Non Cardiac Chest Pain or Angina like Chest Pain. Wafaa El-Aroussy, MD Prof of Cardiovascular Medicine Cardiology Department Cairo University
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1 Non Cardiac Chest Pain or Angina like Chest Pain By Wafaa El-Aroussy, MD Prof of Cardiovascular Medicine Cardiology Department Cairo University
2 Prevalence of CP 7-11 % in primary practice 25% in a life time % NCCP
3 Evaluation of NCCP Patient age F. H. Risk for CAD (HTN-HLP-DM-Smoking) Laboratory: ECG Stress echo Echocardiography Scintigraphy Coronary angio. Careful History Taking
4 Evaluation of CP in ED 6 hour- rule out protocol Symptom resolution Normal cardiac enzymes Stable ECG pattern Graded ex. Tolerance test NO abnormalities suggestive myocardial ischemia Patient is told CP is Unrelated to CAD DISCHARGE NCCP
5 NCCP Psychogenic Skin Musculoskeletal GIT Pulmonary - Herbes Zoster - Mondor - Tietze s syndrome -Chest wall - Thoracic outlet - Esophagus - Peptic - Colon - Gall Bladder Parenchyma Vaculature pleura -P E -P I -Spont pneumothorax - Mediastinal
6 NCCP Neuromusculoskeletal Disorders Localized Presentation Anterior Chest wall Deep within chest cavity May radiate Tests few min to hours
7 NCCP Neuromusculoskeletal Disorders Thoracic outlet syndrome Tietze s syndrome Degenerative arthritis Herpes Zoster
8 NCCP Neuro Musculo Skeletal Disorders Band like associated with parasthesia Unrelated to physical exercise Aggravates by certain body position Not relieved by nitroglycerine Local tenderness, relief by lidocaine
9 NCCP Neuromusculoskeletal Disorders * Chest wall syndrome: Costochondritis 15% Fibromyalgia 30% Fibrositis 30%
10 G I T Oesophagus Stomach Dueodenum Small Intestine Gall Bladder Peptic Ulcer Duodernal Ulcer Spastic Colon Distension Cholecystitis - Oesophageal motility disorders - Gastroesophageal reflux disease GERD - Abnormal isceral nociception
11 Gastrointestinal Causes of NCCP Esophageal motility disorders Esopageal spasm Reflux esophagitis Acute esophageal rupture or others organs Peptic ulcer Biliary colic
12 Esophageal Disorders Relation to meals CP associated with swallowing/ heartburn / regurgitation / dysphagia / odynophagia / epigastric pain Precipitated with extremely hot or cold drinks or emotional upset. Antacids relief
13 Esophageal Disorders Esophageal motility disorders: Achalasia Food impaction
14 G I T Causes Esophageal Disorders Important / large role in NCCP 12% (ph & motor dysfunction) 29% (abn. Acid exposure) [25-60%]
15 Screening & Evaluation for Esophageal Disorders NOTE!!! * Diagnosis of diffuse esophageal spasm is based on:- # History # Exclusion of musculoskeletal causes, # Abnormal motility /manometry
16 Screening & Evaluation for Esophageal Disorders - NOTE!!! * 11% with esophageal cause have NO other esophageal symptoms. * Absence of other esophageal symptoms should not necessarily preclude further evaluation.
17 Pulmonary Disorders Vaculature LUNGS Postpartum/operative Blood Dyspnea PHgases PLEURA Long Vent/perf Tachycardia TR tripsscan CHF Pulmangio Cyanosis RtHF DVT Anxiety / Aggitation Pul. Embolism
18 Pulmonary Disorders Acute agonizing Unilateral LUNGS Pleuritic Severe SOB Young, 30-40y Plain x ray PLEURA Pneumothorax
19 Pulmonary Disorders LUNGS Parenchyma Pneumonia Sharp discomfort variable e respiration shallow breathing Cough / expectoration/hemoptysis
20 NCCP Psychiatric Disorders Panic Disorders Depression Quite common 17.5 % 23.1% panic disorders depression
21 Psychiatric Disorders Anxiety Sharp localized Stabbing Left inframammary Short less than 1 min - days Not related to effort Associated multiple complaints
22 Evaluating NCCP * Screen Psychiatric Disorders: Self administered checklist Derived from Prime MD patient Problem questionnaire Based on criteria from the Diagnostic & Statistical Manual of Mental Disorders 4 th edition (DSM-IV) Similar questionnaire for depression disorders.
23 CONCLUSIONS Evaluating NCCP Exclude CAD Exclude neuromusculoskeletal causes Screen evolution for esophageal disorders Screen psychiatric disorders
24 Natural History of NCCP - Excellent prognosis - Activities need not be limited Ockene et al, % limited activities 51% unable to work 44% believe they ve heart disease
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