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Siska S. Danny, MD
siskadanny@yahoo.com
Chest Pain
Common complaint in Emergency Unit
In the US: 5% of all ED visits or 5 million visits per
year
Wide range of etiologies
Cardiac, Pulmonary, GI, Musculoskeletal
Why does distinguishing these causes matter?
How do you distinguish causes of chest pain?
So
you attend to a 67 yo male complaining of a sudden
pain in the chest and epigastric area. He is also
complaining of shortness of breath and nausea, with
no previous cardiac history but confesses of being a
heavy smoker, had uncontrolled hypertension and
recurrent dyspeptic complaints usually alleviated by
antacids
Braunwald E : Clinical recognition of acute coronary syndromes. In Theroux P. Acute coronary syndrome: a companion to
Braunwalds Heart Diseases, 2nd ed. Philadelphia, Elsevier Saunders, 2011, pp 99.
History matters!
Onset ANGINA
Provocation VS
Quality ATYPICAL CHEST PAIN
Radiation
Severity
STABLE ANGINA VS
Time UNSTABLE ANGINA/ACS
CHEST PAIN IN ACS
ONSET: Could be sudden or gradual acute chest pain. In
determining onset for STEMI, pinpoint the time of most
severe pain
PROVOCATION: Exercise/physical activity or even occurred
at rest
QUALITY: Diffuse, steady substernal chest pain. Other
sensations include a crushing and squeezing feeling in the
chest
SEVERITY: pain may be severe; not relieved by rest or
sublingual vasodilator therapy, requires opioids.
TIME/DURATION: pain continues for more than 15 minutes
Location: variable, but often pain resides behind upper or
middle third of sternum.
Radiation: pain may radiate to the arms (commonly the
left), and to the shoulders, neck, back, or jaw
Associated manifestations: anxiety, diaphoresis, cool
clammy skin, facial pallor, hypertension or hypotension,
bradycardia or tachycardia, palpitations, dyspnea,
disorientation, confusion, restlessness, fainting, nausea
and vomiting
Atypical presentation of ACS
Sometimes chest pain is not very obvious but
patient complain of epigastric pain or
abdominal distress, dull aching or tingling
sensation, shortness of breath, dyspnea and
extreme fatigue
Atypical presentation is more frequent in old
individuals (>75 yo), female, diabetes, chronic
kidney disease or patients with dementia
Non angina chest pain: Characteristic clues
NO
Streptokinase 1.5
million units in 100 cc
Dextrose 5% was given Start
over 60ESC
min fibrinolysis
STEMI Guidelines 2008
Chest pain
resolved and ST
segment elevation
almost returned
to baseline
SUCCESSFUL
FIBRINOLYSIS
.so you thought youre done for the day, but
here comes another patient
TIMES UP
Thank you