1.D.Basem elsaid enany Lecturer of cardiology Ainshams university

2. Acute coronary syndrome History: Substernal/left sided chest pressure or tightness is common Onset is gradual Pain radiating to shoulders or pain with exertion increases relative risk "Atypical" symptoms (eg, dyspnea, weakness) more common in elderly, women, diabetics 3. Examination: Nonspecific May detect signs of HF 4. ECG: ST segment elevations, Q waves, new left bundle branch block are evidence of AMI Single ECG is not sensitive for ACS Prominent R waves with ST segment depressions in V1 and V2 strongly suggests posterior AMI 5. Chest x ray: Nonspecific May show evidence of HF 6. Additional tests: Troponin and/or CK-MB elevations diagnose AMI Single set of biomarkers is not sufficiently sensitive to rule out AMI 7. Additional data: Assume symptoms of ACS within days or a few weeks of PCI or CABG is from an occluded artery or graft 8. Aortic dissection History: Sudden onset of sharp, tearing, or ripping pain Maximal severity at onset Most often begins in chest, can begin in back Can mimic: stroke, ACS, mesenteric ischemia, kidney stone 9. Examination: Absent upper extremity or carotid pulse is suggestive Discrepancy in systolic BP >20 mmHg between right and left upper extremity is suggestive Up to 30 % with neurologic findings Findings vary with arteries affected 10. ECG: Ischemic changes in 15 % Nonspecific ST and T changes in 30 % 11. Chest X ray: Wide mediastinum or loss of normal aortic knob contour is common (up to 76 %) 10 % have normal CXR Additional tests: TEE, MSCT 12. Additional data: Can mimic many diseases depending on branch arteries involved (eg, AMI, stroke) 13. Pulmonary embolism History: Many possible presentations, including pleuritic pain and painless dyspnea Often sudden onset Dyspnea often dominant feature 14. Examiantion: No finding is sensitive or specific Extremity exam generally normal Lung exam generally nonspecific; focal wheezing may be present; tachypnea is common 15. ECG: Usually abnormal but nonspecific Signs of right heart strain suggestive (eg, RAD, RBBB, RAE, sinus tachycardia) 16. Chest X ray: Great majority are normal May show: atelectasis, elevated hemidiaphragm, pleural effusion 17. Additional tests: A high-sensitivity D-dimer is useful to rule out PE only when negative in low-risk patients Echo: RV dilatation, hypokinesia, may see embolus in PA MSCT 18. Tension pneumothorax History: Often sudden onset Initial pain often sharp and pleuritic Dyspnea often dominant feature 19. Examiantion: Ipsilateral diminished or absent breath sounds Subcutaneous emphysema is uncommon 20. Chest X ray: Demonstrates air in pleural space 21. Pericarditis: History: Pain from pericarditis is most often sharp anterior chest pain made worse by inspiration or lying supine and relieved by sitting forward Dyspnea is common 22. Examination: Severe tamponade creates obstructive shock, and causes jugular venous distension, pulsus paradoxus Pericarditis can cause friction rub 23. ECG: Decreased voltage and electrical alternans can appear with significant effusions Diffuse PR segment depressions and/or ST segment elevations can appear with acute pericarditis 24. Chest X ray: May reveal enlarged heart 25. Additional investigation: Ultrasound reveals pericardial effusion with tamponade 26. Mediastinitis History: Forceful vomiting often precedes esophageal rupture Recent upper endoscopy or instrumentation increases risk of perforation Coexistent respiratory and gastrointestinal complaints may occur 27. Examiantion: Ill-appearing; shock, fever May hear (Hamman's) crunch over mediastinum 28. Chest X ray: Large majority have some abnormality: pneumomediastinum, pleural effusion, pneumothorax 29. Noninvasive stress testing is best indicated in patients with an intermediate pretest probability of disease. The addition of an imaging modality to stress is best indicated in patients in whom an exercise ECG will be nondiagnostic for ischemia, eg, LBBB, ventricular pacing, greater than 1 mm of resting ST segment depression. A man over the age 40 and a woman over the age of 60 with typical angina have a high pretest probability for coronary disease and all things being equal should be referred for coronary angiography directly for the diagnosis. A 50-year-old asymptomatic woman has a very low pretest probability for disease and does not warrant further investigation. A 45-year-old woman with a history of atypical chest pain also has a low pre-test probability of disease and may not require a stress test. With a normal resting ECG a stress ECG would be the preferred initial modality. Despite her young age, the symptoms of typical angina, even in a 30-year-old woman, place her at an intermediate risk of coronary disease, increased further by the presence of resting ST segment depression. Given that she would have a nondiagnostic stress ECG a stress imaging study is appropriate. 30. -Thallium and technetium are the two most commonly used isotopes in Nuclear Cardiology tests. Technetium has a higher energy, less radiation danger as better penetration -Sestamibi no redistribution after 24 h , not used in viability 31. What are some of the common causes of chest pain that can be identified on a chest radiograph? Aortic dissection Pneumonia Pneumothorax Pulmonary embolism Subcutaneous emphysema Pericarditis (if a large pericardial effusion is suggested by the radiograph) Esophageal rupture Hiatal hernia 32. Thank you.