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

Non-rheumatic systemic diseases 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