CHIEF COMPLAINT:

Chest Pain

Chest Pain

• Unpleasant sensation in the chest or thoracic area– Tightness, pressure or pain

starting in the middle of the chest and often radiating to other anatomical structures in the upper part of the body

Stedman’s Medical Dictionary 27th Edition

Chest Pain

Pulmonary

Gastrointestinal

Musculoskeletal

Others

Cardiovascular

Myocardial Ischemia and Injury

Angina pectoris

Unstable Angina

Acute myocardial infarction

Aortic stenosis

Chest Pain

Non-ischemic Ischemic

Image retrieved from: http://www.pain-free.eu

• Pericarditis• Aortic dissection• Pulmonary embolism

• Angina• Unstable Angina• Myocardial Infarction• Aortic Stenosis

Cardiovascular System

Chest Pain

Pericarditis

Pulmonary

Embolism

Aortic Dissection

AnginaUnstable Angina

Myocardial Infarction

Aortic Stenosis

Reference: Harrison’s Principles of Internal Medicine 17th edition

Gastrointestinal System

Acid

Reflux

Esophageal Spasm

Trauma - Esophagus

Referre

d PainChest Pain

Reference: Mosby’s Guide to Physical Examination, 6th edition

Respiratory System

Embolism

Pneumothorax

Hydrothorax

Infection /

InflammationChest Pain

Reference: Mosby’s Guide to Physical Examination, 6th edition

Musculoskeletal System

Chest Pain

Compression of nerve roots

Referred pain

TraumaIntercostals

muscle cramps

Infection / Inflammation

References: Mosby’s Guide to Physical Examination, 6th edition. Harrison’s Principles of Internal Medicine 17th edition

Psychoneurotic System

Chest Pain

Stress Panic attack

Emotional Depression

Illicit drug use

Long term effect of

marijuana

References: Mosby’s Guide to Physical Examination, 6th edition. Harrison’s Principles of Internal Medicine 17th edition

Condition Duration Quality Location Associated Features

Angina More than 2 and less than 10 min

Pressure, tightness,

squeezing, heaviness,

burning

Retrosternal, often with radiation to or isolated discomfort

in neck, jaw, shoulders, or arms – frequently on left

Precipitated by exertion, exposure

to cold psychological

stress

Unstable Angina 10-20 minSimilar to angina but often more

severeSimilar to angina

Similar to angina, but occurs with

low levels of exertion or even at

rest

Acute Myocardial Infarction

Variable; often more than 30 min

Similar to angina but often more

severeSimilar to angina

Unrelieved by nitroglycerin; may be associated with evidence of heart

failure or arrythmia

Aortic Stenosis

Recurrent episodes as described for

angina

As described for angina

As described for angina

Late-peaking systolic murmur

radiating to carotid arteries

Reference: Harrison’s Principles of Internal Medicine 17th edition

Reduced size of lumen –artherosclerosis

Anemia

Art

eria

l th

rom

bi

Coronar

y emboli

LV hyp

ertro phy se

conda ry

to hyp

erte nsion

ISCHEMIA

Reference: Harrison’s Principles of Internal Medicine 17th edition

LABORATORY TESTS & other ancillary procedures

LABORATORY EXAMINATIONS

Reference: Harrison’s Principles of Internal Medicine 17th edition

Cardiovascular Disorders

Enzyme markers

Lipid Profile

ECG Non-invasive cardiac imaging

Routine tests for non-specific

inflammation

Electrocardiography

• A graphic recording of electric potentials generated by the heart

• Signals are detected by means of metal electrodes attached to the extremities and the chest wall

• These signals are amplified and recorded by an electrocardiogram

• Adv. : non-invasive, inexpensive, highly versatile• Uses : detect arrhythmias, conduction disturbances, and MI

ECG TRACING

Lead V4 at rest (top) and after 4½ min of exercise (bottom). There is 3 mm (0.3 mV) of horizontal ST-segment depression,

indicating a positive test for ischemia.

Reference: Harrison’s Principles of Internal Medicine 17th edition

2D ECHOCARDIOGRAPHY

• Uses the principle of ultrasound reflection

of cardiac structures to produce images of

the heart

• Ideal imaging modality for assessing left

ventricular size and function

• Useful in the diagnosis of LV hypertrophy

Reference: Harrison’s Principles of Internal Medicine 17th edition

ENZYME MARKERS IN CARDIAC INJURY

Reference: Clinical Chemistry, principles, procedures, correlations 4 th ed.

Enzyme Onset of Elevation

Peak Levels Duration of Elevation

CK-MB 4-8 hours 12-24 hours 3-4 days

AST 8-12 hours 24 hours 5 days

LDH 12-24 hours 72 hours 10 days

Troponin T Few hours 48 hours 5 days

Troponin I (only found in the

myocardium of adult humans)

3-8 hours 12-24 hours 5-10 days