Chest pain

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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 . 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.

Differential Diagnosis of Chest Pain

Life Threatening Diseases to Exclude Immediately

Acute

• Aortic Dissection
• Esophageal Rupture
• Myocardial Infarction
• Pulmonary Embolism
• Tension Pneumothorax

Chronic

• Stable angina
• Aortic stenosis
• Pulmonary hypertension

Treatable chronic conditions

• Esophageal spasm
• Esophageal reflux
• Peptic Ulcer
• Gall stones
• Musculoskeletal disorder
• Psychotic and emotional disorders

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

CARDIOVASCULAR

Condition	Onset	Duration	Type of pain	Location	Exacerbating factors	Alleviating factors	Radiation	Associated features
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	Not specific
Aortic dissection	Sudden severe progressive pain (common) or chronic (rare)	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)	Trauma, Surgical manipulation, pregnancy, Hypertension, connective tissue disease like marfan's syndrome (cystic medial degeneration)
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	Not specific

PULMONARY

Condition	Onset	Duration	Type of pain	Location	Exacerbating factors	Alleviating factors	Radiation	Associated features
Pulmonary embolism	Acute	May last minutes to hours	Sharp, or knifelike pleuritic pain	Localized to side of lesion	Increased on respiratory movements, deep breathing or cough	Not specific	Not specific	Dyspnea, tachypnea, palpitation, and light headedness, hemoptysis, or a history of venous thromboembolism or coagulation abnormalities.
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	Increased on respiratory movements, deep breathing or cough	Not specific	Not specific	Dyspnea, cough, fever
Pulmonary hypertension	Acute, subacute, chronic	Variable	Pressure like	Substernal	Not specific	Not specific	Not specific	Dyspnea, symptoms of right heart failure (edema

GASTROINTESTINAL

Condition	Onset	Duration	Type of pain	Location	Exacerbating factors	Alleviating factors	Radiation	Associated features
GERD, Peptic ulcer	Acute	Minutes to hours (gastroesophageal reflux), prolonged (peptic ulcer)	Burning	Substernal, epigastric	Increases on alcohol, aspirin, post meal lying down, morning, empty stomach	Relieves on antacid, food	Not specific	Not specific
Esophageal spasm	Acute	Minutes to hours	Burning, pressure	Retrosternal	Not specific	Relieved by sublingual nitroglycerine	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, 1-2 hours post meal	Analgesics	Not specific	Not specific

MISCELLANEOUS

Condition	Onset	Duration	Type of pain	Location	Exacerbating factors	Alleviating factors	Radiation	Associated features
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	History of depression, Panic attacks, Agrophobia

Physical Examination

Vitals

• Temperature (pericarditis, pleuritis, fever can precipitate ischemic attacks)
• Absent or decreased pulses in limbs (aortic dissection all four limbs), tachycardia (pulmonary embolism)
• 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)

Central nervous system

• Cerebrovascular accidents (aortic dissection)
• Paraplegia

Genitourinary system

• Rectal examination - occult bleeding (peptic ulcers)

Laboratory Findings

On the basis of the above, a number of tests may be ordered:

Cardiac Markers

• Troponin I or T are now cardiac marker of choice and are preferred over creatine kinase.
• No one marker gives accurate diagnosis so commonly two markers are used for instance Troponin I or T with creatine kinase (and CK-MB fraction in many hospitals)

Blood tests

• D-dimer (when suspicion for pulmonary embolism, aortic dissection)
• Complete blood count
• Electrolytes
• Renal function (creatinine)
• Liver function tests

Electrocardiogram

• It is usually required for initial evaluation.
• ST elevation should require further urgent evaluation for reperfusion therapy.
• Salient findings on ECG are:
  • New ST elevation (>1 mm) or Q waves on ECG (MI)
  • ST depression >1 mm or ischemic T waves (unstable angina)

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 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

• 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

Treatment

General strategies for management of acute chest pain

• 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).
• 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
• 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.
• 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

Immediate Management

• Special attention to: airway, breathing, and circulation. Supplemental O2 should be administered to patients with suspected coronary artery disease
• 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.
• ECG, cardiac marker, blood test and chest Xrays are initial primary tests done.
• 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.
• Treat all underlying etiologies as clinically indicated

Acute Pharmacotherapies

• For patients with coronary artery disease:
  • Aspirin
  • Nitroglycerin
  • Morphine (if necessary)
• For patients with myocardial infarction:
  • Heparin
  • Beta-blockers
  • ACE inhibitors
  • Thrombolytic therapy
  • Glycoprotein IIb/IIIa inhibitors

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.

Sources

• The 2004 ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction
• The 2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients with ST-Elevation Myocardial Infarction
• National Institute for Health and Clinical Excellence (NICE) guidelines

References

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