Chest Pain

Acute Chest Pain 急性胸 痛 DR.LIU LIXIN

Decision-making on Acute Chest pain at Early Stage

早期识别高危胸痛 ♦ Recognize the dangerous of acute chest pain,

especially with those life-threatening ♦ 识别胸 痛的危 险程 度 , 特别 是威胁 生命 的胸 痛 ♦ Establish pain management center to offer a comprehensive range of services for patients with treatment on acute chest pain. ♦ 国外建立疼痛中心建立一系列胸痛诊疗程序

High-risk Chest Pain 急诊常见的高危胸痛 ♦ Cardiogenic pain:Acute

Coronary Syndrome （ UAP 、 AMI) ♦ 高危心源性疼痛 ：急性冠脉 综合征 ♦ Non-cardiogenic pain:aortic dissection, pulmonary embolism and tension pneumothorax ♦ 高危非心源性疼 痛：主动脉 夹层、肺 栓塞、张力性气 胸

Diagnosis on Acute Chest Pain 急性胸痛诊断思路 ♦ Medical history, physical examination ,

laboratory examination and special examination and tests (ECG 、 Chest X-ray 、 enzymology) 病史、 体格 检查、 辅助 检查（ EKG 、 胸片、 酶学等 ） ♦ chest pain division (Cardiogenic and Non cardiogenic) 区分 胸痛系 心源 性或非 心源 性 ♦ Judgement the risk degree 判断 危险度

characteristics of chest pain 有助于胸痛的诊断和鉴别诊断的特点 ♦ Location of pain 疼痛的 部位 :retrosternal, substernal ♦ Quality 疼痛的 性质 : pressure, tightness,

sharp,pleuritic,burning ♦ Duration, aggravation and alleviation of pain 疼痛 的 时间及 影响 因素、 缓解 因素 , exertion, cold, psychologic stress, nitroglycerin ♦ Simultaneous symptoms of pain 疼痛的 伴随症 状 ♦ Previous medical history 既往史

location of chest pain 胸痛的部位 ♦ Angina Pectoris and acute myocardial infarction

are usually retrosternal. most patients do not localize the pain to any small area. They are typically described as tightness, pressure, or squeezing. Pain may radiate to the jaw, neck, arms, back, and epigastria. The left arm is affected more frequently. 心绞痛 与急性 心肌 梗死的 疼痛常 位于 胸骨后 或心 前区， 且放 射到左 肩和左 上臂 内侧。

♦ The pain of esophageal disease, mediastinal

hernia and mediastinal tumer is also a retrosternal . 食管疾患、隔疝 、纵隔肿 瘤的疼痛也位于 胸骨后。 ♦ spontaneous pneumothorax, acute pleuritis and pulmonary embolism et.al often unilateral and pleuritic. 自发性 气胸、急 性胸膜炎、肺栓 塞等常呈患 侧的剧烈 胸痛。

Quality of Chest Pain 胸痛的性 ♦ Intercostal neuralgia causes paroxysmal burning

pain or pricking pain. 肋间神经 痛呈 阵发性 的 灼痛或 刺痛。 ♦ Myosalgia often occurs with aching pain. 肌痛 则 常呈酸 痛； ♦ Ostalgia occurs with aching pain or boring pain 骨 痛呈酸 痛或锥 痛； ♦ Esophagitis and diaphragmatocele often occurs with burning pain or heatburn 食管炎 、膈疝 常 呈灼痛 或灼热 感；

Quality of Chest Pain 胸痛的性质 ♦ Angina Pectoris or myocardial infarction is

usually described as a heaviness, pressure, or squeezing 心绞痛 或心 肌梗死 常呈 压榨样 痛 并常伴 有压迫 感或 窒息感 。 ♦ Borning pain is caused by the erosion of aneurysm of aorta when it corrodes chest pain 主动脉瘤 侵 蚀胸壁 时呈锥 痛。 ♦ The chest suffocation can be diagnosed by primarily lung cancer or mediastinal mass 原发 性肺癌 、纵隔 肿瘤 可有胸 部闷 痛。

Associated features 影响胸痛的因素 ♦ Angina Pectoris is often indused by tension.

It can be released by taking nitroglycerin tablets. Myocardial infarction can be indentified with continuing pain which is not to be released by taking nitroglycerin tablets. 心绞痛常于用力或精神紧张时诱 发，呈阵发性，含服硝酸甘油片迅速缓 解；心肌梗死常呈持续性剧痛，虽含服 硝酸甘油片仍不缓解

♦ Cardiac neurosis is often the reason of chest

pain. It can be relieved by movement. 心脏 神经官能症所致胸痛则常因运动反而好 转 ♦ The chest pain of pleurisy, pneumothorax, and pericarditis can often be exacerbated by cough or deep breathing 胸膜炎、自发性 气胸、心包炎的胸痛常因咳嗽或深呼吸 而加剧

Associated features 影响胸痛的因素 ♦ Neuromusculoskeletal Conditions: Direct pressure

on the chondrosternal and costochondral junctions may reproduce the pain from these and other musculoskeletal syndromes. It is intensified by thoracic activity; Esophageal diseases is often exacerbated by swallowing food 胸壁疾病所致的胸痛常于局部压迫或胸廓活动时 加剧；食管疾病的胸痛常于吞咽食物时发作或 加剧

Simultaneous phenomenon of chest pain 胸痛的伴随症状 Cough: trachea, bronchi and pleural diseases ♦ 胸痛常伴咳嗽： 气管、支气管、胸膜疾 病所致。 ♦ Dysphagia: diseases of esophageal and mediastinum ♦ 胸痛常伴吞咽困 难：食管、纵隔疾病所 致的

♦ Hemoptysis:

tuberculosis, pulmonary embolism and primary lung cancer. ♦ 胸痛常伴有咯血 ：肺结核、肺栓塞、原 发性肺癌。 ♦ Sneeze: thoracic vertebra disease ♦ 胸痛常伴有深吸气或打喷嚏加重： 胸椎 病变

Simultaneous phenomenon of chest pain 胸痛的伴随症状 ♦ Hypertention and/or history of coronary

heart disease: angina pectoris, myocardial infarction ♦ 胸痛常伴有高血 压和 ( 或 ) 冠心病 史 ：心绞痛、心肌梗死

♦ Dyspnea:

pneumonia, pneumothorax, pleurisy, pulmonary embolism and hyperventilation syndrome, etc. ♦ 胸痛常伴有呼吸 困难： 肺炎、气胸、 胸膜炎、肺栓塞、过度换气综合征等 ♦ Abatement position: cardiopericarditis:sitting up and leaning forward; esophageal hiatal hernia: erect position ♦ 胸痛常伴有特定 体位缓解： 心包炎－ 坐位及前倾位；食管裂孔疝－立位

Simultaneous phenomenon of chest pain 胸痛的伴随症状 ♦ Onset suddenly: thoracic organ rupture is

conclued by the symptoms of rapid severe chest pain.such an dissection of aorta, aerothorax,and mediastinal emphysema etc. ♦ 胸痛伴起病急剧 ，胸痛迅速达高峰，往 往提示胸腔脏器破裂，如主动脉夹层、 气胸、纵隔气肿等

♦ Haemodynamics: fatal symptoms are

appeared as hypotension/venous engorgement such as pericardial tamponade, acute myocardial infarction ， severe pulmonary embolism , dissection of aorta ♦ 胸痛伴血流动力 学异常 －低血压／及 静脉怒张则提示致命性胸痛（心包填塞 、急性心肌梗塞、巨大肺栓塞、主动脉 夹层）

Evaluation Cardiogenic Chest Pain 心源性胸痛的急诊评价方法 ♦ History and physical examination

病史、查体 ♦ 12 Leads-ECG (Dynamic Observation)myocardial ischemia (30%) increase ST 12 导 ECG( 动态观察 )--- 心肌缺血 (30%)ST 抬高

♦ Chest pain without typical ECG change:

serum myocardium maker\ treadmill exercise \ UCG \ nuclear cardiology (Nonabnormal 50% AMI during the diagnose of 20%AMI) – dynamic oberservation ♦ 对 ECG 无明显变化的胸痛 - 血清标志物 检查 \ 运动平板 \UCG\ 核素检查 (50%AMI 的 ECG 无异常 --- 观察期间 20%AMI)-- 动态观察—易误诊

Evaluation on Cardiogenic Chest Pain 心源性胸痛的急诊评价方法 ♦ Cardiac marker testing

(TNT 、 TNI 、 CPK-MB 、 GOT 、 LDH) ♦ 血清标志物检测 (TNT 、 TNI 、心肌酶 谱) ♦ CTNT forecasts the acute myocardial ischemia ♦ CTNT 是急性心肌缺血独立危险预报因 子

♦ Radionuclide ： myocardial ischemia after

six hours 核素心肌缺血或梗死 6 小时后 ♦ Identified as non-cardiac chest pain if ECG does not change through observation ♦ 若胸痛经动态观察 ECG 等无变化，考虑 非心源性胸痛。

Characters of chest pain in emergency 急诊 常见疾病的 胸痛特点

心绞痛 Angina Pectoris ♦

疼痛部位在胸骨上 , 中段，少数在心前区或剑突下， 放射于左胸、左背、左肩、左上臂前内侧直达无名指 及小指；亦可放射到颈、咽、下颌及乳突。疼痛性质 为紧缩压榨感，闷胀窒息感、刺痛、锐痛、灼痛甚至 刀割样疼痛，偶有濒死样恐惧，迫使患者立即停止活 动。 Most patients with angina pectoris are identfeid as retrosternal chest discomfort rather than as frank pain. The former is usually described as a pressure, heaviness, squeezing, burning, or choking sensation. Anginal pain may locate primarily in the epigastrium, back, neck, jaw, or shoulders. Typical locations for radiation of pain are at arms, shoulders, and neck. Few presents scares on the brink of death and is forced to quit the work.

Symptoms and signs

♦ 疼痛持续时间约 1—5 分钟，休息或含服硝酸甘油后

1–3 分钟内可缓解症状。 It lasts for approximately 1-5 minutes and is relieved by rest or by nitroglycerin after 1-3 minutes. ♦ 疼痛常因用力、劳累、饱食、情绪激动而诱发 Angina is precipitated by exertion, diet, exposure to cold, or emotional stress. Cardiac marker ♦ 发作时心电图检查可见 S–T 段压低和 T 波改变。 ♦ The ST segment is usually depressed and T-wave changed during angina in EKG. ♦ 心肌酶学无改变 Negative changes in Cardiac marker

急性心肌梗死 Acute myocardial infarction ♦ 胸痛的性质和部位与心绞痛相似，但较

剧烈而持久，持续时间达数小时至数日 ，休息或含服硝酸甘油不能缓解。 ♦ Nature and location of chest pain are similar to that of angina. However, they are more severer and long-lasting. It can last from several hours to several days which can not be alleviated with rest or by taking nitroglycerin.

♦ 常伴有发热、恶心、呕吐、面色苍白、呼吸困

难、心律不齐、血压降低、心力衰竭等。 Sometimes it is accompanied with fever, nausea, vomiting, paleness, difficulty in breathing, arrhythmia, lower blood pressure and heart failure. ♦ 心电图和酶学检查有相应的特异性演变。 Positive result in Cardiac marker and ECG examination

急性下壁心肌梗死 Acute inferior myocardial infarction

主动脉夹层 aortic dissection ♦

本病多 见于 40 岁以上的男性， 多有 高血压和动脉粥 样硬化病史 。 Common in middle-aged patients with hypertension and artherosclerosis.

widened mediastinum

Cardiovascular magnetic resonance (CMR) of a type-A aortic dissection.

♦ 突发性 撕裂样 或刀 割样胸 痛， 向胸前 及背

部放射 ，随夹 层血 肿波及 范围 可延至 腹部 、下肢 、臂及 颈部 ，极为 剧烈 ，疼痛 的高 峰一般 较急性 心梗 的高峰 早。 止痛药 常无 效。 Almost all patients with acute dissections present with severe chest pain, sharp, stabbing, tearing, or ripping pain although some patients with chronic dissections are identified without associated symptoms. Unlike the pain of ischemic heart disease, symptoms of aortic dissection tend to reach peak severity immediately, often causing the patient to collapse from its intensity. ♦ It can radiates to the abdomen, limb, thr arm and the neck. Analgetica is invalid.

诊断 : diagnosis ： ♦ X 线见上 纵隔或主动 脉影增宽。 ♦ X-ray:widen in superior mediastinum or

aorta ♦ UCG ♦ CT 、核磁（ MRI) ♦ 主动脉造影　诊 断的准确率 ９５％ ♦ aortic angiography: Lead to ９５ ％ acurate diagnosis

肺栓塞  Pulmonary Embolism ♦

体循环 静脉或右心 内血栓栓子 脱落 进入肺循环，堵 塞肺动脉或 其分支者 称肺栓塞；由于 肺栓塞或肺 血栓形成 ，引起肺组织缺 氧坏死者称 肺梗死。 ♦ 常有诱因：心脏 病、职业、 长期卧床 、新近手术或外 伤 Common incentives : heart disease, occupational, bedridden, recent surgery or trauma

♦ 肺总动 脉的一支堵 塞，可胸 痛、昏厥

、休克 而猝死。 ♦ 仅肺动 脉一分支堵 塞，则症 状轻重随 血管堵 塞的大小而 不同，主 要表现为 突发性 胸痛、呼吸 困难与紫 绀。疼痛 可为刺 痛、绞痛， 部位在胸 骨后，向 肩部放 射，随呼吸 加剧，同 时伴有发 热、咳 嗽、咯血， 白细胞增 高与转氨 酶 GOT 升高。检查病 变部位有 浊音 ，并可 听到胸膜摩 擦音。

诊断 ♦ D 二聚 体初步筛选

preliminary screening:D-dimer ♦ ECG;SIQ3T3 少见， V1- ４　 ST-T 改 变 ECG:V1-4 wave and ST-T change, ♦ 血气分析 blood gas analysis

♦ X 线摄片 见梗死部位 呈楔形致密影 ，

底边近胸膜，尖 端向肺门， 亦可为圆 形或多发性小片 状影。 ♦ 选择性肺动脉造 影和放射性 核素肺扫 描可确诊。 Final diagnostic examination.selective arteriography of pulmonary arteries and radioactive nuclide scan.

Thank