Chest pain
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Chest pain Microchapters |
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Diagnosis |
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Treatment |
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Case Studies |
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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]
To go back to the chapter on Ustable angina, click here.
Expert algorithm: An expert algorithm to assist in the diagnosis of chest pain can be found here:
Overview
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 12 lead electrocardiogram. A full medical history may assist in the prompt management of the patient with chest pain.
Chest Pain Suggestive of Cardiac Ischemia as the Underlying Cause
- Describing the pain as heaviness, a pressure or a band like tightness.
- Radiation of the pain to neck, jaw or left arm
- Sweating
- Nausea
- Palpitations
- Pain with exertion
- Dizziness
- Shortness of breath
- A sense of impending doom.
Chest Pain Non-characteristic of Myocardial Ischemia
- Muscular pain; reproduced with or brought on by shoulder and/or forearm movements or postural changes,
- Pleura related pain (pleuritic pain); a sharp or knife-like pain brought on by respiratory movements as deep breathing or cough
- Primary or sole location of discomfort in the middle or lower abdominal region
- Pain that may be localized at the tip of one finger, particularly over the left ventricular apex or a costochondral junction
- Pain reproduced with movement or palpation of the chest wall or arms
- Very brief episodes of pain that last a few seconds or less
- Pain that radiates into the lower extremities
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.
5 Life Threatening Diseases to Exclude Immediately
The frequency of conditions exclusive of acute myocardial infarction in a decreasing order is [1]:
- Gastroesophageal disease
- Ischemic heart disease (angina, not myocardial infarction)
- Chest wall syndromes
Differentiating the Life Threatening and Ischemic Causes of Chest Pain from other Disorders
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.
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 |
Diagnosis
Electrocardiogram
- Electrocardiogram 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
NICE guidelines for management of chest pain
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:
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]
- National Institute for Health and Clinical Excellence (NICE) guidelines [9]
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) - ↑ [[]]. PMID 22420013. Missing or empty
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