Chest pain

Chest pain

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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:

• 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."

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:

• Aortic Dissection
• Esophageal Rupture
• Myocardial Infarction
• Pulmonary Embolism
• Tension Pneumothorax

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:

  • Family history
  • Smoking
  • Hyperlipidemia
  • Diabetes

Physical Examination

• Complete physical examination including the following:

  • Auscultation of the chest
  • Jugular venous pulse (JVP)
  • Palpation of the chest
  • Pulse
  • Temperature

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 (CT scanning may be better but is often not available)
• An electrocardiogram (ECG)
• V/Q scintigraphy or CT Pulmonary angiogram (when a pulmonary embolism is suspected)
• Blood tests:
  • Complete blood count
  • Electrolytes and renal function (creatinine)
  • Liver enzymes
  • Creatine kinase (and CK-MB fraction in many hospitals)
  • Troponin I or T (to indicate myocardial damage)
  • D-dimer (when suspicion for pulmonary embolism is present but low)

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

Chest X Ray

• 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

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

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

• Upper gastrointestinal endoscopy if esophagitis is suspected

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

• For patients with coronary artery disease:

  • Aspirin
  • Nitroglycerin
  • Morphine (if necessary)

• For patients with myocardial infarction:

  • Heparin
  • Beta-blockers
  • ACE inhibitors
  • Thrombolytic therapy
  • Glycoprotein IIb/IIIa inhibitors

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.

References

• Chun A, McGee S (2004). "Bedside diagnosis of coronary artery disease: a systematic review". Am J Med. 117 (5): 334–43. PMID 15336583.
• 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. Full text (PDF)
• Butler K, Swencki S (2006). "Chest pain: a clinical assessment". Radiol Clin North Am. 44 (2): 165–79, vii. PMID 16500201.
• Haro L, Decker W, Boie E, Wright R (2006). "Initial approach to the patient who has chest pain". Cardiol Clin. 24 (1): 1–17, v. PMID 16326253.CS1 maint: Multiple names: authors list (link)
• Fox M, Forgacs I (2006). "Unexplained (non-cardiac) chest pain". Clin Med. 6 (5): 445–9. PMID 17080889.

Suggested Links and Web Resources

• Wilderness Medicine: Chest Pain - eMedicineHealth.com
• Angina Pectoris Online Chest pain resource for nurses and those in similar professions.

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