03/02/2026
: دل کا عارضہ اور Epigastric Discomfort
*Critical Care Pearl:
Chest Pain Speaks — Listen to the Pattern!
- Chest pain is a storyteller. The trick is learning its dialects.
- A well-taken history remains one of the strongest diagnostic tools in acute care, long before join the conversation
- Chest pain has accents, and each one points you toward (or away from) catastrophe.
A- The Big Killers: Always Rule Out First:
1- Crushing / pressure / “elephant sitting on the chest → ACS until proven otherwise.
• Associated nausea, diaphoresis, radiation to jaw or arm strengthen the case.
2- Sudden, severe, tearing / ripping pain → Aortic dissection.
• Radiation to the back, pulse/BP differences, or new aortic regurgitation are key breadcrumbs.
3- Sudden chest pain + shortness of breath → Pneumothorax or Pulmonary Embolism (PE).
• Tension pneumothorax = hypotension + unilateral breath sounds + distended neck veins.
B. The Classic Patterns:
1- Exertional, predictable, relieved by rest → Stable angina (oxygen demand > supply).
2- Sharp, positional, better leaning forward → Pericarditis.
• Look for: recent viral illness, ESRD, post-ACS (Dressler’s), fever, friction rub.
3- Sharp, pleuritic, worse with deep inspiration → PE, pneumonia, pneumothorax, pleuritis.
4- Localized, reproducible with palpation → Musculoskeletal pain (costochondritis, muscle strain).
** Note: reproducible tenderness does not fully exclude ACS, but lowers the probability.
C. Additional Clinical Clues:
1- Sudden pain + back radiation + syncope or neurologic symptoms → Highly suggestive of dissection.
2- Absence of dyspnea makes PE less likely, unless high-risk (pregnancy, postop, long travel, cancer).
3- Pericarditis question stems often mention.
• URI, recent PCI/ACS, tuberculosis risk factors, or ESRD.
4- Epigastric pain can be ACS.
• Never downgrade based on pain location alone.
5- Pain worsens after vomiting or with swallowing → Consider esophageal rupture (Boerhaave)—rare, lethal, easy to miss.
D. The Hidden Mimics:
1- Chest pain in diabetics or the elderly may be silent or atypical.
• Unexplained fatigue, nausea, syncope, or dyspnea can all be coronary equivalents.
2- Inferior MI may present as “gas pain” or epigastric burning.
3- PE with normal CXR + unexplained tachycardia → Don’t ignore this combination.
📚References:
1. Amsterdam EA et al. 2014 AHA/ACC Guideline for Management of Patients With Non–ST-Elevation Acute Coronary Syndromes. Circulation.
2. Writing Committee Members (ACC/AHA). 2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease. Circulation.
3. Klein AL et al. 2015 ESC Guidelines for the Diagnosis and Management of Pericardial Diseases. Eur Heart J.
4. Konstantinides SV et al. 2019 ESC Guidelines on Pulmonary Embolism. Eur Heart J.
