Approach to chest pain, case- based and pericarditis guidelines Ahmed Yehia, MD, Internal Medicine, Beni-suef, Egypt How to diagnose different causes of chest pain and causes not to be missed. Pericardial diseases ESC guidelines

1. Approach to chest pain,
case- based
Ahmed Yehia, MD

2. Case 1
A 30 years old lady presents to
the ER with 1 hour of severe
stitching localized central chest
pain.
How to approach?
What is the most likely
diagnosis?

3. Case 2
A 60 years old lady
presents to the ER with
1 hour of severe
stitching localized
central chest pain.
How to approach?
What is the most likely
diagnosis?

4. Most symptoms are
functional but
consider only after
screening for red flags.
•Abdominal pain,
•Headache,
•Bloating,
•Heartburn,
•………..

5. In upper GI symptoms

6. Alarming
signs
(Risk
factors) in
chest
pain
Age
Male sex
Smoking
DM
HTN

7. Case 2
What is the most likely diagnosis?
ECG
We must exclude
IHD.
How to approach?
A 60 years old lady presents to the
ER with 1 hour of severe stitching
localized central chest pain.

8. Case 3
What is the most likely diagnosis?
How to approach?
A 60 years old lady presents to the ER with 10 minutes of
severe crushing central chest pain precipitated by going
upstairs. She is used to have this pain in the same settings
for ~ 6 months and the pain was usually relieved by rest.

9. Chronic
stable angina
ECG
Stress test
Anti-ischemic measures
Control of risk factors

10. Case 4
A 60 years old lady presents to the
ER with 1 hour of severe crushing
central chest pain. She is diabetic
& hypertensive for 10 years.
How to approach?
What is the most likely diagnosis?

11. ECG
Cardiac
markers

12. CK-MB, troponin I : highly positive

13. Reperfusion

14. Case 5
A 60 years old lady presents to the ER
with 1 hour of severe crushing
central chest pain. She is diabetic and
hypertensive for 10 years.
How to approach?
What is the most likely diagnosis?

15. CK-MB, troponin I : highly poisitive

16. How to treat?
Non-STEMI

17. Case 6
• A 60 years old lady presents to the ER with 1 hour of severe
crushing central chest pain. She is diabetic and hypertensive
for 10 years.
– How to approach?
– What is the most likely diagnosis?

18. CK-MB, troponin I : negative

19. Unstable
Angina
How to treat?

20. ACS
algorithm
PORTAL DISEASE OF NO SIGNS
THE MOST IMPORTANT
IS HISTORY: CHEST PAIN.

22. Body
language &
diagnosis
of
ischemia

24. Disease of no
signs
History.. History..
History.. History..

25. Case 7
A 60 years old lady presents to the ER
with 1 hour of severe exertional
dyspnea & diaphoresis. She has no
chest pain. She is diabetic and
hypertensive for 10 years.
How to approach?
What is the most likely diagnosis?

26. CK-MB, troponin I : highly positive

27. Angina
equivalents
Dyspnea Diaphoresis
Dyspepsia
Epigastric
pain

28. Case 8
A 30 years old female patient presented
with acute chest pain & dyspnea.
She had CS 10 days ago.
ECG: only sinus tachycardia.
Chest X ray: normal.
How to approach?
What possibility should be considered?

29. Clues for pulmonary
embolism

30. Case
• A 30 year old man presents with acute chest
pain for 1 hour.

31. Acute pericarditis

32. STEMI

34. Acute Coronary Syndromes - History
“Typical” Chest Pain Story (Pressure-like, squeezing,
crushing pain, worse with exertion, SOB, diaphoresis,
radiates to arm or jaw) The majority of patients with
ACS DO NOT present with these symptoms!
Cardiac Risk Factors (Age, DM, HTN, FH, smoking,
hypercholesterolemia, cocaine abuse)

35. Acute
Coronary
Syndromes
– EKG
Findings
STEMI - ST segment elevation
(>1 mm) in contiguous leads;
new LBBB
T wave inversion or ST
segment depression in
contiguous leads suggests
subendocardial ischemia
5% of patients with AMI have
completely normal EKGs

37. Case 9
• A 70-year-old woman has been healthy except for
hypertension treated with a thiazide diuretic. She
presents with sudden onset of a severe, tearing
chest pain, which radiates to the back & is
associated with dyspnea and diaphoresis. BP is
210/94. Lung auscultation reveals bilateral basilar
rales. A faint murmur of aortic insufficiency is
heard. BNP level is elevated at 550 pg/mL (Normal
< 100). ECG shows nonspecific ST-T changes. Chest
x-ray suggests a widened mediastinum. Which of
the following choices represents the best initial
management?
a. IV furosemide plus IV loading dose of digoxin
b. PCI with consideration of angioplasty and/or
stenting
c. Blood cultures and rapid initiation of vancomycin
plus gentamicin, followed by echocardiography
d. IV beta-blocker to control HR, IV nitroprusside to
control BP, transesophageal echocardiogram
e. IV heparin followed by CT pulmonary angiography

38. Case 9
• A 70-year-old woman has been healthy except for
hypertension treated with a thiazide diuretic. She
presents with sudden onset of a severe, tearing
chest pain, which radiates to the back & is
associated with dyspnea and diaphoresis. BP is
210/94. Lung auscultation reveals bilateral basilar
rales. A faint murmur of aortic insufficiency is
heard. BNP level is elevated at 550 pg/mL (Normal
< 100). ECG shows nonspecific ST-T changes. Chest
x-ray suggests a widened mediastinum. Which of
the following choices represents the best initial
management?
a. IV furosemide plus IV loading dose of digoxin
b. PCI with consideration of angioplasty and/or
stenting
c. Blood cultures and rapid initiation of vancomycin
plus gentamicin, followed by echocardiography
d. IV beta-blocker to control HR, IV
nitroprusside to control BP,
transesophageal echocardiogram
e. IV heparin followed by CT pulmonary angiography

39. The answer is d. (Fauci, pp 1565-1566.)
This patient’s presentation strongly suggests aortic dissection. Aortic
insufficiency is common with proximal dissection, as are hypertension &
evidence of CHF. Hypotension may be present in severe cases. Distal
dissection can lead to obstruction of other major arteries with neurological
symptoms (carotids), bowel ischemia, or renal compromise.
In aortic dissection, the first line of defense is emergent therapy with
parenteral beta-blockers. After betablockade is established, nitroprusside is
commonly used to titrate SBP to less than 120.
The diagnosis is established with transesophageal echo, MR, or CT
angiography. Urgent surgery may be required, especially in proximal (type A)
dissections.

40. Although endocarditis may cause aortic insufficiency, this patient’s sudden
onset of symptoms as well as widened mediastinum would be unusual in
endocarditis.
Myocardial ischemia can cause mitral (but not aortic) insufficiency.
Furosemide might help the pulmonary edema but would not address the
primary problem; digoxin increases shear force on the aortic wall & could
worsen the dissection.
Anticoagulation is contraindicated if aortic dissection is suspected, as it
may increase the risk of fatal rupture & exsanguinating hemorrhage.

41. • The most common causes of chest pain in
outpatients are musculoskeletal & GI
conditions.
• Studies have estimated that ~ one-third to
one-half of patients have musculoskeletal
chest pain, 10 to 20% have a GI causes, 10%
have stable angina, 5% have respiratory
conditions, and ~ 2 to 4% have acute
myocardial ischemia (including MI).

42. History of pain analysis
• O- onset
• P-provocation /palliation
• Q- quality/quantity
• R- region/radiation
• S- severity/scale
• T- timing/time of onset

44. Differential Diagnoses
Cardiovascular Acute myocardial infarction, Acute coronary ischemia, Aortic
dissection, Cardiac tamponade, Unstable angina, Coronary
spasm, Prinzmetal's angina, Cocaine induced, Pericarditis,
Myocarditis, Valvular heart disease, Aortic stenosis, Mitral
valve prolapse, Hypertrophic cardiomyopathy
Pulmonary Pulmonary embolus, Tension pneumothorax,
Pneumothorax, Mediastinitis,
Pneumonia, Pleuritis, Tumor, Pneumomediastinum
Gastrointestinal Esophageal rupture (Boerhaave), Esophageal tear (Mallory-
Weiss), Cholecystitis, Pancreatitis, Esophageal
spasm, Esophageal reflux, Peptic ulcer, Biliary colic
Musculoskeletal Muscle strain, Arthritis, Tumor, Costochondritis, Rib
fracture, Nonspecific chest wall pain
Neurologic Spinal root compression, Thoracic outlet, Herpes
zoster, Postherpetic neuralgia
Other Psychologic, Hyperventilation

45. Life
Threatening
Causes of
Chest Pain
Acute Coronary Syndromes
Pulmonary Embolus
Tension Pneumothorax
Aortic Dissection
Esophageal Rupture
Pericarditis with Tamponade

47. ESC guidelines for
pericardial diseases

49. Etiology
Infectious
• Viral
• Bacterial
• Mycobacterial: TB
• Fungal
• Parasitic
Non-infectious
• Idiopathic
• Inflammatory: FMF
• Immune: SLE, RA
• Iatrogenic
– Intervention
– Drug-induced lupus
• Metabolic: hypothyroid, uremic
• Traumatic
• Malignant

58. Transudate vs Exudate

61. Assessment questions

62. 1. The typical ECG criteria of acute pericarditis
include
A. convex ST segment elevation
B. PR segment depression
C. Prolonged QT interval
D. All of the above
E. None of the above

63. 1. The typical ECG criteria of acute pericarditis
include
A. convex ST segment elevation
B. PR segment depression
C. Prolonged QT interval
D. All of the above
E. None of the above

64. 2. Which of the following support the diagnosis
of acute pericarditis?
A. Elevated CRP and ESR.
B. Pericarditic chest pain.
C. Pericardial effusion.
D. All of the above.
E. None of the above.

65. 2. Which of the following support the diagnosis
of acute pericarditis?
A. Elevated CRP and ESR.
B. Pericarditic chest pain.
C. Pericardial effusion.
D. All of the above.
E. None of the above.

66. 3. The first line therapy for acute pericarditis is
A. Corticosteroids
B. NSAIDs plus colchicine
C. Corticosteroids plus colchicine
D. Azathioprine

67. 3. The first line therapy for acute pericarditis is
A. Corticosteroids
B. NSAIDs plus colchicine
C. Corticosteroids plus colchicine
D. Azathioprine

68. 4. Beck’ s triad for cardiac tamponade includes
all of the following except:
A. Muffled heart sounds
B. Rising neck veins
C. Falling blood pressure
D. Pansystolic murmur

69. 4. Beck’ s triad for cardiac tamponade includes
all of the following except:
A. Muffled heart sounds
B. Rising neck veins
C. Falling blood pressure
D. Pansystolic murmur

70. 5. The commonest cause of acute pericarditis is
A. Viral
B. Bacterial
C. Autoimmune
D. hypothyroid

71. 5. The commonest cause of acute pericarditis is
A. Viral
B. Bacterial
C. Autoimmune
D. hypothyroid

72. 6. Which of the following is recommended in
pericarditis resistant to steroids?
A. Azathioprine
B. IVIG
C. Anakinra
D. All of the above

73. 6. Which of the following is recommended in
pericarditis resistant to steroids?
A. Azathioprine
B. IVIG
C. Anakinra
D. All of the above

74. 7. Acute coronary syndrome includes
A. Unstable angina
B. STEMI
C. NON-STEMI
D. All of the above
E. None of the above

75. 7. Acute coronary syndrome includes
A. Unstable angina
B. STEMI
C. NON-STEMI
D. All of the above
E. None of the above

76. 8. Specific cardiac markers used for assessment
of cardiac muscle injury include:
A. ALT
B. LDH
C. Alkaline phosphatase
D. CK-MB
E. GGT

77. 8. Specific cardiac markers used for assessment
of cardiac muscle injury include:
A. ALT
B. LDH
C. Alkaline phosphatase
D. CK-MB
E. GGT

78. 9.

79. 9. What is the most likely diagnosis in
this ECG?
A. STEMI
B. Non-STEMI
C. Acute pericarditis
D. Pulmonary embolism
E. Atrial fibrillation

80. 9. What is the most likely diagnosis in
this ECG?
A. STEMI
B. Non-STEMI
C. Acute pericarditis
D. Pulmonary embolism
E. Atrial fibrillation

81. 9. According to Light’s criteria, which of the
following findings suggest exudative effusion?
A. Fluid protein: serum protein > 0.5
B. Fluid LDH: serum LDH < 0.6
C. Fluid LDH < 2/3 the upper limit of normal
D. The presence of heart failure
E. The presence of nephrotic syndrome

82. 9. According to Light’s criteria, which of the
following findings suggest exudative effusion?
A. Fluid protein: serum protein > 0.5
B. Fluid LDH: serum LDH < 0.6
C. Fluid LDH < 2/3 the upper limit of normal
D. The presence of heart failure
E. The presence of nephrotic syndrome

83. ‫خيرا‬ ‫هللا‬ ‫جزاكم‬