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| {{Chest pain}}
| | __NOTOC__ |
| {{CMG}}; '''Associate Editor-In-Chief:''' {{CZ}}
| | {| class="infobox" style="float:right;" |
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| ==Overview==
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| '''Chest pain''' is a common clinical symptom.
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| *Several life threatening disorders should be excluded upon presentation.
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| *The first diagnostic study to be ordered within 10 minutes is the [[electrocardiogram|12 lead electrocardiogram]].
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| *A full medical history may assist in the prompt management of the patient with chest pain.
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| ==Chest pain that suggest cardiac ischemia as the underlying cause==
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| * Describing the pain as heaviness, a pressure or a '''band like tightness'''
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| * Radiation of the pain to [[neck]], [[jaw]] or left arm
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| * [[Diaphoresis|Sweating]]
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| * [[Nausea]]
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| * [[Palpitations]]
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| * [[Angina pectoris|Pain with exertion]]
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| * [[Dizziness]]
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| * [[Shortness of breath]]
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| * '''A sense of impending doom'''.
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| ==Chest pain that are not characteristic of myocardial ischemia==
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| *[[Myalgia|Muscular pain]]; reproduced with or brought on by shoulder and/or forearm movements or postural changes,
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| *[[Pleura]] related pain ([[pleuritic pain]]); a sharp or knifelike pain brought on by respiratory movements as deep breathing or[[cough]]
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| *Primary or sole location of discomfort in the middle or lower abdominal region
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| *Pain that may be localized at the tip of one finger, particularly over the left ventricular apex or a costo chondral junction
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| *Pain reproduced with movement or palpation of the chest wall or arms
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| *Very brief episodes of pain that last a few seconds or less
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| *Pain that radiates into the lower extremities
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| '''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.'''
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| ==5 Life Threatening Diseases to Exclude Immediately==
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| * [[Aortic Dissection]]
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| * [[Esophageal Rupture]]
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| * [[Myocardial Infarction]]
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| * [[Pulmonary Embolism]]
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| * [[Tension Pneumothorax]]
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| ==Differential Diagnosis of Chest Pain==
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| {|style="width:70%; height:100px" border="1" | |
| |style="height:100px"; style="width:25%" border="1" bgcolor="LightSteelBlue" | '''Cardiovascular'''
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| |style="height:100px"; style="width:75%" border="1" bgcolor="Beige" | • [[Aortic Dissection|Acute Aortic Dissection]] • [[Acute Coronary Syndrome]] • ([[unstable angina]]) • ([[non ST elevation MI]]) • ([[ST elevation MI]]) • [[Aortic Aneurysm]] • [[Aortic Stenosis]] • [[Arryhthmias]] • [[Bland-White-Garland Syndrome]] • [[Chronic Stable Angina]] • [[Cor pulmonale]] • [[Coronary Heart Disease]] • [[Dressler's syndrome | Dressler's syndrome (postpericardiotomy)]] • [[Cardiomyopathy|Hypertrophic Cardiomyopathy]] •[[Mitral valve prolapse]] • [[STEMI|Myocardial infarction]] • [[Myocarditis]] • [[tamponade|Pericardial tamponade]] •[[Pericarditis]] • [[Takotsubos cardiomyopathy]] • [[Stress cardiomyopathy]]
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Chemical / poisoning'''
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| |bgcolor="Beige"| Carbon monoxide poisoning • Lead poisoning
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Dermatologic'''
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| |bgcolor="Beige"| [[Herpes zoster]] •
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Drug Side Effect'''
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| |bgcolor="Beige"| Drugs to treat [[migraine headache]] •
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Ear Nose Throat'''
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| |bgcolor="Beige"| • [[Retropharyngeal abscess]] •
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Endocrine'''
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| |bgcolor="Beige"| • [[Acromegaly]] • [[Hyperthyroidism]] • [[Hypothyroidism]]
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Environmental'''
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| |bgcolor="Beige"| No underlying causes •
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Gastroenterologic'''
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| |bgcolor="Beige"| • [[Achalasia]] • [[Abdominal distension]] • [[Barret’s esophagus]] • [[Carcinoma]] • [[Cholecystitis]] •[[Cholelithiasis]] • [[Diverticulitis]] • [[Duodenitis]] • [[Esophageal rupture]] • [[Esophageal spasm]] • [[Esophagitis]] •[[Foreign body]] • [[Gastritis]] • [[Gastroesophageal reflux]] ([[GERD]]) • [[Hiatus Hernia]] • [[Impacted stone]] • [[Liver abscess]] • [[Mallory-Weiss Syndrome]] • [[Neoplasm]] • [[nutcracker's esophagus|Nutcracker's esophagus]] • [[Pancreatitis]] •[[Peptic ulcer disease]] • [[Perforated ulcer]] • [[Plummer-Vinson Syndrome]] • [[Pneumoperitoneum]] • [[Splenomegaly|Splenic enlargement]] • [[Splenic infarction]] • Subdiaphragmatic abcsess • [[Subphrenic abscess]] • [[Whipple's Disease]] •
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Genetic'''
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| |bgcolor="Beige"| No underlying causes •
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Hematologic'''
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| |bgcolor="Beige"| [[Sickle cell anemia]] •
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Iatrogenic'''
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| |bgcolor="Beige"| No underlying causes •
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Infectious Disease'''
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| |bgcolor="Beige"| • [[Bornholm disease]] • [[Hepatitis]] • [[HIV|HIV infection]] • [[Herpes Zoster]] •
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| |-bgcolor="LightSteelBlue"
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| | '''Musculoskeletal / Ortho'''
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| |bgcolor="Beige"| • [[Bechterew's Disease]] • [[Bone tumor]] • Chest wall pain syndrome • [[Costochondritis]] • Chosto condral tendinitis • Chosto sternal tendinitis • [[Tietze's syndrome]] • CS/TS osteochondrosis • [[Fibromyalgia]] • [[Fractured rib]] •[[Intercostal muscle spasm]] • Interstitial fibrosis • [[Intercostal neuralgia]] • [[Muscle strain or spasm]] • Myofascial pain •[[Myostitis]] • [[Neuritis]] • [[Radiculitis]] • [[Periostitis]] • [[Precordial catch syndrome]] • [[bursitis|Shoulder bursitis]] •[[tendinitis|Shoulder tendinitis]] • [[tumor|Soft tissue sarcoma or tumor]] • Sternoclavicular arthritis • Strain of pectoralis muscle • [[Thoracic Outlet Syndrome]] • [[Trauma]] • Vertebrogenic thoracic pain
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| |-bgcolor="LightSteelBlue"
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| | '''Neurologic'''
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| |bgcolor="Beige"| • [[Tabes dorsalis]] •
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Nutritional / Metabolic'''
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| |bgcolor="Beige"| No underlying causes •
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Oncologic'''
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| |bgcolor="Beige"| • [[Liver cancer]] • [[Mesothelioma]] • [[Metastatic tumor]] • [[Neurofibroma]] • [[Pheochromocytoma]] •
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Opthalmologic'''
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| |bgcolor="Beige"| No underlying causes •
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Overdose / Toxicity'''
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| |bgcolor="Beige"| No underlying causes •
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Psychiatric'''
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| |bgcolor="Beige"| • [[Anxiety|Anxiety disorders]] • [[Affective disorders]] (e.g., [[depression]]) • [[Da costa's syndrome]] • Thought disorders (e.g., [[delusions|fixed delusions]]) • [[Hyperventilation syndrome]] • [[Hypochondria]] • [[Factitious disorders]] (e.g. [[Münchausen syndrome]] • [[Fabricated or induced illness]] • Hospital addiction syndrome • [[Panic attack]] •[[Somatoform disorder]]s • [[Somatization disorder]] •
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Pulmonary'''
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| |bgcolor="Beige"| • [[Asthma]] • [[Bronchial carcinoma]] • [[Bronchiectasis]] • [[Bronchogenic carcinoma]] • [[Carcinomatous]] •[[Pleural Effusion]] • [[Chronic Obstructive Pulmonary Disease]] ([[COPD]]) • [[Empyema]] • [[Hemothorax]] • [[Lung Abscess]] •[[Lung Cancer]] • [[Lymphoma]] • [[Mediastinitis]] • [[Pleuritis]] • [[Pleurodynia]] • [[Pneumomediastinum]] • [[Pneumonia]] •[[Pneumothorax]] • [[Pulmonary Embolism]] • [[Pulmonary Infarction]] • [[pneumothorax|Tension pneumothorax]] • [[Thymoma]] • Tracheoesophageal abscess • [[Tuberculosis]] •
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Renal / Electrolyte'''
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| |bgcolor="Beige"| No underlying causes •
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Rheum / Immune / Allergy'''
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| |bgcolor="Beige"| [[Familial mediterranean fever]] •
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Substance abuse'''
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| |bgcolor="Beige"| [[Cocaine]] •
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Trauma'''
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| |bgcolor="Beige"| Chest wall injuries •
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Miscellaneous'''
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| |bgcolor="Beige"| • Collagen vascular disease with pleuritis • [[Conn's Syndrome]] • Degenerative changes of cervical spine •[[Peritonitis]] • [[Pott's Disease]] • [[Xiphodynia]] •
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| |- | | |- |
| | | [[File:Siren.gif|30px|link=Chest pain resident survival guide]]|| <br> || <br> |
| | | [[Chest pain resident survival guide|'''Resident'''<br>'''Survival'''<br>'''Guide''']] |
| |} | | |} |
| | {{Chest pain}} |
| | '''For resident survival guide, click [[Chest pain resident survival guide|here]]''' |
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| == Diagnosis ==
| | '''For patient information, click [[Chest pain (patient information)|here]]''' |
| ==History and Symptoms==
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| [[Levine's sign]] | |
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| * Thorough history including:
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| ::* Onset
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| ::* Duration
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| ::* Type of pain
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| ::* Location
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| ::* Exacerbating factors
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| ::* Alleviating factors
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| ::* Radiation
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| * '''Risk factors''' for coronary artery disease:
| | {{CMG}}; '''Associate Editor(s)-In-Chief:''' {{Sara.Zand}} {{Aisha}} {{IQ}} {{CZ}}; [[Priyamvada Singh|Priyamvada Singh, M.B.B.S.]] [mailto:psingh13579@gmail.com] {{AMK}}, {{nuha}} |
| ::* [[Family history]]
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| ::* [[Smoking]]
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| ::* [[Hyperlipidemia]] | |
| ::* [[Diabetes]]
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| ==Physical Examination== | | {{SK}} |
| * Complete physical examination including the following:
| | ==[[Chest pain overview|Overview]]== |
| *:* [[Fever|Temperature]]
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| *:* [[Pulse]]
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| *:* [[Jugular venous pulse]] ([[JVP]])
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| *:* [[Auscultation]] of the chest
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| *:* [[Palpation]] of the chest
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| '''Heart:''' Cardiovascular examination including assessment of [[murmur]]s, [[Heart sounds|gallop]]s or [[Heart sounds|rub]]s,[[carotid bruit]] and [[heart sounds]]
| | ==[[Chest pain historical perspective|Historical Perspective]]== |
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| '''Extremities:''' Evidence of [[lower limb tenderness]] or [[pain]]
| | ==[[Chest pain classification|Classification]]== |
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| '''Other:''' [[Rectal examination]] is required to assess for [[occult bleeding]]
| | ==[[Chest pain pathophysiology|Pathophysiology]]== |
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| ==Laboratory Findings== | | ==[[Chest pain causes|Causes]]== |
| On the basis of the above, a number of tests may be ordered:
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| *'''[[Electrocardiogram]] ([[ECG]]):''' usually required for initial evaluation. [[ST elevation]] should require further urgent evaluation for reperfusion therapy.
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| *[[Blood test]]s:
| | ==[[Chest pain differential diagnosis|Differentiating Chest pain from other Diseases]]== |
| :::* [[Complete blood count]]
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| :::* [[Electrolyte]]s and [[renal function]] ([[creatinine]])
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| :::* [[Liver function tests|Liver enzyme]]s
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| :::* [[Creatine kinase]] (and ''CK-MB'' fraction in many hospitals)
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| :::* [[Troponin]] I or T (to indicate [[myocardium|myocardial]] damage)
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| :::* [[D-dimer]] (when suspicion for [[pulmonary embolism]] is present but low)
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| *[[X-ray]]s of the chest and/or abdomen:
| | ==[[Chest pain epidemiology and demographics|Epidemiology and Demographics]]== |
| ::*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]].
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| ::*[[Computed tomography|CT scanning]] may be better but is often not available
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| *'''Echocardiography or Ultrasound:'''
| | ==[[Chest pain risk factors|Risk Factors]]== |
| ::* [[Echocardiogram]] usually required for patients with suspected [[coronary artery disease]]
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| ::* To rule out [[aortic dissection]], [[transesophageal echocardiogram]] of the chest may be indicated
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| *'''MRI and CT:'''
| | ==[[Chest pain screening|Screening]]== |
| ::* [[CT]] scan of abdomen and chest may be helpful in ruling out [[pulmonary embolism]]
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| ::* To rule out [[aortic dissection]], a [[CT]] scan or [[MRI]] of the chest may be indicated
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| *'''Other Imaging Findings:'''
| | ==[[Chest pain natural history, complications and prognosis|Natural History, Complications, and Prognosis]]== |
| ::*[[Ventilation/perfusion scan|V/Q scintigraphy]] or CT Pulmonary angiogram (when a [[pulmonary embolism]] is suspected)
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| ::*For patients who are suspected to have [[coronary artery disease]] may require stress testing or [[cardiac catheterization]]
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| ::*Peak flow studies and pulmonary function tests may be indicated for patients requiring further evaluation
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| *'''Other Diagnostic Studies:'''
| | ==Diagnosis== |
| ::* Upper gastrointestinal [[endoscopy]] if [[esophagitis]] is suspected
| | [[Chest pain diagnostic study of choice|Diagnostic study of choice]] | [[Chest pain history and symptoms|History and Symptoms]] | [[Chest pain physical examination|Physical Examination]] | [[Chest pain laboratory findings|Laboratory Findings]] | [[Chest pain electrocardiogram|Electrocardiogram]] | [[Chest pain x ray|X-Ray Findings]] | [[Chest pain echocardiography and ultrasound|Echocardiography and Ultrasound]] | [[Chest pain CT scan|CT-Scan Findings]] | [[Chest pain MRI|MRI Findings]] | [[Chest pain other imaging findings|Other Imaging Findings]] | [[Chest pain other diagnostic studies|Other Diagnostic Studies]] |
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| ==Interpretation==
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| *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)''.
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| *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.
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| *Often, no definite cause will be found, and the focus in these cases is on '''excluding severe diseases and reassuring the patient'''.
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| *If [[acute coronary syndrome]] (e.g.[[unstable angina]]) is suspected, many patients are admitted briefly for observation, sequential [[ECG]]s, and determination of cardiac enzyme levels over time ([[creatine kinase|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.
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| ==Treatment== | | ==Treatment== |
| '''Immediate Management:'''
| | [[Chest pain medical therapy|Medical Therapy]] | [[Chest pain interventions|Interventions]] | [[Chest pain surgery|Surgery]] | [[Chest pain primary prevention|Primary Prevention]] | [[Chest pain secondary prevention|Secondary Prevention]] | [[Chest pain cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Chest pain future or investigational therapies|Future or Investigational Therapies]] |
| * Special attention to: '''airway''', '''breathing''', and '''circulation'''
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| * Treat all underlying etiologies as clinically indicated
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| * Supplemental O2 should be administered to patients with suspected [[coronary artery disease]]
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| '''Acute Pharmacotherapies:'''
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| * For patients with [[coronary artery disease]]:
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| *:* [[Aspirin]]
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| *:* [[Nitroglycerin]]
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| *:* [[Morphine]] (if necessary)
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| * For patients with [[myocardial infarction]]:
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| *:* [[Heparin]]
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| *:* [[Beta-blockers]]
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| *:* [[ACE inhibitors]]
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| *:* [[Thrombolytic therapy]]
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| *:* [[Glycoprotein IIb/IIIa inhibitors]]
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| '''Surgery and Device Based Therapy:'''
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| * For patients in which [[myocardial infarction]] is suspected, [[angioplasty]] may be indicated
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| * 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>
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| ==Sources==
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| *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>
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| *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>
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| | ==Case Studies== |
| | [[Chest pain case study one|Case #1]] |
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| | ==Related Chapters== |
| | *[[NICE guidelines for management of chest pain]] |
| | *[[Unstable angina]] |
| | *[[Chronic stable angina]] |
| | *[[Myocardial infarction]] |
| | *[[Pulmonary embolism]] |
| | *[[Pneumonia]] |
| | *[[Costochondritis]] |
| | *[[Cardiogenic shock]] |
| | *[[The Patient History in Cardiovascular Disease]] |
| | *[[Diagnosis Wikidoc: Chest Pain no ST elevation]] |
| | *[[Diagnosis WikiDoc:Chest Pain]] |
| | *[[Pleuritic chest pain]] |
| | *[[GERD]] |
| | *[[Dysphagia]] |
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| ==References== | | ==References== |
| {{reflist|2}} | | {{Reflist|2}} |
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| | {{WikiDoc Sources}} |
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| [[Category:Cardiology]] | | [[Category:Cardiology]] |
| [[Category:Pulmonology]] | | [[Category:Pulmonology]] |
| | [[Category:Symptoms]] |
| [[Category:Signs and symptoms]] | | [[Category:Signs and symptoms]] |
| [[Category:Emergency medicine]] | | [[Category:Emergency medicine]] |
| | | [[Category:Gastroenterology]] |
| {{WikiDoc Help Menu}}
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| {{WikiDoc Sources}}
| | [[Category:Up-To-Date]] |
