Introduction to one of the most common symptoms that can represent a wide range of diseases, from benign to life-threatening, covering number of systems including gastrointestinal, cardiovascular, pulmonary, musculoskeletal and psychiatric. Includes a brief explanation of anti-anginal therapy.
Template design credits - http://www.slidescarnival.com
4. • Mr. Arshad
• 60 Years, Male
• Weight 86 kg
• Height 142 cm
• Diabetic for 10 years
• Ex-smoker
• Family history of IHD
Case
• Presented in E.R
• Chest heaviness (30 min)
• Sudden onset
• Retrosternal
• Radiates to left arm
• Aggravates on exertion
• Relieved by rest
• Associated with sweating
5. Case (cont.)
Physical Examination:
• Pulse - 76 b/m, regular
• B.P. - 150/90 mmHg
• R.R. - 27 b/m
• SpO2 - 95% on room air
• Temp - 98° F
• BSR - 117 mg/dl
• S1 + S2 + 0
• Vesicular breathing
• Abdomen non-tender
• GCS - 15 / 15
• No edema, pallor or jaundice
• 12 Lead ECG was carried out
10. One of the chief complaints in E.R
• Chest Pain is the second most common presentation in E.R visits,
after abdominal pain.
• Can represent range of diseases from benign to life threatening.
• It is upto the clinician to exclude the life threatening causes first.
12. Typical vs Atypical vs Non-Cardiac
Aggravated
by
exertion
or emotional
stress
Relieved
by rest or
nitroglycerin
Diffuse
retrosternal
chest pain or
discomfort
3 / 3
Typical
2 / 3
Atypical
1 / 3
Noncardiac
14. Triple Rule Out C.T Angiography
• TRO-CTA provides a cost-effective evaluation of aorta, coronaries, and
pulmonary arteries in patients presenting with acute chest pain.
• Rules out three life threatening causes:
1 - Coronary Artery Disease
2 - Pulmonary Embolism
3 - Aortic Dissection +/- Cardiac Tamponade
• Can safely eliminate the need of further testing in 75% of the patients.
16. Ischemic Heart Disease
• IHD must be excluded in all patients presenting with chest pain.
• Especially in middle and old age groups. Initial suspicion is on history.
• ECG may be normal in early stages of ACS, so a normal ECG doesn’t
exclude ACS.
• Angina Pectoris is typical chest pain < 30 min (similar episodes in past)
- Seen in stable angina, coronary vasospasm
• Acute Coronary Syndrome (ACS) is typical / atypical chest pain > 30 min
- Seen in unstable angina (38%), NSTEMI (25%), STEMI (30%)
17. Ischemic Heart Disease
• Unstable Angina (UA)
- occurs at rest or with minimal exertion
- it is severe and van be of new onset
- it can occur with a crescendo pattern (distinctively more severe,
prolonged, and frequent than previous episodes)
- may or may not be relieved by rest or S/L nitrates
- can precede myocardial infarction
• Decubitus Angina
- Typical chest pain which appears after lying down
- Due to increase in venous return and preload
- Seen in heart failure and/or severe underlying CAD
18. Angina Pectoris / ACS
Features of chest pain in Angina Pectoris and ACS
Site Diffuse, retro-sternal
Character Discomfort, tightness, heaviness, squeezing, sinking
Radiation Left arm, neck, jaw, shoulders, back, right arm, epigastrium
Association Diaphoresis, dyspnea, nausea, vomiting
Time course Constant, non-spasmodic, non-pleuritic
Exacerbated by Exertion and emotional stress
Relieved by Rest, S/L nitroglycerin (stable angina)
Not relieved by rest, S/L nitrates (unstable angina, MI)
Risk factors Age, Sex, Smoking, Diabetes, Hyperlipidemia, F/H of IHD
20. Classification Of Angina
Canadian Classification Scale (CCS) of Angina
Class I Angina on strenuous, rapid or prolonged exertion
No limitation of ordinary activity like walking or climbing stairs
Class II Slight limitation of ordinary activities like walking or climbing
stairs, in cold, in wind, after meals, or emotional stress
Class III Marked limitation of ordinary activities
i.e . after walking 1-2 blocks, or climbing 1-2 flight of stairs
Class IV Unable to perform any physical activity without discomfort
Angina may be present at rest
21. Ischemia VS Infarction
Feature Stable Angina Unstable Angina Myocardial Infarction
Onset On exertion On rest or exertion On rest or exertion
Relieved by rest Yes No No
S/L nitrates Relieves pain May relieve pain Does not relieve
Duration < 30 min > 30 min > 30 min
ECG Normal or
transient changes
(ST depression and
T wave flattening or
inversions)
Maybe normal initially
transient changes
(ST depression and
T wave flattening or
inversions)
Maybe normal initially
ST elevation and/or depression
(may be transient)
T wave inversions (may persist)
Q waves (permanent)
Cardiac enzymes Within range Within range Raised
22. Medical Therapy in Angina
Objectives:
• Prevent episodes of angina
Short-acting nitrates 5 min before planned exertion
1st line Anti-anginals - Beta Blockers and /or Calcium Channel Blockers
2nd line Anti-anginals - Long-acting nitrate, Ivabradin, Ranolazine, Nicorandil
• Treat episodes of angina
During angina – Take a dose of short-acting nitrates
If no relief after 5 min, repeat dose and call an ambulance
• Secondary prevention of CV disease
- Lifestyle modifications - weight reduction, diet control, regular exercise
- Anti-Platelet Therapy - Aspirin (+/- Clopidogrel)
- Cholesterol lowering therapy - ideally with a statin (alt. is ezetimibe)
- Treat hypertension if present - ideally with an ACEI or ARB
- Refer to endocrinologist for diabetes management if present
23. Acute Pericarditis
• “Sharp” retrosternal chest pain
• Aggravates on movement, inspiration,
cough and lying supine
• Relieves on leaning forward
• Signs: Tachycardia, pericardial friction rub
• There maybe history of recent MI
(Dressler’s syndrome)
• ECG: diffuse ST elevation concave upwards
diffuse PR depression
• Cardiac enzymes: may be elevated
25. Acute Myocarditis
✘“Sharp” retrosternal chest pain
✘Associated symptoms: palpitations, tachypnea
✘Sometimes concomitant with pericarditis, heart failure, arrhythmias
✘May preceded by pro-dromal symptoms like fever, rash, arthritis etc
✘Seen with rheumatic fever, sarcoidosis, SLE or scleroderma
✘Delayed complication = dilated CMP
✘ECG – sinus tachycardia, QT prolongation, diffuse T wave inversions
✘Increased troponin levels due to myocardial inflammation
26. Aortic Stenosis
• Angina mimic – sub-endocardial ischemia due to raised LVEDP
• Syncope (LVOT obstruction & hypotension)
• Features of heart failure may be present
• Ejection Systolic Murmur at aortic area
• Causes: aortic sclerosis (aging), RHD, congenital bicuspid AV
• ECG – LVH, P. mitrale, possibly conduction blocks like LBBB
• Echo – dilated aortic root, thickened / immobile AV, concentric LVH,
On the basis of AVPG, AV area can be determined, AS can be graded as:
Mild, Moderate, Severe, Very Severe
31. Mitral Valve Prolapse
• Symptoms: atypical chest pain, panic, palpitations, pre-syncope, SOB
• Signs: Mid systolic click with a late systolic murmur
Accentuated with standing and Valsalva maneuver
• Significant MR can cause heart failure, and a holosystolic murmur
• Myxomatous degeneration of MV leaflets that bulge backward into LA
• Presents to us in second or third decade of life
• ECG – may be normal, sinus tachycardia, LVH, P mitrale
• Echo – concentric LVH, dilated LA, MR present
classic MVP - thickened mitral leaflets > 5mm
- leaflet displacement > 2mm into LA during systole
37. Aortic Dissection
• Symptoms: Sudden onset of severe “tearing” pain in the inter-scapular
region of the back, sweating, vomiting and lightheadedness
• If ascending aorta is involved - there can be frontal chest pain, and
cardiac tamponade can occur (most common cause of death in A.D)
• MI can occur if aortic root is involved as coronary arteries arise from it
• Abdominal pain and GI bleed due to mesenteric ischemia
• Syncope due to cerebral hypo-perfusion, paralysis due to stroke
• Tear inside the aorta causes the blood to between the layers of the wall
• Etiology: chronic hypertension causing cystic medial degeneration
• CXR – normal, wide mediastinum, wide aortic knob, left pleural effusion
• CT angiogram is diagnostic. MRI is the gold standard.
52. Other Causes
• Empyema
• Herpes Zoster (shingles)
• Post Herpetic Neuralgia
• Acute chest syndrome (sickle cell disease)
• Invasive breast cancer
• Pain of unexplained origin (PUO)
• Pre-cordial catch syndrome (PCS)
53. Psychosomatic Causes
• Da Costa’s syndrome:
physical manifestation of an anxiety disorder
• Generalized Anxiety Disorder (GAD)
• Panic Disorder
• Phobia i.e. agoraphobia
• Post-traumatic stress disorder (PTSD)
• Clinical depression
• Conversion disorder
• Hypochondriasis
54. • Mr. Arshad
• 60 Years, Male
• Weight 86 kg
• Height 142 cm
• Diabetic for 10 years
• Ex-smoker
• Family history of IHD
Case
• Presented in E.R
• Chest heaviness (30 min)
• Sudden onset
• Retrosternal
• Radiates to left arm
• Aggravates on exertion
• Relieved by rest
• Associated with sweating
55. Case (cont.)
Physical Examination:
• Pulse - 76 b/m, regular
• B.P. - 150/90 mmHg
• R.R. - 27 b/m
• SpO2 - 95% on room air
• Temp - 98° F
• BSR - 117 mg/dl
• S1 + S2 + 0
• Vesicular breathing
• Abdomen non-tender
• GCS - 15 / 15
• No edema, pallor or jaundice
• 12 Lead ECG was carried out
