Chest Pain
Wei-Sheng Chung, MD, MS Vice-superintendant, Potzh General Hospital
Etiology (I)
Acute ischemic coronary syndrome Acute pericarditis Aortic dissection Valvular disease • Pulmonary Pulmonary embolus Pneumothorax Pleurisy pneumonia
Cardiac/ vascular
Etiology (II)
Esophageal reflux Esophageal perforation Biliary colic Esophageal rupture Peptic ulcer disease/ gastritis
Gastrointestinal
•Other
Musculoskeletal Herpes zoster psychogenic
Acute ischemic coronary syndrome
Symptoms/ signs
Squeezing chest pain Radiating to arm/jaw Diaphoresis Nausea/vomiting Tachycardia or bradycardia Shortness of breath Signs of CHF
Diagnosis/Treatment
History ECG and Cardiac monitor Cardiac enzyme (CPK-MB, LDH, GOT; troponin I)
Intravenous access Oxygen Pain control (nitrate, morphine) Catheterization, PTCA, or thrombolytic
therapy
Acute pericarditis
Substernal pain, worsening with
inspiration Increased with recumbency Relieved by leaning forward Anorexia Fever Pericardial friction rub Cardiac tamponade signs
Symptoms/Signs
Elevated jugular venous pressure Hypotension Tachycardia Paradoxical puls
Etiology(I)
Idiopathic origin Viral infection Coxsackievirus A and B Echoviruses Adenoviruses HIV Bacterial and purulent infections Staphylococcus aureus Streptococcus pneumoniae Mycoplasma pneumoniae Anaerobic bacteria Gram-negative species
Etiology (II)
Fungal infection Histoplasma capsulatum Aspergillus species Mycobacterial infection Mycobacterium tuberculosis Rickettsial infection Parasitic infection Irradiation Trauma or surgery Postpericardiotomy syndrome
Etiology (III)
Drugs Procainamide HCl Hydralazine HCl (Apresoline) Isoniazid (Nydrazid) Phenytoin (Dilantin)
Metabolic disorders Hypothyroidism Uremia (dialysis-related)
Vasculitis Neoplasms Myocardial infarction
Etiology (IV)
Connective tissue disease Systemic lupus erythematosus Rheumatoid arthritis Sarcoidosis Scleroderma Idiopathic thrombocytopenic purpura Amyloid Aortic dissection Influenza virus vaccine (FluMist, Fluvirin, Fluzone)
Diagnosis/ treatment
ECG CRP, ESR Cardiac enzyme (CPK-MB; troponin I) Echocardiogram Pericardiocentesis
Directly toward the underlying disease NSAID (aspirin, indomethacin, naproxin)
Aortic dissection
Aortic dissection
Symptoms/ Signs
Severe chest pain with radiating to back Paraplegia Cold legs (compromised perfusion)
Differential blood pressure Decreased absent pulses Neurologic deficit Evidence of pleural effusion Evidence of pericardiac tamponade
Diagnosis/ treatment
Chest X-ray Chest CT scan Angiography MRI
Type A: surgical intervention Type B: medical intervention unless o Occlusion of major vessel o leaking
Prognosis
Acutely - mortality ?75 – 80% !
Pulmonary embolus
Symptoms/ Signs
Sudden onset of chest pain Dyspnea Hypoxemia
Diagnosis
Electrocardiography Chest X-ray Blood-gas analysis Plasma D-dimer level Lung scintigraphy Pulmonary angiography Spiral CT Echocardiography
Treatment
Low-molecular-weight heparin aPTT 1.5-2.5 control Oral anticoagulant treatment should be initiated during
Thrombolytic therapy Anticoagulant therapy
the first 3 days with an overlap with heparin treatments for at least 4 to 5 days. Heparins could be discontinued when the international normalized ratio (INR) has been therapeutic (range 2.0 to 3.0) for 2 consecutive days. Patients with a first episode of pulmonary embolism should be treated for at least 3 months if they have a reversible risk factor and for at least 6 months is they have idiopathic venous thromboembolism.
Pneumothorax
Symptoms/ Signs
Chest pain Relative dyspnea hypoxia
Diagnosis/ Treatment
Chest X-ray Chest CT
1.25% absorbed spontaneously a day
100% O2 increases this 4-6 fold Fine needle aspiration If leak persists beyond 7 days o suspect bronchopleural fistula o usually requires surgery o or pleurodesis may have a role
Pneumonia
Pleurisy
Esophageal perforation
Symptoms/ Signs
Chest pain Dyspnea Hypoxia Fever Sepsis signs
Diagnosis/ treatment
Chest X-ray Chest CT
Tube Thoracotomy
Thank You for Your Attention !!