Chest pain: Difference between revisions

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{{Infobox_Disease |
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  Name          = {{PAGENAME}} |
{{Chest pain}}
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{{CMG}}; '''Associate Editor-In-Chief:''' {{CZ}}
  Caption        = |
  DiseasesDB    = |
  ICD10          = |
  ICD9          = |
  ICDO          = |
  OMIM          = |
  MedlinePlus    = |
  eMedicineSubj  = |
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'''For patient information on chest pain click [[{{PAGENAME}} (patient information)|here]]'''
 
'''For patient information on heart attacks click [[Heart attack (patient information)|here]]'''
 
{{SI}}
{{WikiDoc Cardiology Network Infobox}}
{{CMG}}
 
'''Associate Editor-In-Chief:''' {{CZ}}
 
{{Editor Join}}
 
 
'''Click [[Chronic stable angina|''here'']] for the Chronic stable angina main page'''
 


==Overview==
==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 [[electrocardiogram|12 lead electrocardiogram]].
*A full medical history may assist in the prompt management of the patient with chest pain.


'''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 [[electrocardiogram|12 lead electrocardiogram]]. A full medical history may assist in the prompt management of the patient with chest pain.
==Chest pain that suggest cardiac ischemia as the underlying cause==
 
* Describing the pain as heaviness, a pressure or a '''band like tightness'''
'''Associated symptoms of chest pain that suggest cardiac ischemia as the underlying cause include the following:'''
 
* Describing the pain as heaviness, a pressure or a "band like" tightness
* Radiation of the pain to [[neck]], [[jaw]] or left arm
* Radiation of the pain to [[neck]], [[jaw]] or left arm
* [[Diaphoresis|Sweating]]
* [[Diaphoresis|Sweating]]
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* [[Dizziness]]
* [[Dizziness]]
* [[Shortness of breath]]
* [[Shortness of breath]]
* A "sense of impending doom."
* '''A sense of impending doom'''.
 
'''In general, clinical features that are not characteristic of myocardial ischemia include the following:'''


==Chest pain that are not characteristic of myocardial ischemia==
*[[Myalgia|Muscular pain]]; reproduced with or brought on by shoulder and/or forearm movements or postural changes,
*[[Myalgia|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]]
*[[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
*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 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 that radiates into the lower extremities
*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 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==
* [[Aortic Dissection]]
* [[Aortic Dissection]]
* [[Esophageal Rupture]]
* [[Esophageal Rupture]]
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* [[Tension Pneumothorax]]
* [[Tension Pneumothorax]]


==Differential Diagnosis of {{PAGENAME}}==
==Differential Diagnosis of Chest Pain==
{|style="width:70%; height:100px" border="1"
{|style="width:70%; height:100px" border="1"
|style="height:100px"; style="width:25%" border="1" bgcolor="LightSteelBlue" | '''Cardiovascular'''
|style="height:100px"; style="width:25%" border="1" bgcolor="LightSteelBlue" | '''Cardiovascular'''
|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]]
|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]]
|-
|-
|-bgcolor="LightSteelBlue"
|-bgcolor="LightSteelBlue"
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|-bgcolor="LightSteelBlue"
|-bgcolor="LightSteelBlue"
| '''Gastroenterologic'''
| '''Gastroenterologic'''
|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]] •   
|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]] •   
|-
|-
|-bgcolor="LightSteelBlue"
|-bgcolor="LightSteelBlue"
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|-bgcolor="LightSteelBlue"
|-bgcolor="LightSteelBlue"
| '''Musculoskeletal / Ortho'''
| '''Musculoskeletal / Ortho'''
|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
|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
|-
|-
|-bgcolor="LightSteelBlue"
|-bgcolor="LightSteelBlue"
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|-bgcolor="LightSteelBlue"
|-bgcolor="LightSteelBlue"
| '''Psychiatric'''
| '''Psychiatric'''
|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]] •  
|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]] •  
|-
|-
|-bgcolor="LightSteelBlue"
|-bgcolor="LightSteelBlue"
| '''Pulmonary'''
| '''Pulmonary'''
|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]] •   
|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]] •   
|-
|-
|-bgcolor="LightSteelBlue"
|-bgcolor="LightSteelBlue"
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|-bgcolor="LightSteelBlue"
|-bgcolor="LightSteelBlue"
| '''Miscellaneous'''
| '''Miscellaneous'''
|bgcolor="Beige"| • Collagen vascular disease with pleuritis • [[Conn's Syndrome]] • Degenerative changes of cervical spine • [[Peritonitis]] • [[Pott's Disease]] • [[Xiphodynia]] •  
|bgcolor="Beige"| • Collagen vascular disease with pleuritis • [[Conn's Syndrome]] • Degenerative changes of cervical spine •[[Peritonitis]] • [[Pott's Disease]] • [[Xiphodynia]] •  
|-
|-
|}
|}


== Diagnosis ==  
== Diagnosis ==  
 
==History and Symptoms==
=== History and Symptoms ===
[[Levine's sign]]
[[Levine's sign]]


* Thorough history including:
* Thorough history including:
*:* Onset
::* Onset
*:* Duration
::* Duration
*:* Type of pain
::* Type of pain
*:* Location
::* Location
*:* Exacerbating factors
::* Exacerbating factors
*:* Alleviating factors
::* Alleviating factors
*:* Radiation
::* Radiation
* Risk factors for coronary artery disease:
*:* [[Family history]]
*:* [[Smoking]]
*:* [[Hyperlipidemia]]
*:* [[Diabetes]]


== Physical Examination ==  
* '''Risk factors''' for coronary artery disease:
::* [[Family history]]
::* [[Smoking]]
::* [[Hyperlipidemia]]
::* [[Diabetes]]
 
==Physical Examination==  
* Complete physical examination including the following:
* Complete physical examination including the following:
*:* [[Fever|Temperature]]
*:* [[Pulse]]
*:* [[Jugular venous pulse]] ([[JVP]])
*:* [[Auscultation]] of the chest
*:* [[Auscultation]] of the chest
*:* [[Jugular venous pulse]] ([[JVP]])
*:* [[Palpation]] of the chest
*:* [[Palpation]] of the chest
*:* [[Pulse]]
*:* [[Fever|Temperature]]


=== Heart ===
'''Heart:''' Cardiovascular examination including assessment of [[murmur]]s, [[Heart sounds|gallop]]s or [[Heart sounds|rub]]s,[[carotid bruit]] and [[heart sounds]]
* Cardiovascular examination including assessment of [[murmur]]s, [[Heart sounds|gallop]]s or [[Heart sounds|rub]]s, [[carotid bruit]] and [[heart sounds]]


=== Extremities ===
'''Extremities:''' Evidence of [[lower limb tenderness]] or [[pain]]
* Evidence of [[lower limb tenderness]] or [[pain]]


=== Other ===
'''Other:''' [[Rectal examination]] is required to assess for [[occult bleeding]]
* [[Rectal examination]] is required to assess for [[occult bleeding]]


== Laboratory Findings ==  
==Laboratory Findings==  
On the basis of the above, a number of tests may be ordered:
On the basis of the above, a number of tests may be ordered:
* [[X-ray]]s of the chest and/or abdomen ([[Computed tomography|CT scanning]] may be better but is often not available)
*'''[[Electrocardiogram]] ([[ECG]]):''' usually required for initial evaluation. [[ST elevation]] should require further urgent evaluation for reperfusion therapy.
* An [[electrocardiogram]] ([[ECG]])
* [[Ventilation/perfusion scan|V/Q scintigraphy]] or CT Pulmonary angiogram (when a [[pulmonary embolism]] is suspected)
* [[Blood test]]s:
** [[Complete blood count]]
** [[Electrolyte]]s and [[renal function]] ([[creatinine]])
** [[Liver function tests|Liver enzyme]]s
** [[Creatine kinase]] (and ''CK-MB'' fraction in many hospitals)
** [[Troponin]] I or T (to indicate [[myocardium|myocardial]] damage)
** [[D-dimer]] (when suspicion for [[pulmonary embolism]] is present but low)


==Interpretation==
*[[Blood test]]s:
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 ([[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.
:::* [[Complete blood count]]
:::* [[Electrolyte]]s and [[renal function]] ([[creatinine]])
:::* [[Liver function tests|Liver enzyme]]s
:::* [[Creatine kinase]] (and ''CK-MB'' fraction in many hospitals)
:::* [[Troponin]] I or T (to indicate [[myocardium|myocardial]] damage)
:::* [[D-dimer]] (when suspicion for [[pulmonary embolism]] is present but low)


=== [[Electrocardiogram]] ===
*[[X-ray]]s of the chest and/or abdomen:
* [[ECG]] usually required for initial evaluation. ST elevation should require further urgent evaluation for reperfusion therapy.
::*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]].
::*[[Computed tomography|CT scanning]] may be better but is often not available


=== [[Chest X Ray]] ===
*'''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


* 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]].
*'''MRI and CT:'''
::* [[CT]] scan of abdomen and chest may be helpful in ruling out [[pulmonary embolism]]
::* To rule out [[aortic dissection]], a [[CT]] scan or [[MRI]] of the chest may be indicated


=== MRI and CT ===
*'''Other Imaging Findings:'''
* [[CT]] scan of abdomen and chest may be helpful in ruling out [[pulmonary embolism]]
::*[[Ventilation/perfusion scan|V/Q scintigraphy]] or CT Pulmonary angiogram (when a [[pulmonary embolism]] is suspected)
* To rule out [[aortic dissection]], a [[CT]] scan or [[MRI]] of the chest may be indicated
::*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


=== Echocardiography or Ultrasound ===
*'''Other Diagnostic Studies:'''
* [[Echocardiogram]] usually required for patients with suspected [[coronary artery disease]]
::* Upper gastrointestinal [[endoscopy]] if [[esophagitis]] is suspected
* To rule out [[aortic dissection]], [[transesophageal echocardiogram]] of the chest may be indicated


=== Other Imaging Findings ===
==Interpretation==
* Ventilation and quantitative (VQ) scan may be indicated for patients requiring further evaluation
*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)''.
* For patients who are suspected to have [[coronary artery disease]] may require stress testing or [[cardiac catheterization]]
*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.
* Peak flow studies and pulmonary function tests may be indicated for patients requiring further evaluation
*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 [[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.
=== Other Diagnostic Studies ===
* Upper gastrointestinal [[endoscopy]] if [[esophagitis]] is suspected


==Treatment==
==Treatment==
'''Immediate Management:'''
* Special attention to: '''airway''', '''breathing''', and '''circulation'''
* Special attention to: '''airway''', '''breathing''', and '''circulation'''
* Treat all underlying etiologies as clinically indicated
* Treat all underlying etiologies as clinically indicated
* Supplemental O2 should be administered to patients with suspected [[coronary artery disease]]
* Supplemental O2 should be administered to patients with suspected [[coronary artery disease]]


== Pharmacotherapy ==
'''Acute Pharmacotherapies:'''
 
=== Acute Pharmacotherapies ===
* For patients with [[coronary artery disease]]:
* For patients with [[coronary artery disease]]:
*:* [[Aspirin]]
*:* [[Aspirin]]
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*:* [[Glycoprotein IIb/IIIa inhibitors]]
*:* [[Glycoprotein IIb/IIIa inhibitors]]


== Surgery and Device Based Therapy ==
'''Surgery and Device Based Therapy:'''
* 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==
==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 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>
*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==
 
{{reflist|2}}


== Suggested Links and Web Resources ==
== Suggested Links and Web Resources ==
* [http://www.emedicinehealth.com/articles/27608-1.asp Wilderness Medicine: Chest Pain] - eMedicineHealth.com
* [http://www.emedicinehealth.com/articles/27608-1.asp Wilderness Medicine: Chest Pain] - eMedicineHealth.com
* [http://anginapectorisonline.com Angina Pectoris Online] Chest pain resource for nurses and those in similar professions.
* [http://anginapectorisonline.com Angina Pectoris Online] Chest pain resource for nurses and those in similar professions.


 
==References==
[[{{PAGENAME}}#Overview|''Return to top'']]
{{reflist|2}}
 
 
{{Symptoms and signs}}
{{Electrocardiography}}
{{Circulatory system pathology}}
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[[fr:Douleur thoracique]]
[[pt:Dor torácica]]
[[uk:Біль за грудиною]]
[[ur:سینے کا درد]]
[[yi:טשעסט פעין]]
[[pl:Ból w klatce piersiowej]]
[[tr:Göğüs ağrısı]]


[[Category:Cardiology]]
[[Category:Cardiology]]

Revision as of 16:38, 15 July 2011

Chest pain Microchapters

Home

Patient Information

Overview

Historical Perspective

Classification

Pathophysiology

Causes

Differentiating Chest pain from other Diseases

Epidemiology and Demographics

Risk Factors

Screening

Natural History, Complications and Prognosis

Chest Pain in Pregnancy

Diagnosis

Diagnostic Study of Choice

History and Symptoms

Physical Examination

Laboratory Findings

Electrocardiogram

X-ray

Echocardiography and Ultrasound

CT scan

MRI

Other Imaging Findings

Other Diagnostic Studies

Treatment

Medical Therapy

Interventions

Surgery

Primary Prevention

Secondary Prevention

Cost-Effectiveness of Therapy

Future or Investigational Therapies

Case Studies

Case #1

Chest pain On the Web

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cited articles

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CME Programs

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US National Guidelines Clearinghouse

NICE Guidance

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Blogs on Chest pain

to Hospitals Treating Chest pain

Risk calculators and risk factors for Chest pain

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]

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 that suggest cardiac ischemia as the underlying cause

Chest pain that are not 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 knifelike pain brought on by respiratory movements as deep breathing orcough
  • 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 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 (postpericardiotomy) • Hypertrophic Cardiomyopathy •Mitral valve prolapse • Myocardial infarction • Myocarditis • Pericardial tamponade •Pericarditis • Takotsubos cardiomyopathy • Stress 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 • Hyperthyroidism • Hypothyroidism
Environmental No underlying causes •
Gastroenterologic • 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 • Pancreatitis •Peptic ulcer disease • Perforated ulcer • Plummer-Vinson Syndrome • Pneumoperitoneum • Splenic enlargement • Splenic infarction • Subdiaphragmatic abcsess • Subphrenic abscess • Whipple's Disease •
Genetic No underlying causes •
Hematologic Sickle cell anemia •
Iatrogenic No underlying causes •
Infectious Disease • Bornholm disease • Hepatitis • HIV infection • Herpes Zoster •
Musculoskeletal / Ortho • 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 • Shoulder bursitis •Shoulder tendinitis • Soft tissue sarcoma or tumor • Sternoclavicular arthritis • Strain of pectoralis muscle • Thoracic Outlet Syndrome • Trauma • Vertebrogenic thoracic pain
Neurologic • Tabes dorsalis •
Nutritional / Metabolic No underlying causes •
Oncologic • Liver cancer • Mesothelioma • Metastatic tumor • Neurofibroma • Pheochromocytoma •
Opthalmologic No underlying causes •
Overdose / Toxicity No underlying causes •
Psychiatric • Anxiety disorders • Affective disorders (e.g., depression) • Da costa's syndrome • Thought disorders (e.g., fixed delusions) • Hyperventilation syndrome • Hypochondria • Factitious disorders (e.g. Münchausen syndrome • Fabricated or induced illness • Hospital addiction syndrome • Panic attack •Somatoform disorders • Somatization disorder •
Pulmonary • 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 • Tension pneumothorax • Thymoma • 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 •Peritonitis • Pott's Disease • Xiphodynia •

Diagnosis

History and Symptoms

Levine's sign

  • Thorough history including:
  • Onset
  • Duration
  • Type of pain
  • Location
  • Exacerbating factors
  • Alleviating factors
  • Radiation
  • Risk factors for coronary artery disease:

Physical Examination

Heart: Cardiovascular examination including assessment of murmurs, gallops or rubs,carotid bruit and heart sounds

Extremities: Evidence of lower limb tenderness or pain

Other: Rectal examination is required to assess for occult bleeding

Laboratory Findings

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

  • X-rays of the chest and/or abdomen:
  • Echocardiography or Ultrasound:
  • MRI and CT:
  • Other Imaging Findings:
  • Other Diagnostic Studies:

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.

Treatment

Immediate Management:

  • 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

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]

Suggested Links and Web Resources

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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