Download differential diagnosis of chest pain

Prof.Dr. Muzaffer Degertekin
Kardiyoloji ABD
The differential diagnosis of patients
presenting with chest pain is extensive,
ranging from benign musculoskeletal
etiologies to life-threatening cardiac
disease.
CHEST WALL PAIN
 Musculoskeletal pain
 Isolated musculoskeletal chest pain syndromes
(costosternal, posterior chest wall syndromes)
 Rheumatic diseases
 Non-rheumatic systemic diseases
 Costochondritis
 Chest wall pain occurring after CABG
 Costovertebral joint dysfunction syndrome
 Thoracic disk herniation
 Sternalis syndrome, xiphoidalgia, and spontaneous
sternoclavicular subluxation
 Rheumatic diseases
 Involvement of thoracic joints in rheumatic diseases can
be associated with musculoskeletal chest wall pain
 rheumatoid arthritis, ankylosing spondylitis, psoriatic
arthritis, and fibromyalgia
 Non-rheumatic systemic diseases
 stress fractures due to coughing, neoplasms including
pathologic fractures, infections such as septic arthritis
and osteomyelitis, and sickle cell anemia
 Skin and sensory nerves
 herpes zoster
CARDIOVASCULAR CAUSES OF
CHEST PAIN
 Ischemic chest pain syndromes
 Coronary artery disease
 Other ischemic chest pain conditions
 Coronary vasospasm
 Cardiac syndrome X: angina-like chest pain associated with normal
coronary arteries; most commonly seen in premenopausal women
 Valvular heart disease: Aortic stenosis
 Congenital anatomic anomalies of the coronary arteries,
spontaneous coronary artery dissection
Nonischemic cardiac chest pain
syndromes
 Pericarditis:




pleuritic in quality, pericardial friction rub
sudden onset and occurs over the anterior chest.
usually sharp and exacerbated by inspiration
may decrease in intensity when the patient sits up and can
radiate, especially to the trapezius ridge.
 Myocarditis:

chest pain is usually associated with concomitant pericarditis
 Acute aortic syndromes :acute aortic dissection,
intramural aortic hematoma, and penetrating aortic
ulcer.
Aortic dissection
 Pain typically is cataclysmic in onset
 Intense, acute, searing, tearing, throbbing, or migratory
 Radiate to the anterior chest, jaw, back, or abdomen




depending on which segment of aorta is involved
Most common in men older than age 60
Hypertension is the most important risk factor
Marfan's syndrome, congenital bicuspid and
unicommissural aortic valves, aortic coarctation
Preexisting aortic aneurysm (due to vasculitic conditions
such as giant cell arteritis, Takayasu arteritis, and others)
and pregnancy
CHEST PAIN DUE TO
HYPERADRENERGIC STATES
 Catecholamines have various physiological actions in
peripheral circulation (stimulation of heart rate and
vasoconstriction)
 Cocaine and amphetamine intoxication and
pheochromocytoma may cause chest pain due to
either increased demand or decreased delivery of
oxygen
 Tachycardia, hypertension, and evidence of vasospasm
may be seen
GASTROINTESTINAL CAUSES OF
CHEST PAIN
 Esophageal hypersensitivity
 Abnormal motility patterns and achalasia
 Esophageal rupture, perforation, and foreign bodies
 Other causes of esophagitis: medications, infectious
causes
PULMONARY CAUSES OF CHEST
PAIN
 Acute pulmonary embolism
 Pulmonary hypertension and cor pulmonale
 Pneumonia
 Cancer
 Sarcoidosis
 Asthma and COPD
Pleura and pleural space
 Pneumothorax
 Pleuritis
 MEDIASTINAL CAUSES
 PSYCHOGENIC/PSYCHOSOMATIC CAUSES
DIFFERENTIAL DIAGNOSIS
Causes of life threatening chest pain
 Acute coronary syndrome
 Aortic dissection
 Pulmonary embolism
 Tension pneumothorax
 Pericardial tamponade
 Mediastinitis (eg, Esophageal rupture)
PATHOPHYSIOLOGY OF ANGINA
 Angina is caused by myocardial ischemia, which
occurs whenever myocardial oxygen demand exceeds
oxygen supply.
Myocardial oxygen demand




Heart rate
Systolic blood pressure (the clinical marker of afterload)
Myocardial wall tension or stress (the product of
ventricular end-diastolic volume or preload and
myocardial muscle mass)
Myocardial contractility
Myocardial oxygen supply
 Coronary artery diameter and resistance
 Collateral blood flow
 Perfusion pressure
 Heart rate
ETIOLOGY
 Coronary atherosclerosis
 Coronary artery vasospasm
 Coronary artery fibrosis
 Coronary artery embolism
 Coronary artery dissection
 Coronary arteritis
QUALITY
 Angina is usually characterized more as a discomfort
rather than pain, and may be difficult to describe.
 Squeezing, tightness, pressure, constriction,
strangling, burning, heart burn, fullness in the chest,
band-like sensation, knot in the center of the chest,
lump in throat, ache, heavy weight on chest (elephant
sitting on chest), like a bra too tight, and toothache
QUALITY
 Typically gradual in onset and offset, with the intensity
of the discomfort increasing and decreasing over
several minutes
 Angina is a constant discomfort that does not change
with respiration or position
Location and radiation
 Corresponding dermatomes (C7-T4)
Afferent nerves to the same segments of the spinal cord as the heart






Upper abdomen (epigastric)
Shoulders, arms (upper and forearm)
Wrist, fingers
Neck and throat
Lower jaw and teeth
Back (specifically the interscapular region)
Radiation to both arms is a strong predictor of
acute myocardial infarction
Provoking factors
 Activities and situations that increase myocardial
oxygen demand
 Physical activity
 Cold
 Emotional stress
 Sexual intercourse
 Meals
 Cocaine use
Timing
 More commonly in the morning due to a diurnal
increase in sympathetic tone
 Enhanced sympathetic activity raises heart rate, blood
pressure, vessel tone and resistance
 Increased platelet aggregability
Duration and relief
 Angina generally lasts for two to five minutes
 It is not a fleeting discomfort, which lasts only for a
few seconds or less than a minute
 Generally does not last for 20 to 30 minutes, unless the
patient is experiencing an acute coronary syndrome,
especially myocardial infarction
Associated symptoms
 Angina is often associated with other symptoms.
 shortness of breath, which may reflect mild pulmonary
congestion
 Belching, nausea, indigestion, diaphoresis, dizziness,
lightheadedness, clamminess, and fatigue.
Noncardiac chest pain
 Pleuritic pain, sharp or knife-like pain related to respiratory






movements or cough
Primary or sole location in the mid or lower abdominal
region
Any discomfort localized with one finger
Any discomfort reproduced by movement or palpation
Constant pain lasting for days
Fleeting pains lasting for a few seconds or less
Pain radiating into the lower extremities or above the
mandible