Chest Pain

Prof. Idrus Alwi MD, PhD

Division of Cardiology,
Department of Internal Medicine,
Faculty of Medicine,
University of Indonesia

Chest pain yang ke IGD : 11-39 % PJK

Eslick et al. Med J Aust.2000;173:233-4

Atypical chest pain : 49-60 % semua kunjungan

karena chest pain
Capewell S et al. BMJ 2000;320:951-2

Prevalensi Non Cardiac Chest Pain (NCCP)

pada populasi 23,1 %
Van Handel et al. J Gastroenterol Hepatol 2005;20:S6-S13

Gastroesophageal reflux disease (GERD)

merupakan penyebab tersering
Non Cardiac Chest Pain (NCCP) : sampai 60 %
Richter. J Clin Gastroenterol 2000;30(Suppl):S39-S41

Type of Health Care Professional Consulted for Chest Pain

Eslick & Talley. Aliment Pharmacol Ther 2004;20:909-15

ACC/AHA Guideline
Typical angina
1. Retrosternal chest dyscomfort experienced as
pressure or heaviness that lasts several
minutes;
2. Which is induced by exertion, emotion; and
3. Is relieved by rest or nitroglycerin.
Any two of these clinical characteristics are
suggestive of atypical angina
One or none is indicative for Non Cardiac Chest
Pain (NCCP)
Braunwald et al. ACC/AHA Guideline. J Am Coll Cardiol 2000;36:970

Noncardiac Chest Pain

(NCCP)
Terminologi :
unexplained chest pain, esophageal chest pain
Nyeri dada seperti angina berulang atau nyeri
dada substernal yang tidak berhubungan
dengan jantung setelah dilakukan
evaluasi jantung.
Fang et al. Am J Gastroenterol 2001;96:958-68

Cardiac Causes of Chest Pain

Ischemic
Angina
Myocardial infarction
Aortic stenosis
Hypertrophic cardiomyopathy
Coronary vasospasme
Non Ischemic
Pericarditis
Aortic dissection
Mitral valve prolapse
Karnath et al. Hospital Physician 2004;38:24-7

Atypical Chest Pain

(Not Characteristic of Myocardial Ischemia)
Pleuritic pain (i.e, sharp or knife-like pain brought on by
respiratory movements or cough)
Primary or sole location of discomfort in the middle or
lower abdominal region
Pain that may be localized at the tip of one finger,
particularly over the left ventricular apex
Pain reproduced with movement or palpation of the
chest wall or arms
Constant pain that persists for many hours
Very brief episodes of pain that last a few seconds or
less
Pain that radiates into the lower extremities
Braunwald et al. ACC/AHA Guideline. J Am Coll Cardiol 2000;36:970

Noncardiac Chest Pain

Pericardial/
pulmonary causes
Musculoskeletal
causes

Psychological/ comorbidity (anxiety,

depression, etc.)

Esophageal dysmotility
(nutcracker esophagus, *DES, hypertensive lower esophageal
sphincter, etc.)

Gastric / biliary
causes
Psychological causes
(panic disorder)

Esophageal

Gastroesophageal
reflux disease
(primarily nonerosive reflux
disease)

Functional chest pain

of presumed esophageal origin (visceral
hyperalgesia)

Wong et al. Gastroenterol Hepatol 2004;19:S33-43

Diagnosis Banding Non Cardiac Chest Pain

Kachintorn U. J Gastroenterol Hepatol 2005;20:S2-S5

Age Distribution of Cardiac (CCP) and Non Cardiac Chest Pain (NCCP) Patients

Eslick & Talley. Aliment Pharmacol Ther 2004;20:909-15

EXCLUDE Coronary artery disease and

other life-threatening conditions

So, what are those?

Acute Coronary Syndrome

Pulmonary embolus
Aortic dissection
Tension Pneumothorax

*All of these could lead to sudden death*

History
PQRST
Provocative/palliative factors
Quality: character, duration, frequency, associated sxs
Radiation

Severity
Timing
Risk factors: age, tobacco use, family history,
DM/HTN/Lipids, cocaine; other- DVT/PE,
Marfans/Pregnancy, NSAIDS
Past Medical Hx: prior CV w/u & Rx, GI history

Provocation and Palliation

Postprandial? GI or cardiac
disease

Antacids or food? Gastroesophageal origin

Exertion? Angina or
esophageal pain

Sublingual nitro? Esophageal

or cardiac

Cold, emotional stress, sexual

intercourse can promote
ischemic pain

GI Cocktail (viscous lidocaine

and antacid)? GI or cardiac

Worse with swallowing?

Esophageal origin
Body position, movement,
deep breathing?
Musculoskeletal origin

Cessation of activity/rest?
Ischemic origin
Sitting up and leaning forward?
Pericarditis

Bennett. BMJ 2001;323:791-4

Presentasi Gejala yang Berbeda pada

Pasien NCCP yang Sama atau Pasien yang Berbeda

NCCP terkait GERD :

70 % terkait gejala refluks
( heartburn dan regurgitasi
asam )

Faybush et al. Gastroenterol Clin North Am 2004;33:41-54

Evaluation
Region or location:
Radiation to neck, throat, lower jaw, teeth, upper extremity, or
shoulder
Radiation to arms is useful and stronger predictor of acute MI
Between scapulae think aortic dissection

Larger areas of discomfort more likely ischemic etiology

Severity: not useful predictor for presence of CAD

Timing:
Abrupt onset with greatest intensity in beginning: PTX, dissection,
acute PE
Gradual with increasing onset over time: ischemic
Crescendo pattern: esophageal disease
Lasts for seconds or constant over weeks ischemic
Circadian rhythm (morning>afternoon) correlating with increase
sympathetic tome- more likely myocardial ischemia

Associated Symptoms
Belching, bad taste in mouth, dysphagia or odynaphagia
esophageal disease
Vomiting Transmural MI, GI problems

Diaphoresis MI> esphoageal disease

Syncope dissection, PE, critical AS, ruptured AAA
Presyncope myocardia ischemia
Palpitations in setting of new A. Fib + chest pain PE
Fatigue can be presenting complaint of MI esp. in elderly

Any exam findings that might help distinguish

cardiac from non cardiac chest pain?
General Appearance
may suggest seriousness
of symptoms.

Vital signs
marked difference in blood
pressure between arms
suggests aortic dissection

Palpate the chest wall

Hyperesthesia may be due
to herpes zoster

Complete cardiac
examination
pericardial rub
signs of acute AI or AS
Ischemia may result in MI
murmur, S4 or S3

Determine if breath
sounds are symmetric
and if wheezes, crackles
or evidence of
consolidation

Ancillary Studies
EKG
Normal reduces probability chest pain is due to AMI, but
does NOT exclude serious cardiac etiology
(i.e. Unstable Angina)
ST elevation, ST depression, or new Q waves- important
predictor of Acute Coronary Syndrome (AMI or UA)
Nonspecific ST and T wave changes is common- may or
may not indicate heart disease

CXR
Useful in acute setting to avoid missing dangerous diagnoses
(e.g. Pneumothorax, Aortic dissection, Pneumomediastinum)

EKG Infark Miokard Akut dengan Elevasi ST

( STEMI )

EKG Infark Miokard Akut Non ST Elevasi

( NSTEMI )

Likelihood Ratio
Likelihood ratio expresses the odds that a
given level of a diagnostic test result would
be expected in a patient with (as opposed
to without) the target disorder
Sacket, et al. Clinical Epidemiology

Features Increasing Likelihood

of AMI
Clinical Feature

Likelihood Ratio (95% CI)

Pain in chest or left arm

2.7

Chest pain radiation

Right Shoulder

2.9 (1.4-6.0)

Left arm

2.3 (1.7-3.1)

Both left and right arm

7.1 (3.6-14.2)

Chest pain most important symptom 2.0

History of MI

1.5-3.0

Nausea or vomiting

1.9 (1.7-2.3)

Diaphoresis

2.0 (1.9-2.2)

Third heart sound

3.2 (1.6-6.5)

Hypotension (SBP<80)

3.1 (1.8-5.2)

Pulmonary rales on exam

2.1 (1.4-3.1)

Features Decreasing Likelihood

of AMI
Clinical Feature

Likelihood Ratio (95% CI)

Pleuritic chest pain

0.2 (0.2-0.3)

Chest pain sharp or stabbing

0.3 (0.2-0.5)

Positional chest pain

0.3 (0.2-0.4)

Chest pain reproduced with palpation

0.2-0.4

Panju, et al. JAMA 1998;280:14:1256-1263

ECG Findings Increasing

Likelihood of AMI

Panju, et al. JAMA 1998;280:14:1256-1263

High likelihood of ACS

Worsening frequency, intensity, duration, timing
(e.g. nocturnal pain, rest pain) of prior angina
New onset SOB, nausea, sweating, extreme
fatigue in patient with known h/o CVD
Onset of typical anginal symptoms in pt without
h/o CVD
New murmur (or worsening of previously noted
murmur), hypotension, diaphoresis, rales,
pulmonary edema
Transient ST deviation ( 1mm) or TWI in multiple
precordial leads

Choices for Proceeding with Patients with Chest Pain and Normal ECG

Bennett. BMJ 2001;323:791-4

Exclude cardiac disease

Normal EKG, ECHO, stress tests
and coronary angiogram

Ischemic ST waves or
abnormal LV function with
exercise

Noncardiac causes

Esophageal

Musculoskeletal

Consider microvascular
angina i.e. Syndrome X

Psychologic

Empiric BID PPI trial

No Response

Response

24 hour pH testing with

symptom analysis
Normal pH
Empiric therapy for
visceral hyperalgesia with
TCA

Continue as
maintenance Rx
Abnormal pH
Increase
antisecretory
therapy

Lock for trigger

points &
reproducible chest
pain

Anti-inflammatory
and local therapies

Rule out panic

disorder, depression

Self limited prescription

for benzodiazepine and
referral to mental health
for PD

No Response
Esophageal manometry
with provocative testing

Consider Ca Channel blocker

if hypercontractile EMD found

Algorithm for the Approach to

Unexplained Chest Pain
Fang et al..Am J Gastroenterol 2001;96:958-68

Thank You