Chest pain resident survival guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Rim Halaby, M.D. [2] Alejandro Lemor, M.D. [3]

Overview

Chest pain is discomfort or pain that is felt anywhere along the front of the body between the neck and the upper abdomen.

Causes

Life-Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.

• Aortic dissection
• Myocardial infarction
• Pericardial tamponade
• Pneumothorax
• Pulmonary embolism
• Unstable angina

Common Causes

• Biliary colic
• Costochondritis
• Cocaine induced coronary vasospasm
• Esophageal spasm
• GERD
• Myocardial infarction
• Panic attacks
• Pneumonia
• Stable angina

Click here for the complete list of causes.

FIRE: Focused Initial Rapid Evaluation

A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention.

Boxes in the red signify that an urgent management is needed.

Abbreviations:

Identify cardinal findings that increase the pretest probability of life-threatening chest pain ❑ Sudden onset ❑ Severe shortness of breath ❑ Unstable patient ❑ Related to physical exertion

Identify cardinal risk factors of life-threatening chest pain ❑ Age > 45 years ❑ Hypertension ❑ Smoking ❑ History of CAD ❑ Diabetes mellitus ❑ Male gender

Does the patient has the following findings suggestive of acute coronary syndrome (ACS)? ❑ Pain described as a heaviness or crushing sensation ❑ Radiates to the left arm, neck and/or jaw ❑ Associated with: ❑ Diaphoresis ❑ Dyspnea ❑ Nausea or vomiting

YES

NO

❑ Immediately order a 12-lead ECG ❑ Order cardiac enzymes: Troponin, CK-MB

Rule out other life-threatening conditions

Proceed to the complete diagnostic approach below

Does the ECG has ST elevation?

YES

NO

STEMI ❑ Pain described as a heaviness or crushing sensation ❑ Radiates to the left arm, neck and/or jaw ❑ Not alleviated by rest or medications ❑ PR depression is absent New LBBB ❑ EKG evidence of LBBB ❑ QRS ≥ 120 ms ❑ QS or rS in V1 ❑ Monophasic R in I, aVL and V6 ❑ Chest pain with same characteristic as STEMI

Unstable angina/NSTEMI ❑ Pain described as a heaviness or crushing sensation ❑ Radiates to the left arm, neck and/or jaw ❑ Not alleviated by rest or medications ❑ Pain last > 10 min

Pericarditis ❑ Sharp and pleuritic pain that is improved by sitting up and leaning forward ❑ Diffuse, non-specific ST elevation ❑ PR depression ❑ PR elevation in lead aVR

Pneumothorax ❑ Dyspnea ❑ Hypoxia ❑ Tracheal deviation towards the unaffected side ❑ Hyperresonance on the affected side

Aortic dissection ❑ Acute onset of heart failure ❑ Low pitched early diastolic murmur best heard at the 2nd right ICS ❑ Asymmetric blood pressure in the upper extremities ❑ Widened mediastinum on chest X-ray ❑ History of: ❑ Hypertension ❑ Marfan syndrome

Pulmonary embolism ❑ Suddenchest pain ❑ Severe dyspnea ❑ History of DVT, surgery, malignancy, immobility ❑ Elevated D-dimer

Esophageal rupture ❑ Vomiting ❑ Lower chest pain ❑ Cervical subcutaneous emphysema ❑ Overindulgence in alcohol ❑ Overindulgence in food ❑ CXR: Air in the mediastium or peritoneum

Administer: ❑ Aspirin 162-325 mg ❑ Oxygen (2-4 L/min) if satO2 <90% ❑ Beta blockers (unless contraindicated) ❑ Sublingual nitroglycerin 0.4 mg every 5 min for a total of 3 doses Do not delay primary angioplasty or fibrinolysis Click here for the detailed management for STEMI Click here for the detailed management for NSTEMI

❑ Immediately transfer the patient to ICU ❑ Perform pericardial fluid drainage Click here for the detailed management

❑ Immediately insert a 14-16 Gauge needle in the 2nd intercostal space at the midclavicular line of the affected hemithorax Click here for the detailed management

❑ Immediately order a TEE to confirm diagnosis ❑ Transfer to a cardio-thoracic unit for surgical management Click here for the detailed management

Click here for the detailed management

❑ Immediately start antibiotic therapy to prevent mediastinitis and sepsis ❑ Surgical repair of the perforation Click here for the detailed management

Complete Diagnostic Approach

A complete diagnostic approach should be carried out after a focused initial rapid evaluation is conducted and following initiation of any urgent intervention.

Abbreviations: MI: Myocardial infarction; DVT: Deep venous thrombosis; GERD: Gastroesophageal reflux disease; CHD: Coronary heart disease; PE: Pulmonary embolism; COPD: Chronic obstructive pulmonary disease; SLE: Systemic lupus erythematosus; LVH: Left ventricular hypertrophy; ECG: Electrocardiogram; P2: Second heart sound, pulmonary component; S1: First heart sound; S2: Second heart sound; S3: Third heart sound; TTE: Transthoracic echocardiography; TEE: Transesophageal echocardiography; HF: Heart failure; CBC: Complete blood count; ABG: Arterial blood gases; JVD: Jugular venous pressure; CXR: Chest X-ray; TB: Tuberculosis; LBBB: Left bundle branch block; STEMI: ST elevation myocardial infarction; NSTEMI: Non-ST elevation myocardial infarction;

Characterize the chest pain ❑ Onset (sudden or gradual) ❑ Location (retrosternal, epigastric, chest wall, diffuse) ❑ Type (sharp, pleuritic, heaviness, colicky) ❑ Radiation (shoulder, neck, back) ❑ Duration ❑ Worsened by (activities, position, drugs) ❑ Alleviated by (activities, position, drugs)

Characterize the symptoms Non-specific symptoms ❑ Altered mental status ❑ Shortness of breath ❑ Nausea and vomiting ❑ Dizziness ❑ Syncope ❑ Fatigue ❑ Lethargy Symptoms suggestive of cardiac etiology ❑ Heaviness or crushing sensation (suggestive of myocardial ischemia) ❑ Radiating to left arm, neck and/or jaw (suggestive of myocardial ischemia) ❑ Interscapular pain (suggestive of aortic dissection) ❑ Epigastric pain (suggestive of inferior MI) ❑ Sweating ❑ Palpitations ❑ Pain associated with exertion ❑ Loss of consciousness Symptoms suggestive of pulmonary etiology ❑ Pleuritic pain ❑ Sharp or knife-like ❑ Increases with respiratory movements ❑ Dyspnea ❑ Cough ❑ Hemoptysis ❑ Pain and swelling of lower extremities (suggestive of DVT) ❑ Chills (suggestive of pneumonia) Symptoms suggestive of gastrointestinal etiology ❑ Burning sensation (suggestive of GERD) ❑ Colic (suggestive of cholelithiasis) ❑ Epigastric pain ❑ Pain is associated with: ❑ Meals (suggestive of GERD or peptic ulcer) ❑ Medication intake (eg: NSAIDs) ❑ Swallowing ❑ Changes in position ❑ Wakening during night (suggestive of GERD) ❑ Relieved by antacids ❑ Not related to exercise

Inquire about past medical history and risk factors ❑ Previous episodes of chest pain ❑ Cardiovascular disease ❑ Previous MI ❑ DVT ❑ Hypertension ❑ Family history of MI or CHD ❑ Recent medical procedures ❑ CVC (suggestive of pneumothorax) ❑ Bronchoscopy (suggestive of pneumothorax) ❑ Pleural biopsy (suggestive of pneumothorax) ❑ Pulmonary disease ❑ Previous PE ❑ COPD ❑ Asthma ❑ Malignancy ❑ Recent trauma ❑ Psychiatric disorders ❑ Alcohol intake ❑ Smoking ❑ Cocaine use ❑ Methamphetamine use ❑ Hyperlipidemia ❑ Recent surgery (<3 months) ❑ Rheumatoic disorders ❑ SLE ❑ Rheumatoid arthritis

Examine the patient: Vitals ❑ Fever (non-specific) ❑ Heart rate ❑ Tachycardia (non-specific) ❑ Bradycardia ❑ Blood pressure ❑ Narrow pulse pressure (suggestive of aortic stenosis) ❑ Asymmetric blood pressure in extremities (suggestive of aortic dissection) ❑ Tachypnea (non-specific) General appearance ❑ Pale ❑ Diaphoresis ❑ Severe distress Neck ❑ Elevated jugular venous pulse (suggestive of pericarditis) ❑ Kussmaul sign (suggestive of pericarditis) Cardiovascular examination Palpation ❑ Pain on palpation of chest wall (suggestive of costochondritis) ❑ Apical impulse (suggestive of LVH in aortic stenosis) Pulses ❑ Pulsus parvus et tardus (suggestive of aortic stenosis) ❑ Pulsus paradoxus (suggestive of pericarditis) Auscultation ❑ Presence of S3 and/or S4 ❑ Paradoxical splitting of S2 (suggestive of aortic stenosis) ❑ Muffled heart sounds (suggestive of pericarditis) ❑ Pericardial friction rub (suggestive of pericarditis) ❑ Systolic murmur (suggestive of aortic stenosis or hypertrophic cardiomyopathy) ❑ Diastolic murmur (suggestive of aortic dissection Respiratory examination ❑ Shift of the trachea from midline (suggestive of tension pneumothorax) ❑ Hyperresonance over the affected side (suggestive of tension pneumothorax) Auscultation ❑ Absent breath sounds in one hemithorax (suggestive of pneumothorax) ❑ Rales (suggestive of HF or pneumonia) ❑ Wheezing (suggestive of asthma or COPD) ❑ Pleural rub (pleuritis Abdominal examination ❑ Positive Murphy sign (suggestive of acute cholecystitis) ❑ Resonant percussion over the liver (suggestive of perforated peptic ulcer) ❑ Tenderness over the epigastrium (suggestive of gastrointestinal etiology) ❑ Rectal examination that shows occult bleeding (peptic ulcer) Neurological examination ❑ Focal abnormalities (suggestive of stroke due to aortic dissection) ❑ Hemiparesis ❑ Vision loss ❑ Aphasia ❑ Hypertonia Skin ❑ Unilateral vesicular rash located in one or two adjacent dermatomes (suggestive of herpes zoster) ❑ Jaundice (suggestive of acute cholecystitis) ❑ Xanthoma (suggestive of dyslipidemia)

Order labs and tests: ❑ EKG (most important initial test) ❑ Cardiac enzymes (Troponin, CK-MB) In high suspicion of MI, do not delay initial management ❑ CBC ❑ ABG ❑ D-dimer

Order imaging studies According to the suspected etiology ❑ Chest X-ray ❑ Echocardiography

Does the chest pain has any of the following findings suggestive of cardiac etiology? ❑ Pain described as a heaviness or crushing sensation ❑ Radiates to the left arm, neck and/or jaw ❑ Associated with: ❑ Diaphoresis ❑ Dyspnea ❑ Nausea or vomiting

YES

NO

Click here for the cardiac chest pain approach

Click here for the non-cardiac chest pain approach

Cardiac Chest Pain

Does the EKG has ST elevation?

YES

NO

Is the ST elevation specific to an anatomic area? ❑ V1-V2 (Septal) ❑ V3-V4 (Anterior) ❑ V5-V6 (Apical) ❑ I, aVL (Lateral) ❑ II, III, aVF (Inferior)

Does the TTE shows valve or aortic abnormalities?

YES

NO

YES

NO

Consider the following: STEMI ❑ Pain described as a heaviness or crushing sensation ❑ Radiates to the left arm, neck and/or jaw ❑ Not alleviated by rest or medications ❑ CK-MB and Troponin elevation ❑ PR depression is absent New LBBB ❑ EKG evidence of LBBB ❑ QRS ≥ 120 ms ❑ QS or rS in V1 ❑ Monophasic R in I, aVL and V6 ❑ Chest pain with same characteristic as STEMI

Consider the following: Pericarditis ❑ Sharp and pleuritic pain that is improved by sitting up and leaning forward ❑ Diffuse, non-specific ST elevation ❑ PR depression ❑ PR elevation in lead aVR

Consider the following: Aortic stenosis ❑ Systolic ejection murmur with ejection click ❑ Best heard at the upper right sternal border ❑ Bilateral radiation to the carotid arteries ❑ TTE findings of stenosis ❑ Exertional dyspnea ❑ Syncope Aortic dissection ❑ Acute onset of heart failure ❑ Low pitched early diastolic murmur best heard at the 2nd right ICS ❑ Widened mediastinum on chest X-ray ❑ TEE findings of: ❑ Intimal tear ❑ Aortic regurgitation ❑ History of: ❑ Hypertension ❑ Marfan syndrome

Consider the following: Unstable angina/NSTEMI ❑ Pain described as a heaviness or crushing sensation ❑ Radiates to the left arm, neck and/or jaw ❑ Not alleviated by rest or medications ❑ Elevated cardiac enzymes ❑ Pain last > 10 min Stable angina ❑ Pain described as a heaviness or crushing sensation ❑ Normal value of cardiac enzymes ❑ Pain usually lasts < 10 min ❑ Provoked by exertion or stress ❑ Improves with rest or nitroglycerin

Non-Cardiac Chest Pain

Determine the non-cardiac etiology based on the physical examination and tests findings

Pulmonary

Gastrointestinal

Other

Is the onset sudden?

YES

NO

Consider the following: Pulmonary embolism ❑ Suddenchest pain ❑ Severe dyspnea ❑ History of DVT, surgery, malignancy, immobility ❑ Elevated D-dimer Pneumothorax ❑ Dyspnea ❑ Hypoxia ❑ Tracheal deviation towards the unaffected side ❑ Hyperresonance on the affected side Asthma exacerbation ❑ Acute shortness of breath ❑ Wheezing ❑ History of asthma

Consider the following: Pulmonary hypertension ❑ Dyspnea on exertion ❑ Increased P2 ❑ JVD ❑ Lower extremity edema ❑ History of gradual onset of shortness of breath Bacterial pneumonia ❑ Productive cough ❑ Fever ❑ Dyspnea ❑ New infiltrate on the CXR Pulmonary TB ❑ Cough ❑ Hemoptysis ❑ Night sweats ❑ Weight loss ❑ Cavitary lesion on CXR Pleurisy ❑ Sharp pain associated with inspiration and expiration ❑ Shallow breathing ❑ Look for underlying cause

Consider the following: Pancreatitis ❑ Severe epigastric pain radiating to the back ❑ Nausea and vomiting ❑ Increased levels of amilase or lipase ❑ History of alcohol intake or gallstones Acute cholecystitis ❑ RUQ pain associated with meals ❑ Radiation to right shoulder ❑ Positive Murphy's sign ❑ Nausea and vomiting ❑ Jaundice GERD ❑ Burning sensation from the epigastrium towards the throat ❑ After meals ❑ Duration: minutes to hours Peptic ulcer ❑ Epigastric pain: ❑ Starts 5-15 min after a meal (suggestive of gastric ulcer) ❑ Alleviated by meals (suggestive of duodenal ulcer) ❑ Alleviated by antacids Esophageal spasm ❑ Vomiting ❑ Intermittent lower chest pain ❑ Cervical subcutaneous emphysema ❑ Alcohol excess Mallory-Weiss syndrome ❑ Epigastric ± back pain ❑ History of vomiting ❑ Hematemesis

Consider the following: Musculoskeletal pain ❑ Localized pain ❑ Pain on palpation of costochondral joints ❑ Exacerbated by chest wall movements ❑ History of Rheumatoid arthritis Herpes zoster ❑ Burning pain localized in a dermatome ❑ Unilateral vesicular rash ❑ History of immunodepresion or severe stress Psychiatric conditions ❑ Anxiety ❑ Hypochondriasis ❑ Panic attack

Treatment

The management of chest pain will depend on the underlying cause. Click on each disease shown below to see a detail management for every cause of chest pain.
Abbreviations: STEMI: ST elevation myocardial infarction; NSTEMI: Non-ST elevation myocardial infarction; GERD: Gastroesophageal reflux disease

CARDIAC	PULMONARY	GASTROINTESTINAL	OTHER
❑ STEMI/LBBB ❑ NSTEMI/Unstable angina ❑ Pericarditis ❑ Aortic dissection ❑ Aortic stenosis	❑ Pulmonary embolism ❑ Pneumothorax ❑ Asthma exacerbation ❑ Pneumonia ❑ Pleuritis	❑ Pancreatitis ❑ Acute cholecystitis ❑ GERD ❑ Peptic ulcer ❑ Esophageal spasm ❑ Mallory-Weiss syndrome	❑ Musculoskeletal pain: ❑ Costochondritis ❑ Rheumatoid arthritis ❑ Rib fracture ❑ Herpes zoster ❑ Anxiety ❑ Panic disorder

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References

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