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* For patients in which [[myocardial infarction]] is suspected, [[angioplasty]] may be indicated
* For patients in which [[myocardial infarction]] is suspected, [[angioplasty]] may be indicated
* 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>
* 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>
==Sources==
*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>
*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>


==References==
==References==

Revision as of 15:29, 28 May 2009

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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.

Associated symptoms of chest pain that suggest cardiac ischemia as the underlying cause include the following:

In general, clinical features that are not characteristic of myocardial ischemia include the following:

  • Muscular pain; reproduced with or brought on by shoulder and/or forearm movements or postural changes,
  • Pleura related pain (pleuritic pain); a sharp or knifelike 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 costo chondral 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:

Differential Diagnosis of Chest pain

Cardiovascular Acute Aortic DissectionAcute Coronary Syndrome • (unstable angina) • (non ST elevation MI) • (ST elevation MI) • Aortic AneurysmAortic StenosisArryhthmiasBland-White-Garland SyndromeChronic Stable AnginaCor pulmonaleCoronary Heart Disease Dressler's syndrome (postpericardiotomy)Hypertrophic CardiomyopathyMitral valve prolapseMyocardial infarctionMyocarditisPericardial tamponadePericarditisTakotsubos cardiomyopathyStress cardiomyopathy
Chemical / poisoning Carbon monoxide poisoning • Lead poisoning
Dermatologic Herpes zoster
Drug Side Effect Drugs to treat migraine headache
Ear Nose Throat Retropharyngeal abscess
Endocrine Acromegaly
Environmental No underlying causes •
Gastroenterologic AchalasiaAbdominal distensionBarret’s esophagusCarcinomaCholecystitisCholelithiasisDiverticulitisDuodenitisEsophageal ruptureEsophageal spasmEsophagitisForeign bodyGastritisGastroesophageal reflux (GERD) • Hiatus HerniaImpacted stoneLiver abscessMallory-Weiss SyndromeNeoplasmNutcracker's esophagusPancreatitisPeptic ulcer diseasePerforated ulcerPlummer-Vinson SyndromePneumoperitoneumSplenic enlargementSplenic infarction • Subdiaphragmatic abcsess • Subphrenic abscessWhipple's Disease
Genetic No underlying causes •
Hematologic Sickle cell anemia
Iatrogenic No underlying causes •
Infectious Disease Bornholm diseaseHepatitisHIV infectionHerpes Zoster
Musculoskeletal / Ortho Bechterew's DiseaseBone tumor • Chest wall pain syndrome • Costochondritis • Chosto condral tendinitis • Chosto sternal tendinitis • Tietze's syndrome • CS/TS osteochondrosis • FibromyalgiaFractured ribIntercostal muscle spasm • Interstitial fibrosis • Intercostal neuralgiaMuscle strain or spasm • Myofascial pain • MyostitisNeuritisRadiculitisPeriostitisPrecordial catch syndromeShoulder bursitisShoulder tendinitisSoft tissue sarcoma or tumor • Sternoclavicular arthritis • Strain of pectoralis muscle • Thoracic Outlet SyndromeTrauma • Vertebrogenic thoracic pain
Neurologic Tabes dorsalis
Nutritional / Metabolic No underlying causes •
Oncologic Liver cancerMesotheliomaMetastatic tumorNeurofibromaPheochromocytoma
Opthalmologic No underlying causes •
Overdose / Toxicity No underlying causes •
Psychiatric Anxiety disordersAffective disorders (e.g., depression) • Da costa's syndrome • Thought disorders (e.g., fixed delusions) • Hyperventilation syndromeHypochondriaFactitious disorders (e.g. Münchausen syndromeFabricated or induced illness • Hospital addiction syndrome • Panic attackSomatoform disordersSomatization disorder
Pulmonary AsthmaBronchial carcinomaBronchiectasisBronchogenic carcinomaCarcinomatousPleural EffusionChronic Obstructive Pulmonary Disease (COPD) • EmpyemaHemothoraxLung AbscessLung CancerLymphomaMediastinitisPleuritisPleurodyniaPneumomediastinumPneumoniaPneumothoraxPulmonary EmbolismPulmonary InfarctionTension pneumothoraxThymoma • Tracheoesophageal abscess • Tuberculosis
Renal / Electrolyte No underlying causes •
Rheum / Immune / Allergy Familial mediterranean fever
Substance abuse Cocaine
Trauma Chest wall injuries •
Miscellaneous • Collagen vascular disease with pleuritis • Conn's Syndrome • Degenerative changes of cervical spine • PeritonitisPott's DiseaseXiphodynia

Diagnosis

History and Symptoms

Levine's sign

Physical Examination

Heart

Extremities

Other

Laboratory Findings

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

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.

Electrocardiogram

  • ECG usually required for initial evaluation. ST elevation should require further urgent evaluation for reperfusion therapy.

Chest X Ray

MRI and CT

Echocardiography or Ultrasound

Other Imaging Findings

  • Ventilation and quantitative (VQ) scan may be indicated for patients requiring further evaluation
  • 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

Treatment

  • 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

Pharmacotherapy

Acute Pharmacotherapies

Surgery and Device Based Therapy

Sources

  • The 2004 ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction [6]
  • The 2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients with ST-Elevation Myocardial Infarction [7]

References

  1. 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)
  2. 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)
  3. 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)
  4. 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)
  5. Fox M, Forgacs I (2006). "Unexplained (non-cardiac) chest pain". Clin Med. 6 (5): 445–9. PMID 17080889.
  6. 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)
  7. 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)

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