Approach to chest pain

Do not panic

Pain

Subjective symptom

Pain sensitive structures Skin Breast Muscles Bones, joints Parietal pleura Myocardium Pericardium Esophagus Aorta- adventitia Nerve roots

Common causes Cardiac- CAD (angina/MI), pericarditis Vascular- aortic dissection, PE Pulmonary- pleuritis, pneumothorax GI- esophageal reflux/spasm/rupture Skeletal- costochondritis, arthritis Nervous- radicular pain, H. zoster

Tumors, abscesses, muscle cramps etc.

How to go?

Serious or catastrophic causes Cardiac ischemia Pericarditis Aortic dissection Pulmonary emboli Esophageal rupture

Back to basics

History & examination

Myocardial ischemia Pain- described as

heaviness/pressure/squeezing/tightness Onset/worsening with exertion/meals Location- substernal/retrosternal Radiation to arms/jaw/shoulder/back Duration- <20 mins. or >20 mins. Relieved with rest, S/L NTG, morphine Associated with nausea/sweating/sense of doom h/o DM, HT, smoking Family history of CAD

Other causes Pericarditis- ant. chest/back, pleuritic,

worse when supine and relieved by sitting upright & leaning forward

Aortic dissection- abrupt onset, rapidly worsens, retrosternal, radiates to back, lasts hours, no relief with analgesics

GI causes- UGI symptoms Costochondritis- elicitable pain

Relevant examination

Vitals- equal pulses, BP, tachypnea Local tenderness or skin lesion LNE (tumor) Crepitations, pleural rub S3/S4, murmur Upper abdominal examination

Relevant investigation

ECG, trop T stress tests (TMT/ECHO)

Chest X-ray D-dimer CT scan chest

Other X-rays- spine, shoulder

Treatment of pain Angina- NTG MI- morphine Pericarditis/PE- NSAIDs Aortic dissection/esophegeal rupture-

Surgery Esophageal reflux- PPI/H2RB Zoster- amitriptyline, carbamazepine,

pregabalin, gabapentin Bone/joint/muscle pain- NSAIDs

Palpitation

Unpleasant awareness offorceful, rapid, irregular

heart beat

Causes Cardiac Sinus bradycardia Any tachycardia PVC/PAC Sick sinus syndrome Advanced AV block Aortic regurgitation

Non-cardiac Fever Anemia Thyrotoxicosis Pheochromocytoma Drugs Alcohol, CocaineAnxiety/Panic

disorder

Evaluation History Onset/offset, frequency, rate, rhythm Aggravating/relieving factors, associated symptoms h/o cardiac disease Examination Pulse- rate, rhythm Pallor, e/o hyperthyroidism Cardiac examination Investigation ECG, ECHO, Holter, Hb., TSH Treatment- of underlying etiology