Approach to a patient with
chest pain
Terminology: Chest pain vs Precordial pain
Precordial pain: precordium includes the whole skin area in front of the
heart plus the whole area in which anginal pain may be radiating to, this
includes: anterior chest wall, neck and jaw, shoulders and arms, and
epigastric area.
Chest pain causes
Cardiovascular
Coronary artery disease
Stable coronary artery: chronic disease chest pain provoked by
exertion (due to the presence of a stable plaque with exertion causes
supply/demand mismatch → ischemia → resulting in chest pain) and
relived by rest → not considered a CAD anymore?
ST elevation MI (STEMI): the presence of a persistent ST elevation
(measured at the J-point) ≥ 1 mm in 2 or more contiguous leads with the
presence of ischemic symptoms (or ≥ 2.5 mm in men < 40 years, 2 mm
in men > 40 years, or 1.5 mm in women leads V2-V3) in the absence of
LVH or LBBB
Non-ST elevation MI (NSTEMI): the presence of ischemic symptoms
without no persistent ST elevation on ECG however the ECG might
show : ST depression, T-wave inversion, normal ECG, stuttering
course.
Acute aortic syndrome
Severe agonizing tearing pain that is maximal at the start then
decreases, usually radiating to the back.
It can propagate to the abdomen if the pathology involves the
abdominal aorta
atypical chest pain but could present as typical if the dissection flap
causes occlusion of the coronary ostium
Approach to a patient with chest pain 1
, Types:
Aortic dissection - Stanford type A and type B
Intramural hematoma (IMH)
Penetrating aortic ulcer
Other cardiovascular causes
Pulmonary embolism
Myocarditis: mimics STEMI pain and is associated with ST elevation
pericarditis
Non-cardiovascular
Chest
Pneumonia
Pleurisy
Myositis
Costochondritis
Esophageal
Esophageal spasm → relived by nitrates (just like angina)
GERD
Esophagitis
Cutaneous
Pre/post-herpetic neuralgia → Anginal pain that doesn’t cross the
mid-line (to differentiate it from other causes)
⚡ Note that: most anginal pain crosses the mid-line
Breast disease e.g. fibroadenosis
Joint
Frozen shoulder syndrome.
Arthritis.
Risk factors
Approach to a patient with chest pain 2
chest pain
Terminology: Chest pain vs Precordial pain
Precordial pain: precordium includes the whole skin area in front of the
heart plus the whole area in which anginal pain may be radiating to, this
includes: anterior chest wall, neck and jaw, shoulders and arms, and
epigastric area.
Chest pain causes
Cardiovascular
Coronary artery disease
Stable coronary artery: chronic disease chest pain provoked by
exertion (due to the presence of a stable plaque with exertion causes
supply/demand mismatch → ischemia → resulting in chest pain) and
relived by rest → not considered a CAD anymore?
ST elevation MI (STEMI): the presence of a persistent ST elevation
(measured at the J-point) ≥ 1 mm in 2 or more contiguous leads with the
presence of ischemic symptoms (or ≥ 2.5 mm in men < 40 years, 2 mm
in men > 40 years, or 1.5 mm in women leads V2-V3) in the absence of
LVH or LBBB
Non-ST elevation MI (NSTEMI): the presence of ischemic symptoms
without no persistent ST elevation on ECG however the ECG might
show : ST depression, T-wave inversion, normal ECG, stuttering
course.
Acute aortic syndrome
Severe agonizing tearing pain that is maximal at the start then
decreases, usually radiating to the back.
It can propagate to the abdomen if the pathology involves the
abdominal aorta
atypical chest pain but could present as typical if the dissection flap
causes occlusion of the coronary ostium
Approach to a patient with chest pain 1
, Types:
Aortic dissection - Stanford type A and type B
Intramural hematoma (IMH)
Penetrating aortic ulcer
Other cardiovascular causes
Pulmonary embolism
Myocarditis: mimics STEMI pain and is associated with ST elevation
pericarditis
Non-cardiovascular
Chest
Pneumonia
Pleurisy
Myositis
Costochondritis
Esophageal
Esophageal spasm → relived by nitrates (just like angina)
GERD
Esophagitis
Cutaneous
Pre/post-herpetic neuralgia → Anginal pain that doesn’t cross the
mid-line (to differentiate it from other causes)
⚡ Note that: most anginal pain crosses the mid-line
Breast disease e.g. fibroadenosis
Joint
Frozen shoulder syndrome.
Arthritis.
Risk factors
Approach to a patient with chest pain 2
