APPROACH TO THE APPROACH TO THE PATİENT WITH

PATİENT WITH CHEST CHEST PAINPAININ PRIMARY CARE

Learning objectives

0 Understand a diagnostic approach to chest pain and0 How to reduce potential damage to myocardium by

implementing rapid evaluation

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of Family Medicine

0 Know the evaluation of CP and0 How to best implement the primary treatment of CP0 Identify the risks and the need to educate patients

to reduce their risks

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of Family Medicine

0 Be familiar with the DD of CP and0 How to best rule in and out the more life-threatining

problems

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Introduction

0Chest pain is one of the most common medical symptoms. It must always be considered because it may be the first signal of serious, potentially lethal disease.

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0 Skin0 Muscles0 Bones0 Joints0 Heart and Vessels0 Lungs and Airways0 Esophagus0 Nerves

What Lies in the Chest?

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Pathophysiology

0 The heart, lungs, esophagus, and great vessels provide afferent visceral input through the same thoracic autonomic ganglia.

0 A painful stimulus in these organs is typically perceived as originating in the chest, but because afferent nerve fibers overlap in the dorsal ganglia, thoracic pain may be felt (as referred pain) anywhere between the umbilicus and the ear, including the upper extremities.

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0 Painful stimuli from thoracic organs can cause discomfort described as pressure, tearing, gas with the urge to eructate, indigestion, burning, aching, stabbing, and sometimes sharp needle-like pain

0 When the sensation is visceral in origin, many patients deny they are having pain and insist it is merely “discomfort.”

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Aetiology

Emotional & psychiatric Anxiety or depression, hyperventilation

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Causes of chest pain

Some disorders are immediately life threatening: 0 Acute coronary syndromes (acute MI/unstable

angina)0 Thoracic aortic dissection0 Tension pneumothorax0 Esophageal rupture0 Pulmonary embolism (PE)

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Overall, the most common causes are 0 Chest wall disorders %38 (ie, those involving muscle

%20 muscle pain, rib %2 rib fracture, or cartilage %13 chostochondritis)

0 Pleural disorders0 GI disorders% 20 (eg, esophageal reflux or spasm %

13, ulcer disease % 1-2, cholelithiasis % 1)0 Idiopathic0 CV disorders: Acute coronary syndromes % 2-3 AMI /

% 3 US AP and stable angina % 10, others < % 1

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Risk factors for CAD (most common cause

of cardiovascular CP)

0 Should be elicited from the history0 Increased Age0 Male gender0 Hypertension0 Diabetes0 Dyslipidemia0 Smoking0 PMH or FH of CAD0 Obesity0 Substance abuse

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H&PE

0 A careful medical history is the first step. 0 Then, a thorough physical examination and, when

indicated, one or two laboratory tests, an ECG and chest x-ray, completes the baseline information necessary to decide what to do next; watch and wait,

0proceed with management, 0or refer for specialized evaluation.

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History of present illness

0Attributes of paino Location/Radiation o Quality/Quantity o Timing/Duration/Frequency o Aggravating/Relieving Factors o Associated Symptoms (e.g. Breathlessness, cough,

hemoptysis, nausea)

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0 PMH, Drug History, Smoking history, 0 Family History (Coronary Artery disease)0 Review of Systems

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0 It is worth that noting that cardiac causes of chest pain are

often accompanied by shortness of breath; but in contrast

to many respiratory causes of chest pain and dyspnea, and

with the exception of pericarditis, the pain of heart disease

does not vary with breathing.

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Physical Examination

0 General appearance (distress, sweating, pallor, fever)

0 BP in both arms, pulses, JVP, apex beat, heart sounds

0 Lung fields, local tenderness, pain on movement of chest

0 Examination of the lungs0 Upper abdominal examination0 Swelling or tenderness of legs

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0 Neck is inspected for venous distention and hepatojugular reflux, and the venous wave forms are noted.

0 The neck is palpated for carotid pulses, lymphadenopathy, or thyroid abnormality.

0 The carotid arteries are auscultated for bruit.

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0 Palpate the chest and the spinous processes of vertebrae (local tenderness, fractures, symptomes of spinal diseases

0 Crepitus associated with rib fracture, localized pain, signs of trauma.

0 Hyperesthesia, particularly when associated with a rash, is often due to herpes zoster

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0 Lungs are percussed and auscultated for presence and symmetry of breath sounds, signs of congestion (dry or wet rales, rhonchi), consolidation (pectorilloquy), pleural friction rubs, and effusion (decreased breath sounds, dullness to percussion).

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0 Cardiac murmurs, 3rd & 4th heart sounds, pericardial rubs,

0 Intensity of breath sounds, 0 Pleural friction, rub pleurisy, 0 Evidence of pneumothorax (absence of respiratory

sounds, vocal fremitus), pulmonary embolism, pneumonia or pleurisy

Cardiac & Pulmonary Auscultation

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0 The chest is inspected for skin lesions of trauma or herpes zoster infection and palpated for crepitance (suggesting subcutaneous air) and tenderness.

0 The abdomen is palpated for tenderness, organomegaly, and masses or tenderness, particularly in the epigastric and right upper quadrant regions.

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0 The legs are examined for arterial pulses, adequacy of perfusion, edema, varicose veins, and signs of DVT (eg, swelling, erythema, tenderness).

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Red flags: Certain findings raise suspicion of a more serious etiology of

chest pain:0  Abnormal vital signs (tachycardia, bradycardia, tachypnea,

hypotension)0 Signs of hypoperfusion (eg, confusion, ashen color, diaphoresis)0 Shortness of breath0 Asymmetric breath sounds or pulses0 New heart murmurs0 Pulsus paradoxus > 10 mm Hg - abnormally large decrease in

systolic blood pressure and pulse wave amplitude during inspiration.

0 The paradox in pulsus paradoxus is that, on clinical examination, one can detect beats on cardiac oscultationduring inspiration that cannot be palpated at the radial pulse. It results from an accentuated decrease of the blood pressure, which leads to the (radial) pulse not being palpable.

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Cardiovascular causes of chest pain

0 Cardiac ischaemia (lack of oxygen supply to the heart muscle the myocardium; the myocardial infarction, angina pectoris

0 The pericardium; pericarditis0 The aorta; dissecting aneursym

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1Myocardial ischemia (acute MI/unstable

angina/angina)

Acute, crushing pain radiating to the jaw or

arm

Exertional pain relieved by rest (angina pectoris)

S4 gallop

Sometimes systolic murmurs of mitral

regurgitation

Often red flag findings‡

Serial ECGs and cardiac markers; admit or

observe

Stress imaging test or CT angiography

considered in patients with negative ECG

findings and no cardiac marker elevation

Often heart catheterization and

coronary angiography if findings are positive

Cause* Suggestive Findings Diagnostic Approach†

Clinical picture of patient with CAD in primary care

0 Emergent0 Acute coronary syndrome (AMI with or without ST

elevation)0 Unstable angina

0 Nonemergent0 Stable angina0 asymptomatic

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AP

o Quality/Quantity Pain is usually described as an intense “pressure”, “squeezing”, or “constriction”, Location originating underneath or to the left of sternum. Radiation May radiate to one/both arms, neck, or jaw. Timing/Duration/Frequency It seldom lasts more than 15 minutes

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AP Aggravating/Relieving Factors Thus angina

characteristically develops with exertion and it is relieved by rest;

excitement, cold, emotional stress, sexual intercourse or ingestion of food.

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AP

0 It is relieved with seconds or occasionally minutes by glycerly trinitrate (nitroglycerin) and the response to this can be used as a diagnostic test.

0 Associated Symptoms It is often associated with breathlessness due to temporary left ventricular dysfunction, or palpitations.

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AP

0 Cardiac ischemiae may be related to exercise when it causes the pain called angina “angin d’effort”

0 “unstable ”angina should be used to describe unstable patterns (prolonged pain, occurring at rest, increasing frequency, etc)

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Severity of effort can be variable / It should be consistent every time

0 Severe Effort0 Running0 Climbing several steps0 Walking upward

0 Daily activities0 Walking0 Climbing one step

0 Mild Effort0 Activities at home

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Stable AP

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0 DD of AP and UAP is based on history0 AP :

0nonemergent0Follow up and treatment can be organized by FP0Aspirine, nitrates, bete-blocker 7 Ca-Channel bloker, statines

0 UAP: 0emergent0Should be referred to for observation and hospitalization

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MI

0Definition: death or necrosis of heart muscle, occurs when occlusion of a coronary artery causes irreversible ischemia

0Coronary artery occlusion can also cause sudden death, so the term “heart attack” is usually used to encompass both myocardial infarction and sudden death.

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MI

0Quality/Quantity Constricting or crushing pain or

intense dull ache Timing/Duration/Frequency Pain

due to a heart attack is similar in nature to angina

but it usually lasts with several hours and the

diagnosis of infarction is unlikely if the pain settles

within 30 minutes. Pain lasting longer than 48

hours is unlikely to be due to infarction. It is

lasting>1/2h. 3611.04.23

Guldal Izbirak, MD, Assoc Prof of Family Medicine

MI

0 Location/Radiation Similar in location and radiation to that

of angina but in contrast, tends to be much more severe,

Aggravating/Relieving Factors is not relieved by GTN.

Glyceryl trinitrate is ineffective and powerful analgesics

such as morphine are needed for pain relief.

0 Associated Symptoms Important distinguishing features

are accompanying dyspnea, profuse sweating, nausea,

vomiting and profound weakness.

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Variable Points

Age 55 years or older in men; 65 years or older in women

1

Known CAD or cerebrovascular disease

1

Pain not reproducible by palpation

1

Pain worse during exercise 1

Patient assumes pain is cardiogenic

1

Total points: ______

Clinical Decision Rule for Identifying Patients with Chest Pain Caused by CAD

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Algorithm for the evaluation of patients with chest pain in the primary care setting. (ECG = electrocardiography.)

http://www.aafp.org/afp/2011/0301/p603.html Point-of-Care Guides

Pericarditis

Pericardial pain, which is due to inflammation involving the parietal pericardium, Quality/Quantity feels like stabbing, burning or cutting Aggravating/Relieving Factors is made worse by coughing, swallowing, deep breathing, or lying down; diminished by leaning forward. It is not relieved by nitroglycerin.

Timing/Duration/Frequency Pericardial pain can last for hours or days.

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0Location/Radiation It is less variable in character, position, and referral area than myocardial ischemic pain.

0Associated Symptoms May be associated with fever, breathlessness. Signs pericardial rub, tamponade

0Diagnosis History of pain, pericardial friction rub, ECHO,serial chest x-ray(effusion)

0Lab ESR, Leukocytosis

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Dissecting Aneursym

0A tear in the aortic intima through which blood surfes into the aortic wall, stripping the media from the adventitia.

0Quality/Quantity Pain from dissection of the aorta is usually very severe and of a tearing or rending character. Location/Radiation It is sudden interscapular back pain or pain similar to MI ± radiation through to back or down into the abdomen. Associated Symptoms Often the patient is very unwell and shocked.

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Non-cardiovascular causes of chest pain arise in;

0The pleura0The oesophagus0The chest wall

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Pleuritic pain

0Pleuritic pain is usually sharply restricted to the

ipsilateral chest wall or shoulder. Pain, usually well

localized, may be variously described as “sharp”,

“dull”, “achy”, sometimes “burning”, but whatever its

designation, it is worsened and thus prevents deep

inspiration. Also coughing and sneezing.

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0 Aggravation by breathing causes patients to seek,

find, and remain in the body position that most

restricts movement of the affected region. Implies

inflammation or irritation of the pleura. Causes are

chest infection.

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Pulmonary Embolism

0 Venous thrombi (usually from a DVT) pass into the pulmonary circulation and block blood flow to the lungs.

0 Fatal in ~1:10 cases.0 Risk factors: Immobility(long flight or bus journey, post-

op), smoking, COC pills, pregnancy or puerperium, past and/or family history of DVT or PE

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0 Symptoms chest pain, bloody sputum, acute

breathlessness,

0 Signs pleuritic pain,hemoptysis, hypotension,

tachycardia, cyanosis, tachypnoea, syncope, pleural rub,

↑ JVP

0 Screening Postero-anterior and lateral chest x-rays.

0 Therapy Give oxygen as soon as possible.

0 Consult pulmologist.

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Pneumothorax

0Def: Air in the pleural cavity. >1/2 cases are due to trauma of some kind-the rest are spontaneous.

0Symp/Signs: Sudden onset of chest pain and/or increased breathlessness ± pallor, sweating and tachycardia, hypotension, shock

0Physical examination: or absent breath sounds and chest movement, diminished vibration(vocal fremitus), hyperresonance by percussion

0Refer for Chest X-Ray.

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Oesophageal pain

Quality/Quantity May be very similar to cardiac

pain. Reflux or spasm.Reflux pain is burning in nature

Timing/ Duration/ Frequency occurs shortly

after meal. Location a substernal pressure-type pain,

which may last 2 t0 5 minutes, similar to angina.

Radiation It usually radiates to the back rather than

to the arms.

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0 Aggravating/Relieving Factors Not associated with

exertion. Relieved by antacids.

0Relieved by GTN but less rapidly than angina.

0Suspect if related to food or alcohol ingestion or

occurs in bed on lying flat.

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Rib fracture

0 Usually history of injury. Pain well localized and

point tenderness over rib. Pain made by light

pressure over sternum. Chest x-ray, treatment

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Musculoskeletal pain

0 Common. Sharp or dull pain. Due to radiation of

pain from thoracic spine or local muscular injury.

Usually made worse by movement and relieved by

rest and NSAIDs.

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Shingles

0 Reactivation of latent varicella zoster virus0 Sudden onset of the neuralgic –often burning in nature-pain

in a dermatomal unilateral distribution. Clusters of herpetic vesicles appear in a few days later. The pain is frequently intensified by respiratory motion or movements of the trunk.

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Psychiatric disorders

0Certain psychiatric disorders (GAD, PD) are recognized as causing chest pain that simulates angina.

0 Patients with documented heart disease may also have panic attacks or other psychiatric disorders.

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0Characterized with multiple symptoms.

0Associated with stressful life events and the symptoms are transitory.

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Panic disorder

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0 Shortness of breath0 Choking0 Palpitations and

accelerated heart rate0 Chest discomfort0 Sweating0 Dizziness

0 Nausea and abdominal pain

0 Flushes or chills0 Fear of dying0 Fear of doing

something crazy or uncontrolled

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Differential Diagnosis

0 Thorough medical history, esp. Pain itself; questions concerning other cardinal symptoms of cardiorespiratory diseases should be asked (dyspnea, cough and hemoptysis).

0 A thorough physical examination0 CBC, Cardiac enzymes0 Chest X-ray and/or ECG

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Typical Clinical Features of Major Causes of Acute Chest Discomfort

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Typical Clinical Features of Major Causes of Acute Chest Discomfort

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When to Refer

0 Patients with chest pain of cardiac origin may need emergency hospitalization and are likely to require further diagnostic evaluation by a cardiologist for coronary artery disease or valvular dysfunction. This may include ECHO, cardiac catheterization, treadmill testing, or coronary angiography with possible angioplasty or stent placement.

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0 Stable / Unstable Angina0 Emergent / Nonemergent0 Rule out life-threatining conditions

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When to Refer

0Consultation with a pulmologist is needed

for patients who might require fiberoptic

bronchoscopy, pleural biopsy, or specialized

pulmonary function testing.

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When to Refer

0If invasive procedures are needed to evaluate chest pain of possible esophageal origin or somewhere in the abdomen, referral to a gastroenterologist is warranted.

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When to Refer

0In selected cases of intractable chest pain of

presumed psychological origin, referral to a

psychiatrist can be helpful.

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Key Points0 Immediate life threats must be ruled out first.0 Some serious disorders, particularly coronary ischemia and PE,

often do not have a classic presentation.0 Most patients should have pulse oximetry, ECG, cardiac markers,

and chest x-ray.0 Evaluation must be prompt so that patients with ST-elevation MI

can be in the heart catheterization laboratory (or have thrombolysis) within the 90-min standard.

0 If PE is highly likely, antithrombin drugs should be given while the diagnosis is pursued; another embolus in a patient who is not receiving anticoagulants may be fatal.

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References:

0 Bates' Guide to Physical Examination And History Taking (9th Edition) by lynn

S Bickley, Peter G Szilagyi

0 Essentials of Family Practice, Rakel

0 Case Files: Family Medicine, LANGE, McGraw Hill, 2007

0 Decision making, Berman, third edition

0 http://www.aafp.org/afp/2011/0301/p603.html

0 http://www.merckmanuals.com/professional/cardiovascular_disorders/sympto

ms_of_cardiovascular_disorders/chest_pain.html?tabid=tabNav3

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