ANVIN SEMARANG 2015

CHEST PAIN :
DIFFERENTIAL DIAGNOSIS and
CLINICAL EVALUATION

Iwan Dakota MD, PhD , FACC, FESC, FSCAI

Vascular Division - Dept.of Cardiology and Vascular Medicine
Faculty of Medicine, University of Indonesia
 CASE 1
• Laki2, 42 thm mrs dgn keluhan rasa berat di
dada saat nonton TV, sesak timbul tiba-tiba,
keringat dingin(-), penjalaran (-). 2 minggu
sebelumnya, kaki kanan os bengkak dan 1 hari
sebelum masuk rumah sakit, kaki os diurut
oleh tukang urut. Di UGD: kesadaran
menurun, TD 80/50, HR 100x/m, Aksenstuasi
bunyi jantung 2 (P2) mengeras. saturasi 02 yg
dipasang dijari 80%, ECG tidak terdapat ST
elevasi.
ECG
• Lab : CK dan MB masih dalam batas normal,
Trop T (-), D Dimer 2500, L 9000.
• CXR : CTR 50%, tidak terdapat tanda
bendungan paru, lain-lain dbn
• Tak berapa lama kemudian kondisi memburuk,
TD tidak teraba, saturasi bertambah turun dan
EKG monitor: bradikardi, dilakukan CPR 30
menit tidak berhasil, pasien dinyatakan
meninggal.
 Apa diagnosis yang paling mungkin ?
a. Acute Anterior MI (STEMI anterior)
b. Acute Inferior MI (STEMI Inferior)
c. Acute Lung Oedema (ALO)
d. Acute Massive Pulmonary Emboli
e. Acute Aorta Dissection
 Case 2
• Perempuan, 62 th, mrs dgn keluhan sakit di
punggung6 jam smrs, seperti tersayat dan
menjalar ke belikat.Pasen dikenal dengan
hipertensi sejak 10 th berobat tdk teratur, riwayat
merokok, kolesterol tinggi.
• Saat di UGD : CM, masih kesakitan, TD 160/100
(lengan kanan) dan 130/80 (lengan kiri), HR
90x/m, EKG dgn SR, ST depresi 1-2mm di I, aVL,
V5-V6 . CK dan MB dbn, Trop T (-) .D dimer 2400.
• Setelah diberikan isdn tablet sampai 3 tablet SL
sakit di punggung tidak berkurang. Obat
clopidogrel, aspirin diberikan dan sakit tidak
berkurang dan bertambah nyeri.

• Lalu dilakukan kateterisasi jantung namun susah

untuk memasukan kateter dan mengkanulasi
arteri koroner
• Foto toraks menunjukan mediastinum melebar
seperti gambar berikut
Chest X-Ray
Apa diagnosis yang paling mungkin utk
pasien ini?
A. Acute Anterior MI (STEMI Anterior)
B. Acute Antero lateral MI (STEMI antero-lateral)
C. Acute Aortic Dissection
D. Acute Pulmonary Embolism
E. Acute Pericarditis
 Case 3
• Laki2/53th. Keluhan sakit dada sejak 4 jam
smrs, menjalar ke leher dan lengan kiri,
keringat dingin(+), nyeri timbul saat os
memindahkan koper ke lantai atas.
• FR : merokok dan hipertensi.
• Saat di UGD : sakit dada masih ada, berkurang
setelah diberikan isdn sublingual, CK 130 MB
66, Trop (+), L 13.000
• CXR: CTR<50%, tanda bendungan (-), lain2 dbn
 Apa diagnosis anda?
A. Acute Anterior MI (STEMI anterior)
B. Acute Non-STEMI
C. Unstable Angina Pectoris (UAP)
D. Acute Aorta Dissection
E. Acute Pulmonary Embolism
 So, what are the crucial things?
• Acute Coronary Syndrome/Myocardial
infarction
• Pulmonary embolus
• Aortic dissection

*All of these could lead to sudden death*

 Stepwise Approach

1. “Rule in” acute myocardial infarct or unstable

angina instead of ruling out AMI
2. Determine the presence of other acute
cardiovascular or cardiopulmonary conditions,
such as aortic dissection, pulmonary embolism,
pericarditis, etc.
 Stepwise Approach

3. Check whether or not stable coronary artery

disease is present.
4. Identify cardiovascular risk factors.
5. Consider noncardiac diagnoses, which , in
nonurgent cases, can be evaluated further
on an outpatient basis.
 Causes of Chest Pain
1. Angina pectoris/myocardial infarction
2. Other cardiovascular causes
3. Gastro Intestinal
4. Pulmonary
5. Neuro-musculoskletal
6. Psychogenic
Description of Chest Pain
• Location
• Radiation
• Character
• Precipitating factors
• Relieving factors
• Time relationship
(duration, frequency, pattern of recurrence)
• Associated symptoms
How to evaluate the Chest Pain?

1. History taking
2. Physical examination
3. ECG
4. Chest X-ray
5. Serum markers
6. Echocardiography, CT, etc.
 History
• “PQRST”
–Provocative/palliative factors
–Quality: character, duration, frequency,
associated sxs
–Radiation
–Severity
–Timing

•
 Provocation and Palliation
• Postprandial?
GI or cardiac disease • Antacids or food?
Gastro-esophageal origin
• Exertion?
Angina or esophageal pain • Sublingual nitro?
Cardiac
• Cold, emotional stress,
sexual intercourse • Cessation of
can promote ischemic pain activity/rest?
Ischemic origin
• Worse with swallowing?
Esophageal origin
• Sitting up and leaning
• Body position, movement,
forward?
Pericarditis
deep breathing?
Musculoskeletal origin
 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

Location of Ischemic Chest Pain
 Timing:

1. Abrupt onset with greatest intensity in beginning:

PTX, dissection, acute PE
2. Gradual with increasing onset over time: ischemic
3. Crescendo pattern: esophageal disease
4. Lasts for seconds or constant over weeks non
ischemic
5. Circadian rhythm (morning>afternoon) correlating
with increase sympathetic tome- more likely
myocardial ischemia
 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
- Pneumothorax
- Aortic dissection
- Pneumomediastinum
 Factors Provoking Pain

• Ischemic origin • Nonischemic origin

Exercise Pain after completion of
Excitement exercise
Other forms of stress
Provoked by a specific
Cold weather
After meals
body motion
 Angina Pectoris
1. Quality :
→ unpleasant sensation described as:
“pressing”,
“squeezing”
“strangling”
“constricting”,
“bursting” and “burning”
→ “a band across the chest”, “a weight in the center of the
chest
→ Levine’s sign: clenching the fist in front of sternum 2
Anginal equivalents
→ dyspnea
→ discomfort limited to areas of radiation :
Lt. arm, lower jaw, teeth, neck, shoulders
→ development of gas, belching, nausea,
“indigestion”, dizziness, and diaphoresis
 Chest Pain in Acute MI

• Occurs at rest or with less activity than usual

• More severe than angina, sometimes intolerable
• Prolonged duration (> 30min)
• Not relieved by rest or NTG
• Persistent pain : marker for ongoing ischemia
• Without chest pain (silent): old age, DM
→ Sx of acute LV failure, marked weakness, syncope
→ accompanied by diaphoresis, nausea & vomiting
Aortic Dissection

1. Pain character
- sudden onset
- severe, agonizing, unbearable pain
- maximal severity at onset
- “tearing”, “ripping”, “stabbing”, etc.
- tendency to migrate (70%)
- location
anterior only : ascending aorta
(90%)
interscapular only : descending
aorta (90%)
 Aortic Dissection
2. Associated symptoms
- CHF, syncope, CVA, ischemic peripheral neuropathy, and cardiac
arrest
3. Physical findings
- hypertension : 80-90% (distal )
- hypotension : proximal
- “pseudohypotension” : occlusion of brachial a.
- pulse deficits, AR murmur, neurologic signs, symptoms of
peripheral vascular complications
 Aortic Dissection

4. Chest X-ray
- widening of the aortic silhouette (81-90%)
- nonspecific widening of the superior mediastinum
- “calcium sign”
- pleural effusions, mostly left-sided
5. ECG
- 1/3 : LVH, 1/3 : normal
- ischemic ST or T changes : involvement of
coronary arteries
 Aortic Dissection
6. Echo
a. TTE : sensitivity (59-85%), specificity (78-100%)
→ sensitivity : ascending aorta (78-100%)
descending aorta (31-55%)
b. TEE : sensitivity (98-99%), specificity (77-97%)
→ detection of intimal flap : sensitivity (73%)
→ limited visualization of the distal ascending
aorta and proximal arch
7. CT (contrast-enhanced)
- sensitivity (83-94%), specificity (87-100%)
- identification of intimal flap: 2/3 of cases
Echo Images of Aortic Dissection

TTE TEE
Classic Type B aortic dissection.
Entry is not clearly depicted but
might be located around
calcification(arrow).
There might be multiple re-entries in
DTA, and abdominal aorta.
 Pulmonary Embolism:
Presentation
• Presentation variable
• Suspect in any patient c/o new or worsening
dyspnea, chest pain or prolonged hypotension
without obvious etiology
• PIOPED II (Am J Med. 2007 Oct;120(10):871-9)
– Symptoms: dyspnea (sec. to min) > pleuritic chest
pain > cough
– Signs: tachypnea > tachycardia > rales > loud P2
 Clinical Syndromes of Acute PE
• Massive PE
→ cardiogenic shock, dyspnea
• Moderate to large PE
→ RV hypokinesis on Echo, but normal BP
→ lung perfusion defect > 30%
• Small to moderate PE
→ normal BP, normal RV function
• Pulmonary Infarction
→ unremitting chest pain, occasionally hemoptysis
→ involvement of peripheral pulm. arterial tree
near the pleura and diaphragm
→ occurs 3 to 7 days after embolism
→ fever, leukocytosis, CXR findings
 Noni-maging Diagnostic Methods
1. Plasma D-Dimer ELISA
→ 90% sensitivity (>500)
→ false positive : postop, MI, sepsis, acute
systemic illness
2. ABG : nondiagnostic
→ Normal alveolar-arterial O2 gradient cannot
exclude acute PE.
3. ECG
→ rapid detection of right-heart strain due to large
PE
ECG Findings in Pulmonary Embolism
• Incomplete or complete RBBB
• S in Lead I and aVL > 1.5 mm
• Transition zone shift to V5
• Qs in leads III and aVF, but not in Lead II
• QRS axis > 90° or intermediate axis
• Low limb lead voltage
• T-wave inversion in leads III and aVF or in leads V1-
V4
ECG
ECG Findings in Pulmonary Embolism
(II)

Sl - Q3 - T3
 Imaging Diagnostic Methods

1. Chest X-ray :
- near-normal radiograph in the setting of severe
respiratory compromise
- Westermark’s sign: focal oligemia (uncommon)
- Hampton’s hump: peripheral wedge-shaped
density above the diaphragm
- prominent pulmonary artery
- cardiomegaly
2. Echo :
 Echographic Signs of PE
• Direct visualization of thrombus (rare)
• RV dilatation
• RV hypokinesis (with sparing of the apex)
• Abnormal interventricular septal motion
• Tricuspid valve regurgitation
• Pulmonary artery dilatation
• Lack of decreased inspiratory collapse of inferior
vena cava
 Imaging Diagnostic Methods
3. Venous Ultrasonography
4. Contrast Phlebography
5. Lung scanning (Perfusion/Ventilation)
6. Spiral CT, MRI
7. Pulmonary angiography
 CONCLUSIONS
• Chest Pain might be caused by Cardiac or non
cardiac origin
• Life threatened chest pain including : acute
MI, aortic dissection, acute pulmonary
embolism must be well known by all
physicians
• History of illness, proper physical examination,
lab finding and imaging modalities is crucial in
diagnosing life threatening chest pain
56th World Congress of
International College Of Angiology &
7th National Symposium of Vascular Medicine