Chest pain natural history, complications and prognosis
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sara Zand, M.D.[2] Aisha Adigun, B.Sc., M.D.[3]
Overview
Angina pectoris is defined as a retrosternal chest discomfort that increases gradually in intensity (over several minutes). Percipitant factors are physical or emotional stress. In ACS, chest pain may occur during rest. Chest pain is characterized by radiation (left arm, neck, jaw) and its associated symptoms (dyspnea, nausea, lightheadedness). When actively treated or spontaneously resolving, it disappears over a few minutes. Relief with nitroglycerin is not necessarily a diagnostic criterion of myocardial ischemia, especially because other causes such as esophageal spasm may have respons to nitroglycerin. Associated symptoms such as shortness of breath, nausea or vomiting, lightheadedness, confusion, presyncope or syncope, or vague abdominal symptoms are more frequently seen among patients with diabetes, women, and the elderly. A detailed assessment of cardiovascular risk factors, review of systems, past medical history, and family and social history are ncessary in patients with chest pain. It is pivotal to identify and triage the patients presented with chest pain within 10 minutes of arrival to the hospital. Patients diagnosed with STEMI should be scheduled for primary PCI. Early recognition of STEMI may improve outcomes. Stable angina and non-cardiac chest pain should be evaluated in outpaient setting. Common complications of chest pain include arrythmia, heart failure and Death. Depending on the etiology at the time of presentation, the prognosis may vary. However, the prognosis is generally regarded as good.
Natural history, Complications, and Prognosis
- Angina pectoris is defined as a retrosternal chest discomfort that increases gradually in intensity (over several minutes).[1]
- Percipitant factors are physical or emotional stress.
- In ACS, chest pain may occur during rest.
- Chest pain is characterized by radiation (left arm, neck, jaw) and its associated symptoms (dyspnea, nausea, lightheadedness).
- When actively treated or spontaneously resolving, it disappears over a few minutes.
- Relief with nitroglycerin is not necessarily a diagnostic criterion of myocardial ischemia, especially because other causes such as esophageal spasm may have respons to nitroglycerin.
- Associated symptoms such as shortness of breath, nausea or vomiting, lightheadedness, confusion, presyncope or syncope, or vague abdominal symptoms are more frequently seen among patients with diabetes, women, and the elderly.
- A detailed assessment of cardiovascular risk factors, review of systems, past medical history, and family and social history should be done in patients with chest pain.
- It is pivotal to identify and triage the patients presented with chest pain within 10 minutes of arrival to the hospital.
- Patients diagnosed with STEMI should be scheduled for primary PCI.
- Early recognition of STEMI may improve outcomes.
- Stable angina and non-cardiac chest pain should be evaluated in outpaient setting.
Complications
- Common complications associated with lifethereatening causes of chest pain include:
- Arrythmia in the setting of ACS, PTE
- Heart failure in the setting of STEMI, NSTE-ACS, aortic dissection
- Cardiac arrest in the setting of massive PTE, aorta dissection, acute MI
Prognosis
- Prognosis is generally good. [2]. However, depending on the etiology at the time of presentation, the prognosis may vary.
Clinical practice guidelines by the AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guide evaluation based on an objective assessment of prognosis[1].
The Heart score may reduce unnecessary hospital admissions[3][4].
References
- ↑ 1.0 1.1 Gulati M, Levy PD, Mukherjee D, Amsterdam E, Bhatt DL, Birtcher KK, Blankstein R, Boyd J, Bullock-Palmer RP, Conejo T, Diercks DB, Gentile F, Greenwood JP, Hess EP, Hollenberg SM, Jaber WA, Jneid H, Joglar JA, Morrow DA, O'Connor RE, Ross MA, Shaw LJ (November 2021). "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines". Circulation. 144 (22): e368–e454. doi:10.1161/CIR.0000000000001029. PMID 34709879 Check
|pmid=value (help). - ↑ Ilangkovan N, Mickley H, Diederichsen A, Lassen A, Sørensen TL, Sheta HM, Stæhr PB, Mogensen CB (December 2017). "Clinical features and prognosis of patients with acute non-specific chest pain in emergency and cardiology departments after the introduction of high-sensitivity troponins: a prospective cohort study". BMJ Open. 7 (12): e018636. doi:10.1136/bmjopen-2017-018636. PMC 5770919. PMID 29275346.
- ↑ Poldervaart JM, Reitsma JB, Backus BE, Koffijberg H, Veldkamp RF, Ten Haaf ME; et al. (2017). "Effect of Using the HEART Score in Patients With Chest Pain in the Emergency Department: A Stepped-Wedge, Cluster Randomized Trial". Ann Intern Med. 166 (10): 689–697. doi:10.7326/M16-1600. PMID 28437795. Review in: Ann Intern Med. 2017 Aug 15;167(4):JC22
- ↑ Mahler SA, Lenoir KM, Wells BJ, Burke GL, Duncan PW, Case LD | display-authors=etal (2018) Safely Identifying Emergency Department Patients With Acute Chest Pain for Early Discharge. Circulation 138 (22):2456-2468. DOI:10.1161/CIRCULATIONAHA.118.036528 PMID: 30571347