CHEST PAIN BY

MONA ADEL
MD , MACC
CARDIOLOGY CONSULTANT A/PROFESSOR OF CARDIOLOGY

Chest pain is one of the most common complaints heard in both inpatient and outpatient clinics .
It causes a lot of anxiety in the patients and their relatives as they are aware of the serious consequences of heart attacks.

However not all times is a chest pain necessarily caused by heart attacks.

Causes of Chest Pain

Chest pain

organic
1-cardiac 2-pulmonary 3-musculoskeletal

psychogenic
1- anxiety

3-Cardiac neurosis

2- depression

4-Gastrointestinal

CARDIAC CAUSES

Ischemic

Non-Ischemic

Obstructive CAD

Non- Obstructive

Pericarditis Aortic dissection MVP MS

Angina infarction

AS, AR HOCM HTN PH Anemia hypoxia

2. Gastrointestinal

a. b. c.

Esophageal Spasm Esophageal Reflux Esophageal Rupture

d. Peptic Ulcer Disease

E. Gall Bladder Disease

3. Neuromusculoskeletal
a. Thoracic Outlet syndrome b. Lesions of Cervical/Thoracic Spine c. Costochondritis [Tietzes Syndrome] d. Herpes Zoster e. Chest wall pain

4. Pulmonary

a. Pulmonary Embolus/Infarction

b. Pneumothorax
c. Pneumonia with pleural involvement d. Pleurisy

Psychogenic

Anxiety/Depression

There are a lot of personal/social causes to get into

a vicious cycle of anxiety causing various physical symptoms, and those symptoms in turn causing more anxiety. Depression also causes somatization and produces various symptoms, chest pain being one of them.

Character of chest pain

Anginal pain
1-Site 2-Rediation 3-Preceptating factors 4- Relieving factors 5-Character 6-Duration 7Associated symptoms

Character of chest pain

Retrosternal, vague, poorly localized, heavy,
compressive or squeezy feeling .

Radiating to the left shoulder, left arm, neck or

the jaws and associated with palpitation, perspiration, nausea/vomiting, dizziness, blackout or even collapse.

t rarely lasts less than 1 minute or more than 20

minutes, unless it is a heart attack

Patients get prompt relief in less than 5 minutes

on cessation of all activities or use of sublingual nitrates.

ATYPICAL CHEST PAIN

DIABETICS WOMEN THE ELDERLY

Mitral valve Prolapse

This is a common and

benign condition.

Leaflets of the Mitral valve are long,

bulky and redundant. They prolapse into the left atrium during systole.

It is unknown how this causes chest

pain. the pain occurs at rest, sharp, nonradiating and prolonged in duration.

Character of chest pain

Rheumatic Valve Disease
Mitral & aortic stenosis is a
common rheumatic valve condition in females and can cause chest pain and dyspnea

The patient will have associated

cough, expectoration,

There would be a murmur which

will help the diagnosis.

A 2D echocardiography will be
confirmatory.

Neuro-musculo-skeletal
The pain is very well localized, tender on
touch, aggravated on deep inspiration, and not aggravated on exertion. Underlying cause can be pinpointed by suitable investigations like X ray of cervical spine, chest (thoracic outlet syndrome) etc. Pain of herpes zoster sometimes defies diagnosis until the rash develop.

Gastrointestinal
Esophageal reflux is one of the most common
causes of retrosternal pain.

The pain is mostly burning in nature, occurs more

often in reclining posture, and is relieved by assuming upright position.

Character of chest pain

It is more frequent after an oily, heavy meal. Esophageal spasm is a variety of the same
disease.

Sometimes peptic ulcer disease can also cause

pain in lower chest.

Pulmonary

pulmonary embolism/infarct

Usually caused by DVT Combination of oral contraception and smoking

in young females The pain is acute, severe and patient usually is in a critical condition.

Character of chest pain

Pneumonia Can also cause chest pain if there is pleural involvement, which usually is the case. Pneumo-thorax Which is rupture of a lung alveolus into the pleural cavity will cause sudden acute filling up of air pressure in pleura and will cause severe acute chest pain if it is Tension Pneumothorax and moderate dull aching pain if it is simple Pneumothorax

Character of chest pain

Pleurisy

The pain is sharp stab like, occurring on the

slightest act of breathing. Associated features: low grade fever, cough, and malaise, loss of appetite and loss of weight. Rupture of Emphysematous Bullae

Character of chest pain

Anxiety/Depression

Such chest pain can take any form; it can

even mimic Anginal pain. One needs to rule out organic causes before diagnosis of anxiety/depression

 Chest

pain has variable etiologies as we have seen. so clinical examination, appropriate investigations, and reassurance will go a long way in resolving this issue

Chest pain in the absence of obstructive coronary artery disease (CAD) remains a confusing problem that primarily affects women.

Persistent chest pain in women

More than 50% of women with chest pain undergoing coronary angiography in the U.S. are found to have normal or near-normal coronaries, as compared with only 15% of men

Persistent chest pain in women

About 50% of women sent home with normal coronaries continue to experience symptoms that are often unresponsive to conventional anti-ischemic therapy .

Persistent chest pain in women

Prognosis in women with chest pain and normal coronary angiograms is said to be excellent. However women with persistent chest pain PChP and normal coronary angiograms experienced major CV events such as MI and stroke at approximately double the rate found in women with neither PChP nor CAD
Endothelial function predicts future development of coronary artery disease: a study of women with chest pain and normal coronary angiograms. Circulation (2004)

Persistent chest pain in women

European Heart Journal published online on May 23, 2006

Etiology
Women's chest pain in absence of obstructive
CAD may be due to :

1:Coronary atherosclerosis that is relatively

diffuse and not apparent as focal stenosis by angiography

Women and ischaemic heart disease. Pathophysiologic implications from the women's ischemia

syndrome evaluation (WISE) study and future research steps. J Am Coll Cardiol (2006)

 2: coronary macro-vessel or microvessel endothelial dysfunction that limits the coronary microcirculation during stress with abnormal coronary flow reserve,
Women and ischaemic heart disease. Pathophysiologic implications from the women's ischemia syndrome evaluation (WISE) study and future research steps. J Am Coll Cardiol (2006)

The women with PCHP who are at higher risk of cardiovascular disease can be identified by stress echocardiography

Women and ischaemic heart disease. Pathophysiologic implications from the women's ischemia syndrome evaluation (WISE) study and future research steps. J Am Coll Cardiol (2006)

PChP in women should raise concern & considered as a risk factor and such pain should be taken seriously and careful follow up of women & more aggressive risk factor reduction is needed inspite of normal coronary angiograms.

Bugiardini R and Bairey Merz CN. (2005) Angina with normal coronary arteries. A changing philosophy. JAMA 293:477484

TREATMENT
Evidence is accumulating that women with angina and normal coronary arteries may be helped with a wide variety of therapies including: Nitrates Beta blockers, Statins, ACE inhibitors, L-arginine Exercise training

1. 2. 3. 4. 5. 6.

Bugiardini R and Bairey Merz CN. (2005) Angina with normal coronary arteries. A changing

philosophy. JAMA 293:477484.

CONCLUSION
Chest pain can have multiple etiologies Proper evaluation and investigation is needed to reach the cause. Diabetics , women and the elderly may have atypical symptoms.

Women with no obstructive CAD did not receive aggressive risk factor reduction . While those with obstructive CAD were more likely to have lipid lowering and antihypertensive therapies initiated during the follow up period . The women with no obstructive CAD were more likely to receive sedative or hypnotic medications that unlikely to protect against adverse out comes

Conclusion
Women with no obstructive CAD and chronic chest pain symptoms should undergo additional evaluation due to their relatively higher risk of adverse CV events . Evaluation might include provocative coronary angiographic assessment for macro and microvascular dysfunction and documentation of atherosclerosis if not evident on coronary angiogram .

Conclusion

These patients should be closely followed and monitored for the development of infarctions , strokes and other vascular events rather than discharged from CCU as non cardiac

Conclusion

Further researches should be aimed at developing risk stratification tools, ideally non invasive, available to practicing physicians