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| {{Chest pain}} | | {{Chest pain}} |
| {{CMG}}; '''Associate Editor(s)-In-Chief:''' {{CZ}}; [[Priyamvada Singh|Priyamvada Singh, M.B.B.S.]] [mailto:psingh13579@gmail.com] | | {{CMG}}; '''Associate Editor(s)-In-Chief:''' {{CZ}}; [[Priyamvada Singh|Priyamvada Singh, M.B.B.S.]] [mailto:psingh13579@gmail.com] |
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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]]: |
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| '''To go back to the chapter on Ustable angina, click [[unstable angina|here]]. | | '''To go back to the chapter on Ustable angina, click [[unstable angina|here]]. |
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| ==Overview==
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| 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.
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| ==5 Life Threatening Diseases to Exclude Immediately==
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| * [[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>:
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| #[[Gastroesophageal disease]]
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| #[[Ischemic heart disease]] (angina, not myocardial infarction)
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| #[[Chest wall syndromes]]
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| ==Differentiating the Life Threatening and Ischemic Causes of Chest Pain from other Disorders==
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| 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===
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| ====CARDIOVASCULAR====
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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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| |'''[[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====
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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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| |'''[[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====
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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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| |'''[[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==
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| ===Electrocardiogram===
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| * [[Electrocardiogram]] is usually required for initial evaluation.
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| * [[ST elevation]] should require further urgent evaluation for reperfusion therapy.
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| * Salient findings on ECG are:
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| ** New ST elevation (>1 mm) or Q waves on ECG (MI)
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| ** ST depression >1 mm or ischemic T waves (unstable angina)
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| ===X-rays of the chest and/or abdomen===
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| *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]].
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| *[[Computed tomography|CT scanning]] may be better but is often not available
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| ===Echocardiography or Ultrasound===
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| * [[Echocardiogram]] usually required for patients with suspected [[coronary artery disease]]
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| * To rule out [[aortic dissection]], [[transesophageal echocardiogram]] of the chest may be indicated
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| ===MRI and CT===
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| * 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.
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| * To rule out [[aortic dissection]], a [[CT]] scan chest with contrast, [[MRI]] or transesophageal echocardiography can be used.
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| ===Other Imaging Findings===
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| * [[Ventilation/perfusion scan|V/Q scintigraphy]] or CT Pulmonary angiogram (when a [[pulmonary embolism]] is suspected)
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| * For patients who are suspected to have [[coronary artery disease]] may require stress testing or [[cardiac catheterization]]
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| * Peak flow studies and pulmonary function tests may be indicated for patients requiring further evaluation
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| ===Other Diagnostic Studies===
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| * Upper gastrointestinal [[endoscopy]] if [[esophagitis]] is suspected
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| ==Treatment==
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| ===[[NICE guidelines for management of chest pain|NICE guidelines for management of chest pain]]===
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| ===General strategies for management of acute chest pain===
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| * In finding the cause, '''the history given by the patient is often the most important tool'''. In [[angina pectoris]], for example, blood tests and other analysis are not sensitive enough ''(Chun & McGee 2004)''.
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| * The physician's typical approach is to '''rule-out the most dangerous causes of chest pain first''' (e.g., heart attack, blood clot in the lung, aneurysm). By sequential elimination or confirmation from the most serious to the least serious causes, a diagnosis of the origin of the pain is eventually made. Emergency reperfusion therapy either by percutaneous coronary intervention or thrombolytic agents is recommended after diagnosis
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| * Often, no definite cause will be found, and the focus in these cases is on '''excluding severe diseases and reassuring the patient'''.
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| * If [[acute coronary syndrome]] (e.g.[[unstable angina]]) is suspected, many patients are admitted briefly for observation, sequential [[ECG]]s, and determination of cardiac enzyme levels over time ([[creatine kinase|CK-MB]], [[troponin]] or [[myoglobin]]). On occasion, later out-patient testing may be necessary to follow-up and make better determinations on causes and therapies.
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| * Recommendations regarding the minimum length of stay in a monitored bed for a patient who has no further symptoms have decreased in recent years to 12 h or less
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| ===Immediate Management===
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| * Special attention to: '''airway''', '''breathing''', and '''circulation'''. Supplemental O2 should be administered to patients with suspected [[coronary artery disease]]
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| * Once it's ensured that the patient has stable vitals then a detailed history, physical examination and lab tests are required to reach a diagnosis. Special attention to pain's nature and risk factors are required.
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| * ECG, cardiac marker, blood test and chest Xrays are initial primary tests done.
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| * Nitroglycerine and proton pump inhibitors are usually the initial treatment given. However, caution should be taken by the physician in diagnosis based on response to theses therapies as relief of pain on antacids doesn't exclude ischemic heart diseases.
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| * Treat all underlying etiologies as clinically indicated
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| ===Acute Pharmacotherapies===
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| * For patients with [[coronary artery disease]]:
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| ** [[Aspirin]]
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| ** [[Nitroglycerin]]
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| ** [[Morphine]] (if necessary)
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| * For patients with [[myocardial infarction]]:
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| ** [[Heparin]]
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| ** [[Beta-blockers]]
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| ** [[ACE inhibitors]]
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| ** [[Thrombolytic therapy]]
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| ** [[Glycoprotein IIb/IIIa inhibitors]]
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| ===Surgery and Device Based Therapy===
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| * For patients in which [[myocardial infarction]] is suspected, [[angioplasty]] may be indicated
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| * For patients with [[aortic dissection]]s, emergent surgery may be required.<ref name="pmid15336583">{{cite journal |author=Chun AA, McGee SR |title=Bedside diagnosis of coronary artery disease: a systematic review |journal=Am. J. Med. |volume=117 |issue=5|pages=334–43 |year=2004 |month=September |pmid=15336583 |doi=10.1016/j.amjmed.2004.03.021 |url=}}</ref><ref name="pmid16568192">{{cite journal |author=Ringstrom E, Freedman J |title=Approach to undifferentiated chest pain in the emergency department: a review of recent medical literature and published practice guidelines |journal=Mt. Sinai J. Med. |volume=73 |issue=2|pages=499–505 |year=2006 |month=March |pmid=16568192 |doi= |url=http://www.mssm.edu/msjournal/73/732499.shtml}}</ref><ref name="pmid16500201">{{cite journal |author=Butler KH, Swencki SA |title=Chest pain: a clinical assessment |journal=Radiol. Clin. North Am. |volume=44 |issue=2 |pages=165–79, vii |year=2006 |month=March |pmid=16500201 |doi=10.1016/j.rcl.2005.11.002|url=}}</ref><ref name="pmid16326253">{{cite journal |author=Haro LH, Decker WW, Boie ET, Wright RS |title=Initial approach to the patient who has chest pain |journal=Cardiol Clin |volume=24 |issue=1 |pages=1–17, v |year=2006 |month=February |pmid=16326253|doi=10.1016/j.ccl.2005.09.007 |url=}}</ref><ref name="pmid17080889">{{cite journal |author=Fox M, Forgacs I |title=Unexplained (non-cardiac) chest pain |journal=Clin Med |volume=6 |issue=5 |pages=445–9 |year=2006 |pmid=17080889 |doi=|url=http://openurl.ingenta.com/content/nlm?genre=article&issn=1470-2118&volume=6&issue=5&spage=445&aulast=Fox}}</ref>
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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>
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| *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==
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| {{reflist|2}}
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| [[Category:Cardiology]] | | [[Category:Cardiology]] |