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* For patients who are suspected to have [[coronary artery disease]] may require stress testing or [[cardiac catheterization]]
* 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
* Peak flow studies and pulmonary function tests may be indicated for patients requiring further evaluation
===Other Diagnostic Studies===
===Other Diagnostic Studies===
* Upper gastrointestinal [[endoscopy]] if [[esophagitis]] is suspected
* Upper gastrointestinal [[endoscopy]] if [[esophagitis]] is suspected

Revision as of 17:29, 22 January 2013

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

Most recent articles

cited articles

Review articles

CME Programs

Powerpoint slides

Images

Ongoing Trials at Clinical Trials.gov

US National Guidelines Clearinghouse

NICE Guidance

FDA on Chest pain

CDC on Chest pain

Chest pain in the news

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(s)-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]; Priyamvada Singh, M.B.B.S. [3]

To go back to the chapter on Ustable angina, click here.

Expert algorithm: An expert algorithm to assist in the diagnosis of chest pain can be found here:

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.

5 Life Threatening Diseases to Exclude Immediately

The frequency of conditions exclusive of acute myocardial infarction in a decreasing order is [1]:

  1. Gastroesophageal disease
  2. Ischemic heart disease (angina, not myocardial infarction)
  3. Chest wall syndromes

Differentiating the Life Threatening and Ischemic Causes of Chest Pain from other Disorders

Thorough history including: onset, duration, type of pain, location, exacerbating factors, alleviating factors, and radiation. Risk factors for coronary artery disease: family history, smoking, hyperlipidemia, and diabetes.

Clinical Features of Different Conditions Presenting with Acute Chest Discomfort

CARDIOVASCULAR

Condition Onset Duration Type of pain Location Exacerbating factors Alleviating factors Radiation Associated features
Stable Angina Sudden (acute) 2-10 minutes Heaviness, pressure, tightness, squeezing, burning (Levine's sign) Retrosternal Exertion, emotions, cold Rest, sublingual nitroglycerine (within minutes) Radiation to neck, jaw, shoulders, or arms (commonly on left) Sweating, nausea, palpitations, dizziness, shortness of breath, sense of impending doom
Unstable Angina Acute 10-20 minutes same as stable angina but often more severe same as stable angina same as stable angina but occurs with lower levels of exertion & rest same as stable angina same as stable angina same as stable angina
Myocardial Infarction Acute commonly > 20 minutes same as stable angina but often more severe same as stable angina same as stable angina but occurs with lower levels of exertion & rest Usually unrelieved by nitroglycerine and rest same as stable angina same as stable angina
Aortic stenosis Acute, recurrent episodes of angina same as stable angina same as stable angina same as stable angina same as stable angina same as stable angina same as stable angina Not specific
Aortic dissection Sudden severe progressive pain (common) or chronic (rare) Variable Tearing, ripping sensation, knife like Depends on area of dissection Variable unrelenting pain, unrelieved by nitroglycerine and rest Radiating to back, between shoulder blades (dissection in ascending aorta) Trauma, Surgical manipulation, pregnancy, Hypertension, connective tissue disease like marfan's syndrome (cystic medial degeneration)
Pericarditis Acute or subacute May last for hours to days Sharp, localized Retrosternal Increases with coughing, deep breathing, supine position Relieved by sitting up and leaning forward Radiation to shoulder, neck, back abdomen Not specific

PULMONARY

Condition Onset Duration Type of pain Location Exacerbating factors Alleviating factors Radiation Associated features
Pulmonary embolism Acute May last minutes to hours Sharp, or knifelike pleuritic pain Localized to side of lesion Increased on respiratory movements, deep breathing or cough Not specific Not specific Dyspnea, tachypnea, palpitation, and light headedness, hemoptysis, or a history of venous thromboembolism or coagulation abnormalities.
Spontaneous Pneumothorax Acute May last minutes to hours Sharp, localized pleuritic Localized to side of lesion Not specific Not specific Not specific Dyspnea, decreased breath sounds on involved side
Pleuritis Acute, subacute, chronic May last minutes to hours Sharp, localized pleuritic Localized to side of lesion Increased on respiratory movements, deep breathing or cough Not specific Not specific Dyspnea, cough, fever
Pulmonary hypertension Acute, subacute, chronic Variable Pressure like Substernal Not specific Not specific Not specific Dyspnea, symptoms of right heart failure (edema

GASTROINTESTINAL

Condition Onset Duration Type of pain Location Exacerbating factors Alleviating factors Radiation Associated features
GERD, Peptic ulcer Acute Minutes to hours (gastroesophageal reflux), prolonged (peptic ulcer) Burning Substernal, epigastric Increases on alcohol, aspirin, post meal lying down, morning, empty stomach Relieves on antacid, food Not specific Not specific
Esophageal spasm Acute Minutes to hours Burning, pressure Retrosternal Not specific Relieved by sublingual nitroglycerine Not specific Not specific (closely mimic angina)
Cholelithasis Acute, subacute Minutes to hours Burning, colicky Right upper abdomen, substernal, epigastric Increases post meal, fatty food, 1-2 hours post meal Analgesics Not specific Not specific

MISCELLANEOUS

Condition Onset Duration Type of pain Location Exacerbating factors Alleviating factors Radiation Associated features
Musculo-skeletal pain Acute, subacute Variable Pressure, aching Localized to involved area Increases by movement and pressure on involved area Analgesics Not specific Not specific
Psychotic conditions Acute, subacute, chronic Variable Variable Variable Variable Not specific Not specific History of depression, Panic attacks, Agrophobia

Diagnosis

Electrocardiogram

  • Electrocardiogram is usually required for initial evaluation.
  • ST elevation should require further urgent evaluation for reperfusion therapy.
  • Salient findings on ECG are:
    • New ST elevation (>1 mm) or Q waves on ECG (MI)
    • ST depression >1 mm or ischemic T waves (unstable angina)

X-rays of the chest and/or abdomen

Echocardiography or Ultrasound

MRI and CT

  • CT angiography, lung scan may be helpful in ruling out pulmonary embolism These tests are sometimes combined with lower extremity venous ultrasound or D-dimer testing.
  • To rule out aortic dissection, a CT scan chest with contrast, MRI or transesophageal echocardiography can be used.

Other Imaging Findings

Other Diagnostic Studies

Treatment

NICE guidelines for management of chest pain

General strategies for management of acute chest pain

  • 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 analysis 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. Emergency reperfusion therapy either by percutaneous coronary intervention or thrombolytic agents is recommended after diagnosis
  • 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.
  • Recommendations regarding the minimum length of stay in a monitored bed for a patient who has no further symptoms have decreased in recent years to 12 h or less

Immediate Management

  • Special attention to: airway, breathing, and circulation. Supplemental O2 should be administered to patients with suspected coronary artery disease
  • Once it's ensured that the patient has stable vitals then a detailed history, physical examination and lab tests are required to reach a diagnosis. Special attention to pain's nature and risk factors are required.
  • ECG, cardiac marker, blood test and chest Xrays are initial primary tests done.
  • Nitroglycerine and proton pump inhibitors are usually the initial treatment given. However, caution should be taken by the physician in diagnosis based on response to theses therapies as relief of pain on antacids doesn't exclude ischemic heart diseases.
  • Treat all underlying etiologies as clinically indicated

Acute Pharmacotherapies

Surgery and Device Based Therapy

Sources

  • The 2004 ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction [7]
  • The 2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients with ST-Elevation Myocardial Infarction [8]
  • National Institute for Health and Clinical Excellence (NICE) guidelines [9]

References

  1. ↑ Fruergaard P, Launbjerg J, Hesse B, Jørgensen F, Petri A, Eiken P, Aggestrup S, Elsborg L, Mellemgaard K (1996). "The diagnoses of patients admitted with acute chest pain but without myocardial infarction". European Heart Journal. 17 (7): 1028–34. PMID 8809520. Retrieved 2012-05-02. Unknown parameter |month= ignored (help)
  2. ↑ 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)
  3. ↑ 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)
  4. ↑ 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)
  5. ↑ 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)
  6. ↑ Fox M, Forgacs I (2006). "Unexplained (non-cardiac) chest pain". Clin Med. 6 (5): 445–9. PMID 17080889.
  7. ↑ 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)
  8. ↑ 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)
  9. ↑ [[]]. PMID 22420013. Missing or empty |title= (help); |access-date= requires |url= (help)


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