Chest pain
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Chest pain On the Web |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]; Priyamvada Singh, M.B.B.S. [3]
Overview
Chest Discomfort or chest pain is one of the commonest symptoms presented in the emergency department. It can be a manifestation of a benign condition like gastroesophageal reflux diseases to life threatening conditions like myocardial infarction, aortic dissection, tension pneumothorax, or pulmonary embolism. Thus, it requires careful consideration on the physician's part not to miss important diagnosis and also not to over-treat a simple condition. Several life threatening disorders should be excluded upon presentation. The frequency of non-acute myocardial infarction conditions in a decreasing order is: gastroesophageal disease commonest followed by ischemic heart disease, and chest wall syndromes [1]. Other less frequent diagnoses included pulmonary embolism, pleuritis/pneumonia, lung cancer, aortic stenosis, aortic aneurysm and herpes zoster. The first diagnostic study to be ordered within 10 minutes is the 12 lead electrocardiogram. A full medical history may assist in the prompt management of the patient with chest pain. 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.
History and Symptoms
Thorough history including: Onset, duration, type of pain, location, exacerbating factors, alleviating factors, radiation. Risk factors for coronary artery disease: family history, smoking, hyperlipidemia, and diabetes
Clinical features of different conditions presenting with acute chest discomfort
| Condition | Onset | Duration | Type of pain | Location | Exacerbating factors | Alleviating factors | Radiation | Associated features |
|---|---|---|---|---|---|---|---|---|
| Cardiovascular | ||||||||
| Stable Angina | Sudden (acute) | 2-10 minutes | Heaviness, pressure, tightness, squeezing, burning (Levine's sign) | Retrosternal | Exertion, emotions, cold | Rest, sublingual nitroglycerine (within minutes) | Radiation to neck, jaw, shoulders, or arms (commonly on left) | Sweating, nausea, palpitations, dizziness, shortness of breath, sense of impending doom |
| Unstable Angina | Acute | 10-20 minutes | same as stable angina but often more severe | same as stable angina | same as stable angina but occurs with lower levels of exertion & rest | same as stable angina | same as stable angina | same as stable angina |
| Myocardial Infarction | Acute | commonly > 20 minutes | same as stable angina but often more severe | same as stable angina | same as stable angina but occurs with lower levels of exertion & rest | Usually unrelieved by nitroglycerine and rest | same as stable angina | same as stable angina |
| Aortic stenosis | Acute, recurrent episodes of angina | same as stable angina | same as stable angina | same as stable angina | same as stable angina | same as stable angina | same as stable angina | Late systolic murmurs (radiating to carotid arteries) |
| Aortic dissection | Acute, subacute or chronic | Variable | Tearing, ripping sensation, knife like | Depends on area of dissection | Variable | unrelenting pain, unrelieved by nitroglycerine and rest | Radiating to back, between shoulder blades (dissection in ascending aorta) | Hypertension, connective tissue disease (marfan's syndrome), murmur (aortic regurgitation, pericardial rub), impalpable peripheral pulses |
| Pericarditis | Acute or subacute | May last for hours to days | Sharp, localized | Retrosternal | Increases with coughing, deep breathing, supine position | Relieved by sitting up and leaning forward | Radiation to shoulder, neck, back abdomen | Pericardial friction rub |
| Pulmonary | ||||||||
| Pulmonary embolism | Acute | May last minutes to hours | Sharp, or knifelike pleuritic pain | Localized to side of lesion | Increased on respiratory movements as deep breathing or cough | Not specific | Not specific | Dyspnea, tachypnea, tachycardia, and hypotension |
| Spontaneous Pneumothorax | Acute | May last minutes to hours | Sharp, localized pleuritic | Localized to side of lesion | Not specific | Not specific | Not specific | Dyspnea, decreased breath sounds on involved side |
| Pleuritis | Acute, subacute, chronic | May last minutes to hours | Sharp, localized pleuritic | Localized to side of lesion | Not specific | Not specific | Not specific | Dyspnea, cough, fever, rales, pleuritic rub (when associated with pneumonia) |
| Pulmonary hypertension | Acute, subacute, chronic | Variable | Pressure like | Substernal | Not specific | Not specific | Not specific | Dyspnea, signs of right heart failure (edema & elevated jvp |
| Gastrointestinal | ||||||||
| GERD, Peptic ulcer | Acute | Minutes to hours (gastroesophageal reflux), prolonged (peptic ulcer) | Burning | Substernal, epigastric | Increases on post meal lying down | Relieves on antacid, food | Not specific | Not specific |
| Esophageal spasm | Acute | Minutes to hours | Burning, pressure | Retrosternal | Not specific | Not specific | Not specific | Not specific (closely mimic angina) |
| Cholelithasis | Acute, subacute | Minutes to hours | Burning, colicky | Right upper abdomen, substernal, epigastric | Increases post meal, fatty food | Analgesics | Not specific | Not specific |
| Miscellaneous | ||||||||
| Musculo-skeletal pain | Acute, subacute | Variable | Pressure, aching | Localized to involved area | Increases by movement and pressure on involved area | Analgesics | Not specific | Not specific |
| Psychotic conditions | Acute, subacute, chronic | Variable | Variable | Variable | Variable | Not specific | Not specific | Not specific |
Physical Examination
Vitals
- Temperature (pericarditis, pleuritis, fever can precipitate ischemic attacks)
- Pulses in all four limbs (aortic dissection)
- Blood pressure in both the arms (aortic dissection)
General physical examination
- Elevated jugular venous pulse
Cardiovascular
- Auscultation
- Third and fourth heart sound
- Carotid bruit
- Pericardial rub (pericarditis)
- Murmur (systoloic murmur in Hypertrohic cardiomyopathy, aortic stenosis)
Other organ system
Pulmonary
- Palpation - shift in trachea from midline (tension pneumothorax)
- Auscultation - Decreased breath sound (pulmonary edema), pleural rub (pleuritis, pneumonia)
Genitourinary system
- Rectal examination - occult bleeding (peptic ulcers)
Laboratory Findings
On the basis of the above, a number of tests may be ordered:
- Electrocardiogram (ECG): usually required for initial evaluation. ST elevation should require further urgent evaluation for reperfusion therapy.
- Complete blood count
- Electrolytes and renal function (creatinine)
- Liver enzymes
- Creatine kinase (and CK-MB fraction in many hospitals)
- Troponin I or T (to indicate myocardial damage)
- D-dimer (when suspicion for pulmonary embolism is present but low)
- X-rays of the chest and/or abdomen:
- 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.
- CT scanning may be better but is often not available
- Echocardiography or Ultrasound:
- Echocardiogram usually required for patients with suspected coronary artery disease
- To rule out aortic dissection, transesophageal echocardiogram of the chest may be indicated
- MRI and CT:
- CT scan of abdomen and chest may be helpful in ruling out pulmonary embolism
- To rule out aortic dissection, a CT scan or MRI of the chest may be indicated
- Other Imaging Findings:
- 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:
- Upper gastrointestinal endoscopy if esophagitis is suspected
Interpretation
- 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 analyses are not sensitive enough (Chun & McGee 2004).
- 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.
- Often, no definite cause will be found, and the focus in these cases is on excluding severe diseases and reassuring the patient.
- If acute coronary syndrome (e.g.unstable angina) is suspected, many patients are admitted briefly for observation, sequential ECGs, and determination of cardiac enzyme levels over time (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.
5 Life Threatening Diseases to Exclude Immediately
Differential Diagnosis of Chest Pain
Treatment
Immediate Management:
- Special attention to: airway, breathing, and circulation
- Treat all underlying etiologies as clinically indicated
- Supplemental O2 should be administered to patients with suspected coronary artery disease
Acute Pharmacotherapies:
- For patients with coronary artery disease:
- Aspirin
- Nitroglycerin
- Morphine (if necessary)
- For patients with myocardial infarction:
Surgery and Device Based Therapy:
- For patients in which myocardial infarction is suspected, angioplasty may be indicated
- For patients with aortic dissections, emergent surgery may be required.[2][3][4][5][6]
Sources
- The 2004 ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction [7]
- The 2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients with ST-Elevation Myocardial Infarction [8]
References
- ↑ Fruergaard P, Launbjerg J, Hesse B, Jørgensen F, Petri A, Eiken P, Aggestrup S, Elsborg L, Mellemgaard K (1996). "The diagnoses of patients admitted with acute chest pain but without myocardial infarction". European Heart Journal. 17 (7): 1028–34. PMID 8809520. Retrieved 2012-05-02. Unknown parameter
|month=ignored (help) - ↑ Chun AA, McGee SR (2004). "Bedside diagnosis of coronary artery disease: a systematic review". Am. J. Med. 117 (5): 334–43. doi:10.1016/j.amjmed.2004.03.021. PMID 15336583. Unknown parameter
|month=ignored (help) - ↑ Ringstrom E, Freedman J (2006). "Approach to undifferentiated chest pain in the emergency department: a review of recent medical literature and published practice guidelines". Mt. Sinai J. Med. 73 (2): 499–505. PMID 16568192. Unknown parameter
|month=ignored (help) - ↑ Butler KH, Swencki SA (2006). "Chest pain: a clinical assessment". Radiol. Clin. North Am. 44 (2): 165–79, vii. doi:10.1016/j.rcl.2005.11.002. PMID 16500201. Unknown parameter
|month=ignored (help) - ↑ Haro LH, Decker WW, Boie ET, Wright RS (2006). "Initial approach to the patient who has chest pain". Cardiol Clin. 24 (1): 1–17, v. doi:10.1016/j.ccl.2005.09.007. PMID 16326253. Unknown parameter
|month=ignored (help) - ↑ Fox M, Forgacs I (2006). "Unexplained (non-cardiac) chest pain". Clin Med. 6 (5): 445–9. PMID 17080889.
- ↑ 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 (2004). "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)". Circulation. 110 (9): e82–292. PMID 15339869. Unknown parameter
|month=ignored (help) - ↑ Antman EM, Hand M, Armstrong PW; et al. (2008). "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". Circulation. 117 (2): 296–329. doi:10.1161/CIRCULATIONAHA.107.188209. PMID 18071078. Unknown parameter
|month=ignored (help)