1. APPROACH TO THE PATİENT WITH CHEST PAIN
IN PRIMARY CARE

2. Guldal Izbirak, MD, Assoc Prof of Family Medicine
Learning objectives
Understand a diagnostic approach to chest pain and
How to reduce potential damage to myocardium by implementing rapid evaluation
Guldal Izbirak, MD, Assoc Prof of Family Medicine

3. Guldal Izbirak, MD, Assoc Prof of Family Medicine
Know the evaluation of CP and
How to best implement the primary treatment of CP
Identify the risks and the need to educate patients to reduce their risks
Guldal Izbirak, MD, Assoc Prof of Family Medicine

4. Guldal Izbirak, MD, Assoc Prof of Family Medicine
Be familiar with the DD of CP and
How to best rule in and out the more life-threatining problems
Guldal Izbirak, MD, Assoc Prof of Family Medicine

5. Guldal Izbirak, MD, Assoc Prof of Family Medicine
Introduction
Chest pain is one of the most common medical symptoms. It must always be considered because it may be the first signal of serious, potentially lethal disease.
Guldal Izbirak, MD, Assoc Prof of Family Medicine

6. What Lies in the Chest? Skin Muscles Bones Joints Heart and Vessels
Lungs and Airways
Esophagus
Nerves

7. Guldal Izbirak, MD, Assoc Prof of Family Medicine
Pathophysiology
The heart, lungs, esophagus, and great vessels provide afferent visceral input through the same thoracic autonomic ganglia.
A painful stimulus in these organs is typically perceived as originating in the chest, but because afferent nerve fibers overlap in the dorsal ganglia, thoracic pain may be felt (as referred pain) anywhere between the umbilicus and the ear, including the upper extremities.
Guldal Izbirak, MD, Assoc Prof of Family Medicine

8. Guldal Izbirak, MD, Assoc Prof of Family Medicine
Painful stimuli from thoracic organs can cause discomfort described as pressure, tearing, gas with the urge to eructate, indigestion, burning, aching, stabbing, and sometimes sharp needle-like pain
When the sensation is visceral in origin, many patients deny they are having pain and insist it is merely “discomfort.”
Guldal Izbirak, MD, Assoc Prof of Family Medicine

10. Aetiology Emotional & psychiatric
Anxiety or depression, hyperventilation

11. Guldal Izbirak, MD, Assoc Prof of Family Medicine
Causes of chest pain
Some disorders are immediately life threatening:
Acute coronary syndromes (acute MI/unstable angina)
Thoracic aortic dissection
Tension pneumothorax
Esophageal rupture
Pulmonary embolism (PE)
Guldal Izbirak, MD, Assoc Prof of Family Medicine

12. Guldal Izbirak, MD, Assoc Prof of Family Medicine
Overall, the most common causes are
Chest wall disorders %38 (ie, those involving muscle %20 muscle pain, rib %2 rib fracture, or cartilage %13 chostochondritis)
Pleural disorders
GI disorders% 20 (eg, esophageal reflux or spasm % 13, ulcer disease % 1-2, cholelithiasis % 1)
Idiopathic
CV disorders: Acute coronary syndromes % 2-3 AMI / % 3 US AP and stable angina % 10, others < % 1
Guldal Izbirak, MD, Assoc Prof of Family Medicine

13. Risk factors for CAD (most common cause of cardiovascular CP)
Should be elicited from the history
Increased Age
Male gender
Hypertension
Diabetes
Dyslipidemia
Smoking
PMH or FH of CAD
Obesity
Substance abuse
Guldal Izbirak, MD, Assoc Prof of Family Medicine

14. Guldal Izbirak, MD, Assoc Prof of Family Medicine
H&PE
A careful medical history is the first step.
Then, a thorough physical examination and, when indicated, one or two laboratory tests, an ECG and chest x-ray, completes the baseline information necessary to decide what to do next; watch and wait,
proceed with management,
or refer for specialized evaluation.
Guldal Izbirak, MD, Assoc Prof of Family Medicine

15. History of present illness
Attributes of pain
Location/Radiation
Quality/Quantity
Timing/Duration/Frequency
Aggravating/Relieving Factors
Associated Symptoms (e.g. Breathlessness, cough, hemoptysis, nausea)
Guldal Izbirak, MD, Assoc Prof of Family Medicine

16. Guldal Izbirak, MD, Assoc Prof of Family Medicine
PMH, Drug History, Smoking history,
Family History (Coronary Artery disease)
Review of Systems
Guldal Izbirak, MD, Assoc Prof of Family Medicine

17. Guldal Izbirak, MD, Assoc Prof of Family Medicine
It is worth that noting that cardiac causes of chest pain are often accompanied by shortness of breath; but in contrast to many respiratory causes of chest pain and dyspnea, and with the exception of pericarditis, the pain of heart disease does not vary with breathing.
Guldal Izbirak, MD, Assoc Prof of Family Medicine

18. Guldal Izbirak, MD, Assoc Prof of Family Medicine
Physical Examination
General appearance (distress, sweating, pallor, fever)
BP in both arms, pulses, JVP, apex beat, heart sounds
Lung fields, local tenderness, pain on movement of chest
Examination of the lungs
Upper abdominal examination
Swelling or tenderness of legs
Guldal Izbirak, MD, Assoc Prof of Family Medicine

19. Neck is inspected for venous distention and hepatojugular reflux, and the venous wave forms are noted.
The neck is palpated for carotid pulses, lymphadenopathy, or thyroid abnormality.
The carotid arteries are auscultated for bruit.

20. Palpate the chest and the spinous processes of vertebrae (local tenderness, fractures, symptomes of spinal diseases
Crepitus associated with rib fracture, localized pain, signs of trauma.
Hyperesthesia, particularly when associated with a rash, is often due to herpes zoster

21. Lungs are percussed and auscultated for presence and symmetry of breath sounds, signs of congestion (dry or wet rales, rhonchi), consolidation (pectorilloquy), pleural friction rubs, and effusion (decreased breath sounds, dullness to percussion).

22. Cardiac & Pulmonary Auscultation
Cardiac murmurs, 3rd & 4th heart sounds, pericardial rubs,
Intensity of breath sounds,
Pleural friction, rub pleurisy,
Evidence of pneumothorax (absence of respiratory sounds, vocal fremitus), pulmonary embolism, pneumonia or pleurisy

23. The chest is inspected for skin lesions of trauma or herpes zoster infection and palpated for crepitance (suggesting subcutaneous air) and tenderness.
The abdomen is palpated for tenderness, organomegaly, and masses or tenderness, particularly in the epigastric and right upper quadrant regions.

24. Guldal Izbirak, MD, Assoc Prof of Family Medicine
The legs are examined for arterial pulses, adequacy of perfusion, edema, varicose veins, and signs of DVT (eg, swelling, erythema, tenderness).
Guldal Izbirak, MD, Assoc Prof of Family Medicine

25. Guldal Izbirak, MD, Assoc Prof of Family Medicine
Red flags:
Certain findings raise suspicion of a more serious etiology of chest pain:
 Abnormal vital signs (tachycardia, bradycardia, tachypnea, hypotension)
Signs of hypoperfusion (eg, confusion, ashen color, diaphoresis)
Shortness of breath
Asymmetric breath sounds or pulses
New heart murmurs
Pulsus paradoxus > 10 mm Hg - abnormally large decrease in systolic blood pressure and pulse wave amplitude during inspiration.
The paradox in pulsus paradoxus is that, on clinical examination, one can detect beats on cardiac oscultationduring inspiration that cannot be palpated at the radial pulse. It results from an accentuated decrease of the blood pressure, which leads to the (radial) pulse not being palpable.
Guldal Izbirak, MD, Assoc Prof of Family Medicine

26. Cardiovascular causes of chest pain
Cardiac ischaemia (lack of oxygen supply to the heart muscle the myocardium; the myocardial infarction, angina pectoris
The pericardium; pericarditis
The aorta; dissecting aneursym
Guldal Izbirak, MD, Assoc Prof of Family Medicine

27. Cause* Suggestive Findings Diagnostic Approach†
1Myocardial ischemia (acute MI/unstable angina/angina)
Acute, crushing pain radiating to the jaw or arm
Exertional pain relieved by rest (angina pectoris)
S4 gallop
Sometimes systolic murmurs of mitral regurgitation
Often red flag findings‡
Serial ECGs and cardiac markers; admit or observe
Stress imaging test or CT angiography considered in patients with negative ECG findings and no cardiac marker elevation
Often heart catheterization and coronary angiography if findings are positive
Guldal Izbirak, MD, Assoc Prof of Family Medicine

28. Clinical picture of patient with CAD in primary care
Emergent
Acute coronary syndrome (AMI with or without ST elevation)
Unstable angina
Nonemergent
Stable angina
asymptomatic
Guldal Izbirak, MD, Assoc Prof of Family Medicine

29. Guldal Izbirak, MD, Assoc Prof of Family MedicineAP
Quality/Quantity Pain is usually described as an intense “pressure”, “squeezing”, or “constriction”, Location originating underneath or to the left of sternum. Radiation May radiate to one/both arms, neck, or jaw. Timing/Duration/Frequency It seldom lasts more than 15 minutes
Guldal Izbirak, MD, Assoc Prof of Family Medicine

30. Guldal Izbirak, MD, Assoc Prof of Family MedicineAP
Aggravating/Relieving Factors Thus angina characteristically develops with exertion and it is relieved by rest;
excitement,
cold,
emotional stress,
sexual intercourse or
ingestion of food.
Guldal Izbirak, MD, Assoc Prof of Family Medicine

31. Guldal Izbirak, MD, Assoc Prof of Family MedicineAP
It is relieved with seconds or occasionally minutes by glycerly trinitrate (nitroglycerin) and the response to this can be used as a diagnostic test.
Associated Symptoms It is often associated with breathlessness due to temporary left ventricular dysfunction, or palpitations.
Guldal Izbirak, MD, Assoc Prof of Family Medicine

32. Guldal Izbirak, MD, Assoc Prof of Family MedicineAP
Cardiac ischemiae may be related to exercise when it causes the pain called angina “angin d’effort”
“unstable ”angina should be used to describe unstable patterns (prolonged pain, occurring at rest, increasing frequency, etc)
Guldal Izbirak, MD, Assoc Prof of Family Medicine

33. Guldal Izbirak, MD, Assoc Prof of Family Medicine
Stable AP
Severity of effort can be variable / It should be consistent every time
Severe Effort
Running
Climbing several steps
Walking upward
Daily activities
Walking
Climbing one step
Mild Effort
Activities at home
Guldal Izbirak, MD, Assoc Prof of Family Medicine

34. Guldal Izbirak, MD, Assoc Prof of Family Medicine
DD of AP and UAP is based on history
AP :
nonemergent
Follow up and treatment can be organized by FP
Aspirine, nitrates, bete-blocker 7 Ca-Channel bloker, statines
UAP:
emergent
Should be referred to for observation and hospitalization
Guldal Izbirak, MD, Assoc Prof of Family Medicine

35. Guldal Izbirak, MD, Assoc Prof of Family Medicine
Definition: death or necrosis of heart muscle, occurs when occlusion of a coronary artery causes irreversible ischemia
Coronary artery occlusion can also cause sudden death, so the term “heart attack” is usually used to encompass both myocardial infarction and sudden death.
Guldal Izbirak, MD, Assoc Prof of Family Medicine

36. Guldal Izbirak, MD, Assoc Prof of Family Medicine
Quality/Quantity Constricting or crushing pain or intense dull ache Timing/Duration/Frequency Pain due to a heart attack is similar in nature to angina but it usually lasts with several hours and the diagnosis of infarction is unlikely if the pain settles within 30 minutes. Pain lasting longer than 48 hours is unlikely to be due to infarction. It is lasting>1/2h.
Guldal Izbirak, MD, Assoc Prof of Family Medicine

37. Guldal Izbirak, MD, Assoc Prof of Family Medicine
Location/Radiation Similar in location and radiation to that of angina but in contrast, tends to be much more severe, Aggravating/Relieving Factors is not relieved by GTN. Glyceryl trinitrate is ineffective and powerful analgesics such as morphine are needed for pain relief.
Associated Symptoms Important distinguishing features are accompanying dyspnea, profuse sweating, nausea, vomiting and profound weakness.
Guldal Izbirak, MD, Assoc Prof of Family Medicine

38. Guldal Izbirak, MD, Assoc Prof of Family Medicine
Clinical Decision Rule for Identifying Patients with Chest Pain Caused by CAD
Variable
Points
Age 55 years or older in men; 65 years or older in women 1
Known CAD or cerebrovascular disease
Pain not reproducible by palpation
Pain worse during exercise
Patient assumes pain is cardiogenic
Total points:
______
Guldal Izbirak, MD, Assoc Prof of Family Medicine

39. Guldal Izbirak, MD, Assoc Prof of Family Medicine
Algorithm for the evaluation of patients with chest pain in the primary care setting. (ECG = electrocardiography.)
Point-of-Care Guides
Guldal Izbirak, MD, Assoc Prof of Family Medicine

40. Guldal Izbirak, MD, Assoc Prof of Family Medicine
Pericarditis
Pericardial pain, which is due to inflammation involving the parietal pericardium, Quality/Quantity feels like stabbing, burning or cutting Aggravating/Relieving Factors is made worse by coughing, swallowing, deep breathing, or lying down; diminished by leaning forward. It is not relieved by nitroglycerin.
Timing/Duration/Frequency Pericardial pain can last for hours or days.
Guldal Izbirak, MD, Assoc Prof of Family Medicine

41. Guldal Izbirak, MD, Assoc Prof of Family Medicine
Location/Radiation It is less variable in character, position, and referral area than myocardial ischemic pain.
Associated Symptoms May be associated with fever, breathlessness. Signs pericardial rub, tamponade
Diagnosis History of pain, pericardial friction rub, ECHO,serial chest x-ray(effusion)
Lab ESR, Leukocytosis
Guldal Izbirak, MD, Assoc Prof of Family Medicine

42. Guldal Izbirak, MD, Assoc Prof of Family Medicine
Dissecting Aneursym
A tear in the aortic intima through which blood surfes into the aortic wall, stripping the media from the adventitia.
Quality/Quantity Pain from dissection of the aorta is usually very severe and of a tearing or rending character. Location/Radiation It is sudden interscapular back pain or pain similar to MI ± radiation through to back or down into the abdomen. Associated Symptoms Often the patient is very unwell and shocked.
Guldal Izbirak, MD, Assoc Prof of Family Medicine

43. Non-cardiovascular causes of chest pain arise in;
The pleura
The oesophagus
The chest wall
Guldal Izbirak, MD, Assoc Prof of Family Medicine

44. Guldal Izbirak, MD, Assoc Prof of Family Medicine
Pleuritic pain
Pleuritic pain is usually sharply restricted to the ipsilateral chest wall or shoulder. Pain, usually well localized, may be variously described as “sharp”, “dull”, “achy”, sometimes “burning”, but whatever its designation, it is worsened and thus prevents deep inspiration. Also coughing and sneezing.
Guldal Izbirak, MD, Assoc Prof of Family Medicine

45. Guldal Izbirak, MD, Assoc Prof of Family Medicine
Aggravation by breathing causes patients to seek, find, and remain in the body position that most restricts movement of the affected region. Implies inflammation or irritation of the pleura. Causes are chest infection.
Guldal Izbirak, MD, Assoc Prof of Family Medicine

46. Guldal Izbirak, MD, Assoc Prof of Family Medicine
Pulmonary Embolism
Venous thrombi (usually from a DVT) pass into the pulmonary circulation and block blood flow to the lungs.
Fatal in ~1:10 cases.
Risk factors: Immobility(long flight or bus journey, post-op), smoking, COC pills, pregnancy or puerperium, past and/or family history of DVT or PE
Guldal Izbirak, MD, Assoc Prof of Family Medicine

47. Guldal Izbirak, MD, Assoc Prof of Family Medicine
Symptoms chest pain, bloody sputum, acute breathlessness,
Signs pleuritic pain,hemoptysis, hypotension, tachycardia, cyanosis, tachypnoea, syncope, pleural rub, ↑ JVP
Screening Postero-anterior and lateral chest x-rays.
Therapy Give oxygen as soon as possible.
Consult pulmologist.
Guldal Izbirak, MD, Assoc Prof of Family Medicine

48. Guldal Izbirak, MD, Assoc Prof of Family Medicine
Pneumothorax
Def: Air in the pleural cavity. >1/2 cases are due to trauma of some kind-the rest are spontaneous.
Symp/Signs: Sudden onset of chest pain and/or increased breathlessness ± pallor, sweating and tachycardia, hypotension, shock
Physical examination:  or absent breath sounds and chest movement, diminished vibration(vocal fremitus), hyperresonance by percussion
Refer for Chest X-Ray.
Guldal Izbirak, MD, Assoc Prof of Family Medicine

49. Guldal Izbirak, MD, Assoc Prof of Family Medicine
Oesophageal pain
Quality/Quantity May be very similar to cardiac pain. Reflux or spasm.Reflux pain is burning in nature Timing/ Duration/ Frequency occurs shortly after meal. Location a substernal pressure-type pain, which may last 2 t0 5 minutes, similar to angina. Radiation It usually radiates to the back rather than to the arms.
Guldal Izbirak, MD, Assoc Prof of Family Medicine

50. Guldal Izbirak, MD, Assoc Prof of Family Medicine
Aggravating/Relieving Factors Not associated with exertion. Relieved by antacids.
Relieved by GTN but less rapidly than angina.
Suspect if related to food or alcohol ingestion or occurs in bed on lying flat.
Guldal Izbirak, MD, Assoc Prof of Family Medicine

51. Guldal Izbirak, MD, Assoc Prof of Family Medicine
Rib fracture
Usually history of injury. Pain well localized and point tenderness over rib. Pain made by light pressure over sternum. Chest x-ray, treatment
Guldal Izbirak, MD, Assoc Prof of Family Medicine

52. Guldal Izbirak, MD, Assoc Prof of Family Medicine
Musculoskeletal pain
Common. Sharp or dull pain. Due to radiation of pain from thoracic spine or local muscular injury. Usually made worse by movement and relieved by rest and NSAIDs.
Guldal Izbirak, MD, Assoc Prof of Family Medicine

53. Guldal Izbirak, MD, Assoc Prof of Family Medicine
Shingles
Reactivation of latent varicella zoster virus
Sudden onset of the neuralgic –often burning in nature-pain in a dermatomal unilateral distribution. Clusters of herpetic vesicles appear in a few days later. The pain is frequently intensified by respiratory motion or movements of the trunk.
Guldal Izbirak, MD, Assoc Prof of Family Medicine

55. Psychiatric disorders
Certain psychiatric disorders (GAD, PD) are recognized as causing chest pain that simulates angina.
Patients with documented heart disease may also have panic attacks or other psychiatric disorders.
Guldal Izbirak, MD, Assoc Prof of Family Medicine

56. Guldal Izbirak, MD, Assoc Prof of Family Medicine
Characterized with multiple symptoms.
Associated with stressful life events and the symptoms are transitory.
Guldal Izbirak, MD, Assoc Prof of Family Medicine

57. Guldal Izbirak, MD, Assoc Prof of Family Medicine
Panic disorder
Shortness of breath
Choking
Palpitations and accelerated heart rate
Chest discomfort
Sweating
Dizziness
Nausea and abdominal pain
Flushes or chills
Fear of dying
Fear of doing something crazy or uncontrolled
Guldal Izbirak, MD, Assoc Prof of Family Medicine

58. Differential Diagnosis
Thorough medical history, esp. Pain itself; questions concerning other cardinal symptoms of cardiorespiratory diseases should be asked (dyspnea, cough and hemoptysis).
A thorough physical examination
CBC, Cardiac enzymes
Chest X-ray and/or ECG
Guldal Izbirak, MD, Assoc Prof of Family Medicine

59. Typical Clinical Features of Major Causes of Acute Chest Discomfort

60. Typical Clinical Features of Major Causes of Acute Chest Discomfort

61. Guldal Izbirak, MD, Assoc Prof of Family Medicine
Guldal Izbirak, MD, Assoc Prof of Family Medicine

62. Guldal Izbirak, MD, Assoc Prof of Family Medicine
When to Refer
Patients with chest pain of cardiac origin may need emergency hospitalization and are likely to require further diagnostic evaluation by a cardiologist for coronary artery disease or valvular dysfunction. This may include ECHO, cardiac catheterization, treadmill testing, or coronary angiography with possible angioplasty or stent placement.
Guldal Izbirak, MD, Assoc Prof of Family Medicine

63. Guldal Izbirak, MD, Assoc Prof of Family Medicine
Stable / Unstable Angina
Emergent / Nonemergent
Rule out life-threatining conditions
Guldal Izbirak, MD, Assoc Prof of Family Medicine

64. Guldal Izbirak, MD, Assoc Prof of Family Medicine
When to Refer
Consultation with a pulmologist is needed for patients who might require fiberoptic bronchoscopy, pleural biopsy, or specialized pulmonary function testing.
Guldal Izbirak, MD, Assoc Prof of Family Medicine

65. Guldal Izbirak, MD, Assoc Prof of Family Medicine
When to Refer
If invasive procedures are needed to evaluate chest pain of possible esophageal origin or somewhere in the abdomen, referral to a gastroenterologist is warranted.
Guldal Izbirak, MD, Assoc Prof of Family Medicine

66. Guldal Izbirak, MD, Assoc Prof of Family Medicine
When to Refer
In selected cases of intractable chest pain of presumed psychological origin, referral to a psychiatrist can be helpful.
Guldal Izbirak, MD, Assoc Prof of Family Medicine

67. Guldal Izbirak, MD, Assoc Prof of Family Medicine
Key Points
Immediate life threats must be ruled out first.
Some serious disorders, particularly coronary ischemia and PE, often do not have a classic presentation.
Most patients should have pulse oximetry, ECG, cardiac markers, and chest x-ray.
Evaluation must be prompt so that patients with ST-elevation MI can be in the heart catheterization laboratory (or have thrombolysis) within the 90-min standard.
If PE is highly likely, antithrombin drugs should be given while the diagnosis is pursued; another embolus in a patient who is not receiving anticoagulants may be fatal.
Guldal Izbirak, MD, Assoc Prof of Family Medicine

68. Guldal Izbirak, MD, Assoc Prof of Family Medicine
References:
Bates' Guide to Physical Examination And History Taking (9th Edition) by lynn S Bickley, Peter G Szilagyi
Essentials of Family Practice, Rakel
Case Files: Family Medicine, LANGE, McGraw Hill, 2007
Decision making, Berman, third edition
Guldal Izbirak, MD, Assoc Prof of Family Medicine