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| | {| class="infobox" style="float:right;" |
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| | | [[File:Siren.gif|30px|link=Chest pain resident survival guide]]|| <br> || <br> |
| | | [[Chest pain resident survival guide|'''Resident'''<br>'''Survival'''<br>'''Guide''']] |
| | |} |
| {{Chest pain}} | | {{Chest pain}} |
| {{CMG}}; '''Associate Editor(s)-In-Chief:''' {{CZ}}; [[Priyamvada Singh|Priyamvada Singh, M.B.B.S.]] [mailto:psingh13579@gmail.com]
| | '''For resident survival guide, click [[Chest pain resident survival guide|here]]''' |
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| '''To go back to the chapter on Ustable angina, click [[unstable angina|here]]. | | '''For patient information, click [[Chest pain (patient information)|here]]''' |
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| '''Expert algorithm:''' An expert algorithm to assist in the diagnosis of chest pain can be found [[Diagnosis WikiDoc:Chest Pain|here]]: | | {{CMG}}; '''Associate Editor(s)-In-Chief:''' {{Sara.Zand}} {{Aisha}} {{IQ}} {{CZ}}; [[Priyamvada Singh|Priyamvada Singh, M.B.B.S.]] [mailto:psingh13579@gmail.com] {{AMK}}, {{nuha}} |
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| ==Overview== | | {{SK}} |
| Chest pain is a common clinical symptom. Several life threatening disorders should be excluded upon presentation. The first diagnostic study to be ordered within 10 minutes is the [[electrocardiogram|12 lead electrocardiogram]]. A full medical history may assist in the prompt management of the patient with chest pain. | | ==[[Chest pain overview|Overview]]== |
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| ==Chest Pain Suggestive of Cardiac Ischemia as the Underlying Cause== | | ==[[Chest pain historical perspective|Historical Perspective]]== |
| * Describing the pain as heaviness, a pressure or a band like tightness.
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| * Radiation of the pain to [[neck]], [[jaw]] or left arm
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| * [[Diaphoresis|Sweating]]
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| * [[Nausea]]
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| * [[Palpitations]]
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| * [[Angina pectoris|Pain with exertion]]
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| * [[Dizziness]]
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| * [[Shortness of breath]]
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| * A sense of impending doom.
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| ==Chest Pain Non-characteristic of Myocardial Ischemia== | | ==[[Chest pain classification|Classification]]== |
| *[[Myalgia|Muscular pain]]; reproduced with or brought on by shoulder and/or forearm movements or postural changes,
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| *[[Pleura]] related pain ([[pleuritic pain]]); a sharp or knife-like pain brought on by respiratory movements as deep breathing or [[cough]]
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| *Primary or sole location of discomfort in the middle or lower abdominal region
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| *Pain that may be localized at the tip of one finger, particularly over the left ventricular apex or a costochondral junction
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| *Pain reproduced with movement or palpation of the chest wall or arms
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| *Very brief episodes of pain that last a few seconds or less
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| *Pain that radiates into the lower extremities
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| '''The relief of chest pain by administration of sublingual [[nitroglycerin]] in outpatient setting is not diagnostic of [[coronary artery disease]].''' For instance, esophageal pain can be relieved by administration of [[nitroglycerin]]. Likewise, '''the relief of chest pain by the administration of liquid or chewable [[antacids]] and anti reflux drugs does not exclude [[coronary artery disease]] as the underlying etiology of the pain.'''
| | ==[[Chest pain pathophysiology|Pathophysiology]]== |
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| ==5 Life Threatening Diseases to Exclude Immediately== | | ==[[Chest pain causes|Causes]]== |
| * [[Aortic Dissection]]
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| * [[Esophageal Rupture]]
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| * [[Myocardial Infarction]]
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| * [[Pulmonary Embolism]]
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| * [[Tension Pneumothorax]]
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| The frequency of conditions exclusive of acute myocardial infarction in a decreasing order is <ref name="pmid8809520">{{cite journal |author=Fruergaard P, Launbjerg J, Hesse B, Jørgensen F, Petri A, Eiken P, Aggestrup S, Elsborg L, Mellemgaard K |title=The diagnoses of patients admitted with acute chest pain but without myocardial infarction |journal=[[European Heart Journal]] |volume=17 |issue=7 |pages=1028–34 |year=1996 |month=July |pmid=8809520 |doi= |url=http://eurheartj.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=8809520 |accessdate=2012-05-02}}</ref>:
| | ==[[Chest pain differential diagnosis|Differentiating Chest pain from other Diseases]]== |
| #Gastroesophageal disease
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| #[[Ischemic heart disease]] (angina, not myocardial infarction)
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| #[[Chest wall syndromes]]
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| | ==[[Chest pain epidemiology and demographics|Epidemiology and Demographics]]== |
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| ==Differentiating the Life Threatening and Ischemic Causes of Chest Pain from other Disorders== | | ==[[Chest pain risk factors|Risk Factors]]== |
| Thorough history including: onset, duration, type of pain, location, exacerbating factors, alleviating factors, and radiation. Risk factors for coronary artery disease: [[family history]], [[smoking]], [[hyperlipidemia]], and [[diabetes]].
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| ===Clinical Features of Different Conditions Presenting with Acute Chest Discomfort=== | |
| ====CARDIOVASCULAR====
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| {| border="1" cellpadding="5" cellspacing="0" align="center" class="sortable" style="text-align:center;"
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| ! Condition
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| ! Onset
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| ! Duration
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| ! Type of pain
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| ! Location
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| ! Exacerbating factors
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| ! Alleviating factors
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| ! Radiation
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| ! Associated features
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| |'''[[Stable Angina]]'''
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| |Sudden (acute)
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| |2-10 minutes
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| |Heaviness, pressure, tightness, squeezing, burning ([[Levine's sign]])
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| |Retrosternal
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| |Exertion, emotions, cold
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| |Rest, sublingual nitroglycerine (within minutes)
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| |Radiation to neck, jaw, shoulders, or arms (commonly on left)
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| |[[Diaphoresis|Sweating]], [[nausea]], [[palpitations]], [[dizziness]], [[shortness of breath]], sense of impending doom
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| |-
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| |'''[[Unstable Angina]]'''
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| |Acute
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| |10-20 minutes
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| |same as stable angina but often more severe
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| |same as stable angina
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| |same as stable angina but occurs with lower levels of exertion & rest
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| |same as stable angina
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| |same as stable angina
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| |same as stable angina
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| |-
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| |'''[[Myocardial Infarction]]'''
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| |Acute
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| |commonly > 20 minutes
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| |same as stable angina but often more severe
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| |same as stable angina
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| |same as stable angina but occurs with lower levels of exertion & rest
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| |Usually unrelieved by nitroglycerine and rest
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| |same as stable angina
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| |same as stable angina
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| |-
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| |'''[[Aortic stenosis]]'''
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| |Acute, recurrent episodes of angina
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| |same as stable angina
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| |same as stable angina
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| |same as stable angina
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| |same as stable angina
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| |same as stable angina
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| |same as stable angina
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| |Not specific
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| |-
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| |'''[[Aortic dissection]]'''
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| |Sudden severe progressive pain (common) or chronic (rare)
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| |Variable
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| |Tearing, ripping sensation, knife like
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| |Depends on area of dissection
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| |Variable
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| |unrelenting pain, unrelieved by nitroglycerine and rest
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| |Radiating to back, between shoulder blades (dissection in ascending aorta)
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| |Trauma, Surgical manipulation, pregnancy, [[Hypertension]], [[connective tissue disease]] like [[marfan's syndrome]] (cystic medial degeneration)
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| |-
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| |'''[[Pericarditis]]'''
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| |Acute or subacute
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| |May last for hours to days
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| |Sharp, localized
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| |Retrosternal
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| |Increases with coughing, deep breathing, supine position
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| |Relieved by sitting up and leaning forward
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| |Radiation to shoulder, neck, back abdomen
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| |Not specific
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| |-
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| |}
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| ====PULMONARY==== | | ==[[Chest pain screening|Screening]]== |
| {| border="1" cellpadding="5" cellspacing="0" align="center" class="sortable" style="text-align:center;"
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| |-
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| ! Condition
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| ! Onset
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| ! Duration
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| ! Type of pain
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| ! Location
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| ! Exacerbating factors
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| ! Alleviating factors
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| ! Radiation
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| ! Associated features
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| |-
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| |'''[[Pulmonary embolism]]'''
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| |Acute
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| |May last minutes to hours
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| |Sharp, or knifelike pleuritic pain
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| |Localized to side of lesion
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| |Increased on respiratory movements, deep breathing or cough
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| |Not specific
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| |Not specific
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| |[[Dyspnea]], [[tachypnea]], [[palpitation]], and [[light headedness]], hemoptysis, or a history of venous thromboembolism or coagulation abnormalities.
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| |-
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| |'''[[Pneumothorax|Spontaneous Pneumothorax]]'''
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| |Acute
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| |May last minutes to hours
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| |Sharp, localized pleuritic
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| |Localized to side of lesion
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| |Not specific
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| |Not specific
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| |Not specific
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| |Dyspnea, decreased breath sounds on involved side
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| |-
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| |'''[[Pleuritis]]'''
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| |Acute, subacute, chronic
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| |May last minutes to hours
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| |Sharp, localized pleuritic
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| |Localized to side of lesion
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| |Increased on respiratory movements, deep breathing or cough
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| |Not specific
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| |Not specific
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| |Dyspnea, cough, fever
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| |-
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| |'''[[Pulmonary hypertension]]'''
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| |Acute, subacute, chronic
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| |Variable
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| |Pressure like
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| |Substernal
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| |Not specific
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| |Not specific
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| |Not specific
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| |Dyspnea, symptoms of [[right heart failure]] ([[edema]]
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| |-
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| |}
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| ====GASTROINTESTINAL==== | | ==[[Chest pain natural history, complications and prognosis|Natural History, Complications, and Prognosis]]== |
| {| border="1" cellpadding="5" cellspacing="0" align="center" class="sortable" style="text-align:center;"
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| |-
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| ! Condition
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| ! Onset
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| ! Duration
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| ! Type of pain
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| ! Location
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| ! Exacerbating factors
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| ! Alleviating factors
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| ! Radiation
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| ! Associated features
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| |-
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| |'''[[GERD]], [[Peptic ulcer]]'''
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| |Acute
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| |Minutes to hours (gastroesophageal reflux), prolonged (peptic ulcer)
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| |Burning
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| |Substernal, epigastric
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| |Increases on alcohol, aspirin, post meal lying down, morning, empty stomach
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| |Relieves on antacid, food
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| |Not specific
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| |Not specific
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| |-
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| |'''[[Esophageal spasm]]'''
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| |Acute
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| |Minutes to hours
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| |Burning, pressure
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| |Retrosternal
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| |Not specific
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| |Relieved by sublingual nitroglycerine
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| |Not specific
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| |Not specific (closely mimic angina)
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| |-
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| |'''[[Gallstone disease| Cholelithasis]]'''
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| |Acute, subacute
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| |Minutes to hours
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| |Burning, colicky
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| |Right upper abdomen, substernal, epigastric
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| |Increases post meal, fatty food, 1-2 hours post meal
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| |Analgesics
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| |Not specific
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| |Not specific
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| |-
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| |}
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| ====MISCELLANEOUS====
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| {| border="1" cellpadding="5" cellspacing="0" align="center" class="sortable" style="text-align:center;"
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| |-
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| ! Condition
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| ! Onset
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| ! Duration
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| ! Type of pain
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| ! Location
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| ! Exacerbating factors
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| ! Alleviating factors
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| ! Radiation
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| ! Associated features
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| |-
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| |'''[[Muscular pain|Musculo-skeletal pain]]'''
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| |Acute, subacute
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| |Variable
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| |Pressure, aching
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| |Localized to involved area
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| |Increases by movement and pressure on involved area
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| |Analgesics
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| |Not specific
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| |Not specific
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| |-
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| |Psychotic conditions
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| |Acute, subacute, chronic
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| |Variable
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| |Variable
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| |Variable
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| |Variable
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| |Not specific
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| |Not specific
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| |History of depression, Panic attacks, Agrophobia
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| |-
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| |}
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| ==Diagnosis== | | ==Diagnosis== |
| | [[Chest pain diagnostic study of choice|Diagnostic study of choice]] | [[Chest pain history and symptoms|History and Symptoms]] | [[Chest pain physical examination|Physical Examination]] | [[Chest pain laboratory findings|Laboratory Findings]] | [[Chest pain electrocardiogram|Electrocardiogram]] | [[Chest pain x ray|X-Ray Findings]] | [[Chest pain echocardiography and ultrasound|Echocardiography and Ultrasound]] | [[Chest pain CT scan|CT-Scan Findings]] | [[Chest pain MRI|MRI Findings]] | [[Chest pain other imaging findings|Other Imaging Findings]] | [[Chest pain other diagnostic studies|Other Diagnostic Studies]] |
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| | ==Treatment== |
| | [[Chest pain medical therapy|Medical Therapy]] | [[Chest pain interventions|Interventions]] | [[Chest pain surgery|Surgery]] | [[Chest pain primary prevention|Primary Prevention]] | [[Chest pain secondary prevention|Secondary Prevention]] | [[Chest pain cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Chest pain future or investigational therapies|Future or Investigational Therapies]] |
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| | ==Case Studies== |
| | [[Chest pain case study one|Case #1]] |
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| ===Electrocardiogram=== | | ==Related Chapters== |
| * [[Electrocardiogram]] is usually required for initial evaluation. | | *[[NICE guidelines for management of chest pain]] |
| * [[ST elevation]] should require further urgent evaluation for reperfusion therapy. | | *[[Unstable angina]] |
| * Salient findings on ECG are:
| | *[[Chronic stable angina]] |
| ** New ST elevation (>1 mm) or Q waves on ECG (MI)
| | *[[Myocardial infarction]] |
| ** ST depression >1 mm or ischemic T waves (unstable angina)
| | *[[Pulmonary embolism]] |
| | | *[[Pneumonia]] |
| ===X-rays of the chest and/or abdomen===
| | *[[Costochondritis]] |
| *A [[chest X-ray]] can be useful in the initial evaluation of the patient to ascertain if there is [[cardiomegaly]], [[pulmonary edema]] and [[aortic dissection]]. | | *[[Cardiogenic shock]] |
| *[[Computed tomography|CT scanning]] may be better but is often not available | | *[[The Patient History in Cardiovascular Disease]] |
| | | *[[Diagnosis Wikidoc: Chest Pain no ST elevation]] |
| ===Echocardiography or Ultrasound===
| | *[[Diagnosis WikiDoc:Chest Pain]] |
| * [[Echocardiogram]] usually required for patients with suspected [[coronary artery disease]] | | *[[Pleuritic chest pain]] |
| * To rule out [[aortic dissection]], [[transesophageal echocardiogram]] of the chest may be indicated | | *[[GERD]] |
| ===MRI and CT===
| | *[[Dysphagia]] |
| * CT angiography, lung scan may be helpful in ruling out [[pulmonary embolism]] These tests are sometimes combined with lower extremity venous ultrasound or D-dimer testing. | |
| * To rule out [[aortic dissection]], a [[CT]] scan chest with contrast, [[MRI]] or transesophageal echocardiography can be used. | |
| ===Other Imaging Findings===
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| * [[Ventilation/perfusion scan|V/Q scintigraphy]] or CT Pulmonary angiogram (when a [[pulmonary embolism]] is suspected) | |
| * For patients who are suspected to have [[coronary artery disease]] may require stress testing or [[cardiac catheterization]] | |
| * Peak flow studies and pulmonary function tests may be indicated for patients requiring further evaluation | |
| ===Other Diagnostic Studies===
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| * Upper gastrointestinal [[endoscopy]] if [[esophagitis]] is suspected
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| ==Sources==
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| *The 2004 ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction <ref name="pmid15339869">{{cite journal |author=Antman EM, Anbe DT, Armstrong PW, Bates ER, Green LA, Hand M, Hochman JS, Krumholz HM, Kushner FG, Lamas GA, Mullany CJ, Ornato JP, Pearle DL, Sloan MA, Smith SC, Alpert JS, Anderson JL, Faxon DP, Fuster V, Gibbons RJ, Gregoratos G, Halperin JL, Hiratzka LF, Hunt SA, Jacobs AK |title=ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of Patients with Acute Myocardial Infarction) |journal=Circulation |volume=110 |issue=9|pages=e82–292 |year=2004 |month=August |pmid=15339869 |doi= |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=15339869}}</ref> | |
| *The 2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients with ST-Elevation Myocardial Infarction <ref name="pmid18071078">{{cite journal |author=Antman EM, Hand M, Armstrong PW, ''et al'' |title=2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines: developed in collaboration With the Canadian Cardiovascular Society endorsed by the American Academy of Family Physicians: 2007 Writing Group to Review New Evidence and Update the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction, Writing on Behalf of the 2004 Writing Committee|journal=Circulation |volume=117 |issue=2 |pages=296–329 |year=2008 |month=January |pmid=18071078|doi=10.1161/CIRCULATIONAHA.107.188209 |url=}}</ref>
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| * National Institute for Health and Clinical Excellence (NICE) guidelines <ref name="pmid22420013">{{cite journal |author= |title= |journal=[[]] |volume= |issue= |pages= |year= |pmid=22420013 |doi= |url= |accessdate=2012-05-08}}</ref>
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| ==References== | | ==References== |
| {{reflist|2}} | | {{Reflist|2}} |
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| [[Category:Emergency medicine]] | | [[Category:Emergency medicine]] |
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