2. Peril’s & Pearls - Chest Pain Dx
In the absence of CAD, the most important “LAB”
test in the patient with chest pain is the AP chest
X-RAY, it provides valuable visual clues to many
life-threatening causes of non-cardiac chest pain
While not a highly sensitive test, there are highly
specific findings often present suggesting relevant
Dx
The most important procedure in the evaluation of
the stable patient with chest pain and a normal
EKG is a METICULOUS, PRECISE, EXACTING (TIME-
CONSUMING) HISTORY.
2
3. “The Time Honored statement
is still true today”
it takes a professional lifetime for physicians
to learn how to take a history.
3
4. The Problem
of Pain is the
compelling 1940
book by C. S.
Lewis that
provides an
intellectual
Christian
response to the
eternal question
of existential
suffering. For
patients with a
Christian
viewpoint on life
it is an aid to
confronting and
understanding
the suffering
dimension of
illness.
4
5. The single
most important
book to read
about chest
pain
syndromes. Of
value to
medical
student,
house-officer,
staff
physicians.
Highly distilled
and relevant
clinical
wisdom.
http://www.amazon.com/Chest-Pain-J-Willis-Hurst/dp/0879934824/ref=sr_1_1?
s=books&ie=UTF8&qid=1341675849&sr=1-1&keywords=Chest+Pain
5
6. The Problem of Chest Pain
Somatic
(Precisely
Vs
Mapped) Visceral
(Vague/Enteric
Pain
/Vagal)
Pain
6
7. The Problem of Chest Pain
Somatic Visceral
Diffuse & poorly localized, felt in
Localization Focused
dermatomal distribution, radiates
Sharp,
Aching,
Quality Vague discomfort
Burning,
Stabbing
Associated Motor Motor reflexes + Vagal Symptoms
Symptoms Reflexes (faint, nausea, sweats)
Tissue Organ Distention/Contraction/
Triggers
Injury Ischemia
7
8. LIFE THREATENING
Unstable Angina - Acute Coronary Syndrome
Myocardial Infarction
IV & Non-IV Drug Addiction (esp Cocaine)
Cardiac Arrhythmia (esp AFib or PSVT)
Critical Aortic Stenosis (common >75%)
Critical Mitral Stenosis (rare <10% cases)
Asymmetrical LV Hypertrophy (ASH)/IHSS
Dilated Cardiomyopathy
Malignant Dz Of The Breast
8
9. LIFE THREATENING
Pericarditis With Tamponade
Toxicological (Lead Poisoning, CO Poisoning, Cyanide)
Aortic Dissection
Spontaneous Pneumothorax
Pneumomediastinum (Diving accident or loss of cabin pressure at altitude)
Decompression Sickness (“Chokes”)
Air Embolism
Lymphoma
Superior Vena Cava Syndrome
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11. Spontaneous Pneumothorax
(Detailed Diff Dx)
Secondary (Infectious Disease)
AIDS with Pneumocystis carinii
Non AIDS related Pneumocystis carinii
PNA
TB
Necrotizing PNA
11
16. LIFE THREATENING
Pulmonary Artery Hypertension
Pneumonia
Pulmonary Embolism/Infarction
Oncological disease of bone (i.e., multiple myeloma
or bone met to T-spine/sternum/ribs)
16
18. NON LIFE THREATENING
Syndrome X (Angina + ST depression on Stress EKG + Nml CA’s)
Takotsubo Cardiomyopathy (Transient Apical Ballooning) (Broken Heart Syndrome)
Barlow’s Syndrome (Click-murmur or Mitral Valve Prolapse Syndrome)
Mondor’s Syndrome (Superficial Thrombophlebitis of Chest Wall)
Nonmalignant Dz’s Of The Breast
Pericarditis Without Tamponade
Dressler’s Syndrome (Postmyocardial Infarction Syndrome)
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19. NON LIFE THREATENING
Viral or Non-viral (Rheumatological) Pleurisy
Familial Mediterranean Fever
Tietze’s Syndrome (Chostochondritis)
Cyriax’s (Slipping Rib) Syndrome
Precordial “Catch” Syndrome (Texidor’s Twinge)
Herpes Zoster
19
20. NON LIFE THREATENING
Cervical/thoracic disk or joint disease (e.g., T-spine
compression fractures in the elderly)
Thoracic outlet syndromes
Rib fracture
Shoulder Pain/Injury
Shoulder-Hand Syndrome (Cardiac Causalgia - RSD)
Peptic Dz (Esophagitis (GERD) vs Ulcer Dz)
Pill-induced Esophagitis - HIV Assoc Esophageal Dz
“Nutcracker” esophagitis or esophageal spasm
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27. Non Life Threatening
Hyperventilation Syndrome
Panic Attack/Panic Disorder
Da Costa Syndrome (Old Soldier’s Heart) (neurocirculatory asthenia)
(Cardiac Neurosis)
Undifferentiated Anxiety D/O
Depression
Conversion D/O
Factious Illness
Munchausen Syndrome
Malingering
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28. The Take Home
Chest Pain Evaluation is much more
complicated than simply R/O MI
The Job Is NOT done until you have a
defined and defensible explanation for the
episode or episodes of chest pain
Dx is most dependent on a careful, detailed,
and meticulous history combined with a
focused physical examination NOT by
deploying exhaustive and expensive testing
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Notas do Editor
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More so than perhaps any other clinical problem the chest pain differential diagnosis is encyclopedic in complexity and scope. \n
This talk will focus on developing in a short period of time the most detailed differential diagnosis for chest pain possible. \n
The problems inherent in chest pain can not be overstated or underestimated. \n\nChest pain represents a problem in which encompassed in its bewildering breadth of conditions manifesting with chest pain lies the leading cause of death in the developed world, the leading cause of successful malpractice claims (20% of all dollars paid out in malpractice actions relate to missed myocardial infarction), and for the justifiable fear of missing a life threatening cause of chest pain lies the source of many unnecessary hospitalizations in our society. \n
Chest pain syndromes encompass the entire pantheon of internal medicine diseases and pathophysiological processes. \n
The problem of chest pain is related principally to the fact that the majority of causes of chest pain are related to pain in an organ rather than pain in a cutaneous or musculoskeletal structure and therefore the diagnostician must confront the dual problems of poor spatial mapping of the pain&#x2019;s origin as well as the confusion attendant to the phenomena of pain radiation. \n\nSomatic pain reflects pain as perceived by the neo-cortex, while visceral pain reflects pain as perceived by the more primitive and less accurately mapped reptilian nervous system. \n
This table illustrates the fundamental clinical differences in somatic vs visceral pain syndromes. \n
While at the head of the list, and of undoubtable importance (4 Jumbo Jets worth of patient&#x2019;s die of AMI every day in the USA), yet the minority of the patient&#x2019;s presenting to an USA Emergency Room with chest pain turn out to be suffering from acute myocardial infarction or unstable coronary artery disease. \n\nThe commonality for all the chest pain etiologies listed on this slide is their precise relationship to diseases of the heart. \n\nNote that IHSS (idiopathic hypertrophic subaortic stenosis) represents the older and less favored way to describe the dynamic subaortic outflow tract obstruction characteristic of asymmetrical LV hypertrophy. \n
While in the USAF I had the opportunity to review in detail the lethal missed diagnosis of pneumomediastinum occurring in a National Guard pilot who was ferrying a F-100 from Arizona to Florida where it was to be used as a target drone. \n\nHe developed severe chest pain enroute, declared an in-flight emergency and was evaluated at Charity Hospital in New Orleans. He died due to failure to consider the diagnosis. The great tragedy of the case related to the high likelihood of survival attendant to prompt treatment with hyperbaric/dive chamber therapy. \n
The next series of slides are related to a more exhaustively detailed exploration of the potential causes for development of a spontaneous pneumothorax. \n
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In this group, the most interesting and most important diagnostic entity is pulmonary embolism. While much less frequently seen than myocardial infarction, it remains a highly lethal condition with reported rates of one hour mortality as high as 60% in some historical clinical series. It rightfully is more feared than coronary occlusive disease. \n
In these GI causes of potentially threatening chest pain, the most feared entity is Boerhauve&#x2019;s Syndrome as GI tract soiling of the mediastinum is of greater technical complexity in its management than the more common GI tract soiling of the peritoneal cavity. \n\nOne of the most interesting cases of chest pain that I am personally aware of was the case of gut ischemia which was developed by one of our staff GYN physicians in Eagle Pass Texas. I was consulted for what was felt to be an inferior wall myocardial infarction. The physician was in intense vagal pain, diaphoretic, shocky but with a normal EKG, emergency cardiac ultrasound confirmed completely normal LV segmental wall motion. Emergency Contrast CT of the chest and abdomen showed total occlusion of the origin of the superior mesenteric artery due to a mid-gut volvulus. \n
Syndrome X, the object of intense research interest in cardiology for over 40 years represents the clinical perplexity of normal coronary arteries combined with the presence of predictable exertional angina, reproducible and repetitively abnormal non-nuclear and nuclear stress tests. This syndrome is also characterized by some authorities by the presence of increased levels of coronary sinus lactic acid during RV pacing. \n\nClosely related to Syndrome X due to its pathophysiology being related to micro-circulatory dysfunction is Takotsubo Cardiomyopathy or broken heart syndrome. While originally \n
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Da Costa Syndrome (old soldier&#x2019;s heart) was orginally described during the Civil War \n\nPsychological chest pain syndromes are among the most common if not the most common underlying cause for chest pain ED visits. \n