Ibrahim AlHumaid 130073

Abdulaziz Eshaq
Ahmad Fothan
Mario Sanad
Islam Elsayed
 Objectives
• Definition
• Prevalence
• Causes
• History
• Physical exam
• Investigation
• Treatment
 Definition
• Discomfort felt in the upper abdomen, thorax,
neck, or shoulders.

• 5 million patients/ year present to the ED with chest pain

1.5 million patients/ year are admitted for workup of acute
coronary syndrome (ACS)

• The most common etiologies of chest pain in

primary care practice include musculoskeletal
and gastrointestinal causes, followed by cardiac,
psychiatric, pulmonary, and other causes.
Prevalence
 Chest pain

Critical Benign
What are the 6 cause of
chest pain that can kill?
 Chest Pain That Can Kill
• Acute Coronary Syndromes
• Pulmonary Embolism
• Aortic Dissection
• Esophageal Rupture
• Pneumothorax
• Pneumonia

Various others: Pulmonary HTN, Myocarditis,

Tamponade
Nine significant causes of chest/upper abdominal pain:
THE 6 P’s
• PTx
• PE
• Pneumonia
• pericarditis,
• perforated esophagus
• PUD

THE 3 A’s
• ACS
• Aortic dissection
• AAA
Common “benign”
causes of chest pain?
 Benign Causes
• Musculoskeletal
• Esophagitis
• Bronchitis (Chest Pain secondary to cough)
• “Non-Specific Chest Pain” *

*Most common – means we don’t know, but it is not

going to hurt you.
Acute coronary syndrome
• sudden, reduced blood flow to the heart.
• symptoms may include the type of chest pressure
that you feel during a heart attack, or pressure in
your chest while you're at rest or doing light physical
activity (unstable angina).
• Risk factors:
o Smoking
o Age >45 men >55 women
o HTN
o DM
o Family History
o Dyslipidemia
o Lack of physical activity
 Aortic dissection
• Pain is severe, sharp and tearing, is often felt in or
penetrating through to the back, and is typically
abrupt in onset
• The pain follows the path of the dissection
• Risk factors
o Uncontrolled HTN
o atherosclerosis
o Pre existing aortic aneurysm
o Bicuspid aortic valve
o Aortic coarctation
o Social hx
 Pericardial temponade
• An acute type of pericardial effusion in which fluid,
pus, blood, clots, or gas accumulates in the
pericardium, resulting in slow or rapid compression
of the heart.
• Caused by  trauma, myocardial rupture, cancer,
uremia, pericarditis, cardiac surgery

• Bech’s triad:
o Low blood pressure  decreased stroke volume
o JVP distension  impaired venous return
o Muffled sound  because of fluid build up
 Pulmonary Embolism
• Dyspnea at rest or with excretion, pleuritic pain,
cough
• Orthopnea, calf or thigh pain and swelling

• Pleuritic chest pain:

• Sharp
• Worse with deep inspiration
• Sudden onset
 History taking
• ID :
o Name
o Age
o Gender
o Occupation
o Residence

• Chief complaint with the duration.

 History matters!
SOCRATES
• Site: Central, left, or right
• Onset: Gradual or sudden onset
• Characteristic : Visceral vs somatic
(pleuritic, positional, sharp, reproducible with
palpation)
• Radiation: Back, neck, arm
• Associated symptoms: SOB, sweating, nausea
• Timing
• Provocation: What makes worse or better?
• Severity: Scale of 1-10
 Associated symptoms
• painful swallowing
• Vomiting
• Diaphoresis
• Dyspnea
• Cough
• Palpitations
• Syncope
 What are the key
parts of the rest of the
History?

What can you get out of the pt in 4

minutes?
 The Rest of the History
• PMH – cardiac diseases or conditions
• Meds – Cardiac meds? Nitro? ASA? Plavix?
Coumadin?
• Allergies – Always important!
• Social – Smoker? Alcoholic? Cocaine?
• Family – Sudden Death? Early MI? DVT? PE?

• Don’t forget to ask about the risk factors!!

 What are the key
parts of the Physical?

What can you exam in only 2 minutes?

 Key Emergency Physical
• General Appearance
• Vital Signs
• Heart (Muffled? Regular? Fast?)
• Lungs (Equal? Wet? Tympanitic?)
• Neck (JVD?)
• Abdomen (Distention?)
• LE (Edema? calf tenderness?)
 Physical examination
• The general appearance of the patient. (look for sweating and pallor)

• Vital signs. (hemodynamically stable)

• A complete cardiac examination should be performed in a sitting and

supine position  pericardial rub or signs of acute aortic insufficiency or
aortic stenosis.

• Determine if the breath sounds are symmetric and if wheezes, crackles or

pleural rub.

• Examination of the abdomen is important, with attention to the right

upper quadrant, epigastrium, and the abdominal aorta.

• Focal neurologic signs in the setting of acute chest pain may be helpful in
diagnosing acute aortic dissection
• The initial goal in the office evaluation of chest pain
in stable individuals is to exclude acute coronary
syndrome (ACS) and other potentially life-
threatening conditions.

• This is usually accomplished with the history, physical

examination, and certain ancillary studies (eg, ECG,
chest radiograph, and further testing for ACS,
pulmonary embolism, or aortic dissection as
indicated
This guy is rushed back by EMS,
what do you do?
Approach to Chest Pain

INITIAL GOAL in ED is to identify

life threats
o MI, PE, aortic dissection

Remember ABCs always first

Investigations
 Next 5 minutes?

What are 2 bedside tests to consider?

What is an important and cheap medication

you should consider?

 Next 5 Minutes
• Brief History
• Brief Physical (ABCs)
.

• What are 2 bedside tests that can be

done to help stratify the pt?
o EKG
o Portable CXR

• What is an important and cheap

medication you should consider?
o ASA (aspirin)
 Next 10 Minutes
• Patient already stabilized, initial data
gathered, and initial orders submitted
• Secondary survey: More detailed history
and physical exam
• Address patient’s pain
• Goal now is to categorize patient
1) Chest wall pain- Musculoskeletal
2) Pleuritic chest pain- Respiratory
3) Visceral chest pain- Cardiac
Possible ECG presentations
 ST elevation: > 1 mm in 2 or more contiguous precordial
leads or 2 or more adjacent limb leads.
•New ST elevation is sensitive and specific for myocardial
infarction. Usually appears within minutes after symptom onset.
However, this is present on initial admission ECG in only ~30–40%
of hospitalized patients with AMI.

 ST depression: > 1 mm in V1-V6 or >1.5 mm in aVF and

lead III
•ST depression indicates ischemia, but has poor power to
identify ongoing myocardial infarction (only ~50% of patients
with ST depression develop MI).

 T-wave inversion: nonspecific. Multiple differential

diagnoses. Only about one-third of patients with chest
pain and T-wave inversion on admission ECG develops MI.
 1) Electrocardiogram
• New ST Elevation – Sensitive & Specific for MI
• ST depression - indicates ischemia, but not ongoing
myocardial infarction
• Arrhythmia
• Tachycardia/ bradycardia

• About one-third of patients admitted to emergency

department with acute chest pain have normal
ECG!! Therefore Serial ECGs and other Tests are
essential.
• About one-third of patients admitted to
emergency department with acute chest pain
have normal ECG.

• Repeat the ECG in 5 minutes to re-evaluate

• Serial ECGs, aided by other tests (biochemical

markers, stress test, etc), are essential in the
chest pain evaluation if the initial ECG is not
diagnostic.
 2) Cardiac Markers &
Other Blood Tests
• Troponins - regulatory proteins found in
skeletal and cardiac muscle
o cardiac markers of choice for patients with ACS
o Elevated troponin is an independent predictor of adverse
cardiac outcome in patients presenting with chest pain,
with or without diagnostic ECG changes

• CK-MB

• Myoglobin – heme protein

o better marker from 3 to 6 hrs after the onset of symptoms
compared with CK-MB mass and troponin
 Cardiac First Rise mean time Time to
Marker specificity after to peak return to
necrosis in elevation normal
(hrs)? range

Myoglobin No 1-3 6-7 12-24 hrs

CK total No 4-8 24 36-48 hrs

CK-MB ++ 3-4 24 24-36 hrs

Troponin T ++++ 3-4 12-48 10-14 hrs

Troponin I ++++ 4-6 24 4 -7 hrs

 Other Important Labs
• Full blood count (FBC):
• Anemia low oxygen carrying capacity leading to MI

• Pericarditis raised WBC count

• Urine and electrolyte:
• Hyper and hypokalemia, hypo and hypercalcemia, hypo and hypomagnesemia all le
arrhythmias.

• Lipid & glucose:

• Important for management of risk factors.
Summary
 Imaging Studies
Chest X-Rays
• Obtained routinely
• Often nonspecific in
ACS
• Can Diagnose:
o Pneumothorax
o Aortic Dissection
o Heart Failure complications
(Cardiomegaly, Pulmonary
edema)
 Further Imaging
Suspicion of Cardiac Suspicion of Non Cardiac
• If ECG/ Cardiac markers • Aortic Dissection
are equivocal  Rest o Stable pt.  CT or MRI
myocardial perfusion o Unstable  TEE
scan or an echo an be
helpful
• PE  V/Q scan or Spiral
CT
• Early use of treadmill
exercise testing unless
there is pain at rest or
ECG has ischemic
changes
 Management of ACS
o Supplemental oxygen
o Sublingual nitroglycerin
o Oral beta blockers in the first 24 hours EXCEPT in
• heart failure, low output state, cardiogenic
shock, asthma
o nondihydropyridine calcium channel blocker for
continuing or recurrent ischemia
• Cases contraindicated to beta blockers
o Aspirin 162 to 325 mg
o Morphine (or fentanyl) for pain control
o clopidogrel with a 300- to 600-mg loading dose
• High risk patients
o should receive aggressive care, including aspirin,
clopidogrel, unfractionated heparin or low–
molecular-weight heparin (LMWH), IV platelet
glycoprotein IIb/IIIa complex blockers (eg,
tirofiban, eptifibatide), and a beta blocker. The
goal is early revascularization.

• Intermediate risk patients

o rapidly undergo diagnostic evaluation and
further assessment to determine their appropriate
risk category.

• Low risk patients

o further follow-up with biomarkers and clinical
assessment.
• Monitor and immediately treat arrhythmias in the
first 48 hours.
• Pay attention to exacerbating factors, such as
disturbances in electrolytes (especially potassium
and magnesium), hypoxemia, drugs, or acidosis.

• Patients presenting with cardiogenic shock 

percutaneous coronary intervention (PCI)
 References
• Medscape
• Up to date
• A Clinical Approach To Medicine second edition
• Davidson's Principles and Practice of Medicine
• Toronto Notes