1. DIFFERENTIAL DIAGNOSIS OF CHEST PAIN
Prof.Dr. Muzaffer Degertekin
Kardiyoloji ABD

2. The differential diagnosis of patients presenting with chest pain is extensive, ranging from benign musculoskeletal etiologies to life-threatening cardiac disease.

3. 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

4. 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

5. 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

6. 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.

7. 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

8. 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

9. 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

10. PULMONARY CAUSES OF CHEST PAIN
Acute pulmonary embolism
Pulmonary hypertension and cor pulmonale 
Pneumonia
Cancer
Sarcoidosis
Asthma and COPD 

11. Pleura and pleural space
Pneumothorax
Pleuritis 
MEDIASTINAL CAUSES  
PSYCHOGENIC/PSYCHOSOMATIC CAUSES  

12. DIFFERENTIAL DIAGNOSIS Causes of life threatening chest pain
Acute coronary syndrome
Aortic dissection
Pulmonary embolism
Tension pneumothorax
Pericardial tamponade
Mediastinitis (eg, Esophageal rupture)

13. PATHOPHYSIOLOGY OF ANGINA
Angina is caused by myocardial ischemia, which occurs whenever myocardial oxygen demand exceeds oxygen supply.

14. 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

15. Myocardial oxygen supply
Coronary artery diameter and resistance
Collateral blood flow
Perfusion pressure
Heart rate

16. ETIOLOGY Coronary atherosclerosis Coronary artery vasospasm
Coronary artery fibrosis
Coronary artery embolism
Coronary artery dissection
Coronary arteritis

17. 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

18. 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

19. 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

20. Provoking factors 
Activities and situations that increase myocardial oxygen demand
Physical activity
Cold
Emotional stress
Sexual intercourse
Meals
Cocaine use

21. 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

22. 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

23. 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.

24. 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