CHEST PAIN (CBCR)

Our case will be on acute chest pain, before we make a diagnosis, we will ask questions on it.

1) What is chest pain?

Major opening complains due to inflammation of the pericardium.
2) What additional info to gather
Location, radiation, duration, intensity, character, timing, aggravating or reducing factors, medications
3) Mechanism?
4) Give some examples of diseases in which chest pain is present?
ischemic (angina pectoris, MI, cardiosclerosis, endocarditis, pericarditis), functional (right, left Hf)
rheumatic heart disease, aortic dissection
5) Other reasons of chest pain – gastroesophageal reflux, pleuritis, lung abscess, hydrothorax, peptic ulcer
disease, gastritis, pneumothorax, pulmonary embolism, hydropneumothorax, atelectasis

Slide no. 5

Slide 06:

Slide no. 6

Amnesias Vitae – emotional stress levels, job, working conditions, bad habits (smoking, alcohol, drugs), hereditary,
past disease, allergies, living condition (living area, diet, physical activity), medications, prior investigations

Additional – predisposing anemic conditions, cardiac dyspnea, edema, palpitation, fever, sweating, abdominal pain,
cardiac asthma, altered mental status, loss of consciousness

2ndry complaints – insomnia, general weakness, fatigue, nausea, vomit

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Slide no. 7

MI – characterized by heavy chest pressure or squeezing, a “burning” feeling, or difficulty in breathing. The
discomfort or pain often radiates to the left shoulder, neck, or arm.

Stable angina - most often begins slowly and gets worse over the next few minutes before going away. Typically, the
chest pain feels like tightness, heavy pressure, squeezing, or a crushing feeling.

Unstable angina - severe, comes more often, or occurs with less activity or while you are at rest.

Aortic dissection – tearing / ripping pain of aorta

Pulmonary embolus - first signs of pulmonary embolism are usually shortness of breath and chest pains that get
worse if you exert yourself or take a deep breath.

Pneumothorax - chest pain is pleuritic, sharp, severe, and radiates to the ipsilateral shoulder. Stabbing type, worsens
when trying to breathe

Lobar pneumonia – abdominal pain, chest pain due to irritation of pleura during cough

Pleuritis – friction between pleura, pain receptors elicited, sharp chest pain when breathing deeply

Esophagus - A feeling of heartburn or a squeezing type of chest pain. Chest pain that may spread to the neck, arm or
back.
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Costochondritis -When the costochondral joint becomes inflamed it can result in sharp chest pain and tenderness

Fibrositis - an intense stabbing sensation primarily in the center of the chest, around the breastbone and rib cage.

Sternoclavicular arthritis -Pain may only be present when the arm is lifted overhead, moved across the body or when
lifting objects.

Herpes zoster -Chest pain associated with shingles often feels like a band of sharp pain. The rash may appear a few
days after you notice chest pain.

Anxiety - surge of adrenaline and cortisol through your body. These hormones immediately trigger a rapid rise in
your heart rate and blood pressure. As a result, many people experience chest pain and sweating, or have a hard time
breathing.

Slide no. 9

Amlodipine – Ca2+ channel blocker, to lower bp

Atorvastatin – lowers LDL, for hypercholesterolemia

No drug allergies

Presence of genetic predisposition

Tachycardiac slightly – 120bpm

Lowered bp

increased respiratory rate

no fever

O2 saturation normal

Slide no. 10

AD (4) – abdominal pain present, no jaw pain, functional

PH – pulmonary hypertension
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Down arrow – hypotension

Nitroglycerin – vasodilation

Slide no. 11

Inspection - Facial expressions (facies hypertonia, dull face), position (orthopneic position due to cyanosis) – active
or forced position in breathing difficulty,

Palpation – hyperalgesia, hyperesthesia, (PMI laterally displaced to midclavicular line, diameter > 2cm), more
forceful tapping amplitude, duration sustained

Percussion – no changes in borders

Auscultation – heart sounds may decrease, S1 diminished, S2 no change (since less oxygenated blood at coronary
circulation thus less forceful contractions resulted so heart valves close weakly)

Tests –

 Electrocardiogram (ECG or EKG). This first test done to diagnose a heart attack records electrical signals
as they travel through the heart. Sticky patches (electrodes) are attached to the chest and sometimes the
arms and legs. Signals are recorded as waves displayed on a monitor or printed on paper. An ECG can show
if you are having or have had a heart attack.
 Blood tests. Certain heart proteins slowly leak into the blood after heart damage from a heart attack. Blood
tests can be done to check for these proteins (cardiac markers). Check for troponin levels and CKMB.
Check for WBC count, ESR, blood glucose levels (psychiatric, pancreatic, hormonal function), urea &
electrolytes (kidney function), blood cholesterol levels (check LDLs: HDLs)
(Troponin - Cardiac troponins are regulatory proteins within the myocardium that are released into the
circulation when damage to the myocyte has occurred. Therefore, serum troponin is an exquisitely sensitive
marker of myocardial injury) (CKMB - enzyme, creatine kinase-myocardial band, released during heart
problems / myocyte damage, indicates infections/ inflammation of heart muscle)
 Chest X-ray. A chest X-ray shows the condition and size of the heart and lungs.
 Echocardiogram. Sound waves (ultrasound) create images of the moving heart. This test can show how
blood moves through the heart and heart valves. An echocardiogram can help identify whether an area of
your heart has been damaged.
 Coronary catheterization (angiogram). A long, thin tube (catheter) is inserted into an artery, usually in the
leg, and guided to the heart. Dye flows through the catheter to help the arteries show up more clearly on
images made during the test.
 Cardiac CT or MRI. These tests create images of the heart and chest. Cardiac CT scans use X-rays. Cardiac
MRI uses a magnetic field and radio waves to create images of your heart. For both tests, you usually lie on
a table that slides inside a long tubelike machine. Each test can be used to diagnose heart problems. They
can help show the severity of heart damage.

Slide no. 12

 ECG – why ST elevation occurs? An acute ST-elevation myocardial infarction occurs due to occlusion of
one or more coronary arteries, causing transmural myocardial ischemia which in turn results in myocardial
injury or necrosis.
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 Cardiac troponins normal levels –

o Normal: 0 – 0.04 ng/ml

o If the result is between 0.04 - 0.39 ng/ml, this often indicates a heart problem, so it is important to
see a doctor to look for other symptoms and order other tests before making a diagnosis.
o High: Above 0.40 ng/ml
 CKMB normal levels - Normal reference values for serum CK–MB range from 3 to 5% (percentage of total
CK) or 5 to 25 IU/L.
 Hypercholesterolemia – normal levels: Total cholesterol: Levels below 200 mg/dL (5.2 mmol/L) LDL
cholesterol: Levels below 130 mg/dL (3.4 mmol/L) HDL cholesterol: Levels above 40 mg/dL (1 mmol/L)
in men and above 50 mg/dL (1.3 mmol/L) in women. Ratio of HDL: LDL is 5: 1

Slide no. 13

MYOCARDIAL INFARCTION

Slide no. 15

Pathophysiology of MI

Slide no. 16

Emergency Medical Treatment

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Even before reaching the hospital, emergency personnel may begin treatment of a suspected heart attack with:

Aspirin, clopidogrel, heparin, or other anticlotting agents to prevent new clots

Thrombolytic drugs to dissolve existing clots ("clot-busting" drugs such as tPA)

Oxygen to protect heart tissue

Nitroglycerin to widen coronary vessels

Drugs to decrease the heart's workload and pain, relieve anxiety, or regulate heart rhythm

Procedures, Devices & Surgery

In many cases, a minimally invasive procedure can be used to restore blood flow to the heart muscle (sometimes in
combination with medication to dissolve clots). Examples of these procedures include:

Balloon angioplasty is used to open blocked coronary vessels. During this minimally invasive procedure, a catheter
(a long, thin flexible tube) is guided into the blocked artery and a tiny balloon is inflated to clear the way so that
blood flow is restored. A small mesh tube (stent) is often inserted to keep the artery open.

Stenting - small mesh tube typically used to hold open passages in the body, Stents used for coronary arteries,
long term effect of maintaining proper blood flow in a blood vessel

Bypass surgery is a common approach that surgeons use to create new routes through which blood can flow around
blocked or narrowed arteries. These “bypasses” are created using healthy vessels taken from the chest, arms or legs.

Follow-Up Treatment

After you leave the hospital, you may feel weak or a little depressed or anxious. This is common and your medical
team will work with you to help overcome these problems. Often, this involves lifestyle changes and medications
aimed at reducing your risk of another heart attack.

Lifestyle

Changes in lifestyle, such as dieting, quitting smoking and losing weight, can help you reduce the risk of a repeat
heart attack. You should talk with your doctor about an exercise plan that is safe for you. In some cases, your doctor
may recommend that you take part in a formal cardiac rehabilitation program which provides exercise training and
counseling.

Medications

After a heart attack, your doctor may recommend that you start taking medication to help reduce your risk of heart
attack and improve cardiovascular function. These could include:

aspirin or anticoagulants (to prevent blood clots)

beta blockers, calcium channel blockers, or ACE inhibitors (to improve blood flow, slow the heart rate, and/or
reduce the strain on the heart)

anti-diabetic medications (to control blood sugar)

statins (to reduce cholesterol)

beta blockers, ACE inhibitors, or diuretics (to reduce blood pressure)

nitrates (to reduce angina)

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AFTER QUESTION 7

1) Coronary angioplasty:
 Advantages –
A minimally invasive alternative to some cases that would have otherwise required a CABG
procedure.
Long term effect of maintaining proper blood flow in a blood vessel.
Reduction of the risk of stroke
 Disadvantages –
blood cells can become sticky and clump together to form a small mass
Patient can be allergic to the dye
2) Stenting:
 Advantages –
A minimally invasive
Long term effect of maintaining proper blood flow in a blood vessel.
Improvement of organ function, including the kidneys
 Disadvantages –
damage to the artery where the sheath was inserted