angina
 Valvular heart disease
 Infectious or inflammatory causes-pericarditis
myocarditis endocarditis
Pulmonary causes:
 Infections-pneumonia,tracheitis, bronchitis
 Asthma exacerbations
 Pul. Malignancy
 Pleural effusion

7. GI causes:
 GERD
 Esophageal spasm, rupture or inflammation
 Sliding hiatus hernia
 Pancreatitis-pain referred to chest
Musculoskeletal causes:
 Rib contusions & fractures
 Intercoastal muscle strains
 Costochondritis
Psychiatric causes:
 Panic attacks

8.  Other causes:
 Herpes zoster referred pain
 Collagen vascular disease
 Lupus
 Sarcoid
 Scleroderma
 Kawasaki disease
 Polyarteritis nodosa
 Takayasu arteritis

9. History: obtain detailed history of:
 onset of pain
 Provocation/ palliation
 Quality of pain
 Radiation
 Site of pain
 Timing
 Prior diagnostic studies for similar studies or prior
studies
 Associated symptoms
 h/o HTN, DM, PVD,malignancy
 h/o recent events-trauma, major surgery or
medical procedures, period of immobilization
 h/o use of cigarettes, cocaine etc

10. Ancillary studies:
Electrocardiogram:
 best immediately available test for detecting
ACS
 should be repeated as frequently as every 10 min
if initial ECG is not diagnostic & there is high
suspiscion of AMI
 Limited value in pul. Embolism
 Tamponade- ECG findings shows low voltage &
electrical alterans
 Pericarditis: mimic AMI & vary as disease
progresses. PR segment depression, ST segment
elevation & T wave inversion
 Aortic dissection: completely normal to ST
segment elevation

11. Laboratory studies:
Cardiac biomarkers:
 Cardiac troponin I: In AMI elevates within 3 hrs, peaks
at 12 hrs & remains elevated for 7-10 days
 Creatine kinase MB- raise to twice normal at 6 hrs &
peaks app. 24 hrs
D- dimer:
 Among pts with low pretest probability for
pul.embolus, this test with high sensitivity can rule
out diagnosis
 Pts likely to have elevated D-dimer at baseline are
elderly, malignancy, sepsis, recent trauma or surgery
 can rule out aortic dissection

12. Complete blood count:
 WBC count may be raised in inflammatory or
infectious conditions
 Anemia in pts with exertional chest pain-suggestive
of myocardial ischemia
B-type natriuretic peptide:
 Levels >100pg/ml are sensitive for acute heart
failure & levels < 50 have negative predictive
value for HF
Arterial blood gas:
 For diagnosing or excluding pul.embolism
 Not routinely indicated

13. Chest radiography:
 Indicated in all chest pain pts with hemodynamic
instability or potentially life threatening diagnosis
 Aortic dissection-widened mediastinum or aortic
knob
 Pul.embolism- normal or nonspecific
 Pneumonia & pneumothorax- diagnosed by CXR
 Acute heart failure-pul.vascular congestion &
cardiomegaly
 In pts with severe vomiting or recent
instrumentation of esophagus, mediastinal
emphysema & pleural effusion suggest esophageal
tear

14. Other imaging:
Aortic dissection: CT, MRI, transesophageal
echocardiography
Pulmonary embolism: CT, nuclear imaging or
pul. Angiography
 Pul.angiography combined with venography can
detect DVT
 Nuclear cardiac imaging: exercise stress test with
or without nuclear imaging as well as stress
echocardiography can assist in risk stratification
 Bedside ultrasonography:helps to exclude or
support certain diagnosis
 Used to assess pts with blunt trauma for
effusions,tamponade,wall motion
abnormalities,valvular & septal abnormalities etc

15.  Assessment & stabilization of airway, breathing &
circulation
Acute coronary syndrome:
 requires serial ECG’s
 Pts with STEMI-require immediate
revascularization or fibrinolysis
Aortic dissection:
 Emergent treatment-BP & HR control to reduce
force & intensity of cardiac flow
 Best achieved with combination of beta-blockers
(esmolol)&Na nitroprusside(or nitroglycerin)
 Beta-blockers should be started first to prevent
rebound tachycardia

16. Pulmonary embolism:
 Initial management-anticoagulation
 Pts with massive or submassive emboli require
thrombolytics or embolectomy
Pneumothorax:
 Tension pneumothorax-immediate tube or needle
thoracostomy
Pericardial tamponade:
 Tamponade with overt hemodynamic compromise
requires removal of pericardial fluid
 Early tamponade with mild hemodynamic
compromise may be treated conservatively with
careful monitoring

17. Mediastinitis:
 Broad spectrum antibiotics -in suspected
mediastinitis
 If required-surgical debridement & possible repair
Disposition:
 Pt with hemodynamic instability or respiratory
distress-admitted in ICU
 Pts with aortic dissection, pneumothorax, cardiac
tamponade, & mediastinitis require admission
 Pts with pul.emboli with hemodynamic instability,
STEMI ,high risk of ACS-admitted in ICU
 pts with stable angina-do not require inpatient
evaluation