Chest Pain


Article Author:
Ken Johnson


Article Editor:
Sassan Ghassemzadeh


Editors In Chief:
Marc Robins
William Tarver


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Frank Smeeks
Kristina Soman-Faulkner
Trevor Nezwek
Radia Jamil
Patrick Le
Sobhan Daneshfar
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
3/13/2019 4:27:32 PM

Introduction

Chest pain is a common complaint and encompasses a broad differential diagnosis that includes several life-threatening causes. A workup must focus on ruling out serious pathology before a physician considers more benign causes.

Etiology

It sometimes is helpful to consider the different etiologies of pain. Visceral pain usually presents with a vague distribution pattern meaning that the patient is unlikely to localize the pain to a specific spot. When asking patients to point with one finger where they feel the pain, they will often move their hand around a larger area. Common descriptors of visceral pain are dull, deep, pressure and squeezing. Visceral pain also refers to other locations as a result of the nerves coursing through somatic nerve fibers as they reach the spinal cord. Ischemic heart pain, for example, may refer to the left or right shoulder, jaw or left arm. Symptoms like nausea and vomiting may also be a sign of visceral pain. Diaphragmatic irritation may refer to the shoulders as well. [1] Somatic pain is more specific than visceral pain, and patients will usually be able to point to a specific spot. Somatic pain is also less likely to refer to other parts of the body. Common descriptors of somatic pain are sharp, stabbing, and poking.

Epidemiology

In the emergency department chest pain is the second most common complaint comprising approximately 5% of all emergency department visits. In evaluating for chest pain, the provider should always consider life-threatening causes of chest pain. These are listed below with approximate percent occurrence in patients presenting to the emergency department with chest pain based on a study by Fruerfaard et al. [2]

  • Acute coronary syndrome (ACS), 31%
  • Pulmonary embolism (PE), 2%
  • Pneumothorax (PTX), unreported
  • Pericardial tamponade, unreported (pericarditis 4%)
  • Aortic dissection, 1%
  • Esophageal perforation, unreported

 Other common causes of chest pain with approximate percent occurrence in patients presenting to the emergency department with chest pain include:

  • Gastrointestinal reflux disease, 30%
  • Musculoskeletal causes, 28%
  • Pneumonia/pleuritis, 2%
  • Herpes zoster 0.5%
  • Pericarditis, unreported

History and Physical

History

Like all workups, chest pain evaluation starts with taking a complete history. Start by getting a good understanding of their complaint.

  • Onset: In addition to when the pain started, ask what the patient was doing when the pain started. Was the pain brought on by exertion or were they at rest?
  • Location: Can the patient localize the pain with one finger or is it diffuse?
  • Duration: How long did the pain last?
  • Character: Let the patient describe the pain in his or her own words.
  • Aggravation/alleviating factors: It is very important to find out what makes the pain worse. Is there an exertional component, is it associated with eating or breathing? Is there a positional component? Don't forget to ask about new workout routines, sports, and lifting. Ask what medications they have tried.
  • Radiation: This may clue you into visceral pain.
  • Timing: How many times do they experience this pain? For how long does it let up?

Ask about other symptoms such as:

  • Shortness of breath
  • Nausea and vomiting
  • Fever
  • Diaphoresis
  • Cough
  • Dyspepsia
  • Edema
  • Calf pain or swelling
  • Recent illness

Evaluate for any of the following risk factors:

  • ACS risks: prior myocardial infarction(MI), family history of cardiac disease, smoking, hypertension (HTN), hyperlipidemia (HLD), and diabetes
  • Pulmonary embolism (PE) risks: prior deep venous thrombosis (DVT) or PE, hormone use (including oral birth control), recent surgery, cancer, or periods of non-ambulation
  • Recent gastrointestinal (GI) procedures like scopes
  • Drug abuse (cocaine and methamphetamines)

Carefully review the patient’s medical history for cardiac history, coagulopathies, and kidney disease. Ask about family history, especially cardiac, and ask about social histories like drug use and tobacco use.

Once you have thoroughly ruled out life-threatening causes, move on to other possibilities. Pneumonia should be considered in patients with a productive cough and/or recent upper respiratory infection (URI). Gastroesophageal reflux disease (GERD) is a common cause of chest pain so ask about any reflux symptoms. New exercise routines or recent trauma may help support a musculoskeletal cause. [2]

Physical

The physical exam should include:

  • Full set of vitals including blood pressure (BP) measurements in both arms
  • General appearance, noting diaphoresis and distress
  • Skin exam for the presence of lesions (shingles)
  • Neck exam for jugular venous distension (JVD), especially with inspiration (Kussmaul sign)
  • Chest, palpate for reproducible pain and crepitus
  • Heart exam
  • Lung exam
  • Abdominal exam
  • Extremities for unilateral swelling, calf pain, edema, and symmetric, equal pulses

Evaluation

Many facilities have protocols in place to evaluate for chest pain, but at a minimum, the provider should order the following:

  • Electrocardiogram (ECG) preferably in the first 10min of arrival, (consider serial ECGs)     
  • Chest x-ray
  • Complete blood count (CBC), basic metabolic panel (BMP), troponin level (consider serial troponin levels 4hr apart), lipase
  • Computed tomography pulmonary angiography (CTPA) if you are considering PE or ventilation-perfusion (VQ) scan if CTPA is contraindicated
  • Bedside ultrasound (US) if you are considering pericardial tamponade

Treatment / Management

Acute coronary syndrome (ACS)

A complete discussion of the management of ACS is beyond the scope of this paper however initial steps should be performed in patients with a diagnosis of ACS. Place patient on a cardiac monitor, establish intravascular access (IV) access, give 162 mg to 325 mg chewable aspirin, clopidogrel, or ticagrelor (unless bypass surgery is imminent), control pain and consider oxygen (O2) therapy. Nitroglycerin has shown a mortality benefit, aim for 10% mean arterial pressure (MAP) reduction in normotensive patients and 30% MAP reduction in hypertensive patients; avoid in hypotensive patients and those with inferior ST elevation. Patient with ST elevation on ECG patients should receive immediate reperfusion therapy either pharmacologic (thrombolytics) or transfer to the catheterization laboratory for percutaneous coronary intervention (PCI). PCI is preferred and should be initiated within 90 minutes onsite or 120 minutes if transferred to outside facility. If PCI is not possible thrombolytics should be initiated within 30 min. Patients with non-ST elevation myocardial infarction (NSTEMI) and unstable angina should be admitted for cardiology consult and work up. Patients with stable angina may be appropriate for outpatient work up. In elderly patients and those with comorbidities, patients should be admitted for observation and further cardiac work up. [3][4]

Pulmonary embolism (PE)

CT pulmonary angiogram (CTPA) is the best confirmatory test, a VQ scan can also be used, but this test is not as accurate in patients with chronic lung disease. Patients who are hemodynamically unstable should be started on thrombolytics; stable patients should be started on anticoagulants. [5][6]

Pneumothorax (PTX)

Pneumothorax should be decompressed with a chest tube. [7][8]

Pericardial tamponade

Bedside ultrasound is useful to establish a diagnosis. A fluid bolus may be used as a temporizing measure. Needle pericardiotomy or pericardial window to relieve pressure inside the pericardial sack.[9]

Aortic dissection

Often immediate surgery is required, consult cardiothoracic surgery early. CT angiography is the best test to evaluate for dissection. Place two large-boar IVs and quickly lower patient’s blood pressure to systolic between 100 mmHg to 130 mmHg. Start with beta-blocker therapy to prevent reflux tachycardia. [10][11][12]

Esophageal perforation

A left pleural effusion on chest x-ray may suggest esophageal rupture. Contrast esophagram is the best confirmatory test. This is a medical emergency, and immediate surgical consult is warranted. [11]

Gastrointestinal reflux disease

The patient can be given viscus lidocaine mixed with Maalox (known as a GI cocktail). While this is therapeutic it is not diagnostic. ACS can present with dyspepsia and may respond to GI cocktail, it is therefor improtant to rule out ACS before assigning GERD as a final diagnosis. Long-term treatment of GERD is best accomplished with proton pump inhibitor (PPI) or H2 blocker therapy.[13]

Pearls and Other Issues

Aortic dissection can cause a stroke. Do not forget to consider this in your workup. Younger patients and those without risk factors can still have an MI. People with diabetes and the elderly may have nerve damage which may make it difficult for them to interpret pain. They may have more atypical presentations of disease like acute coronary syndrome (ACS).

Enhancing Healthcare Team Outcomes

Chest pain is a common symptom encountered in clinical practice by the nurse practitioner, primary provider, internist, emergency department physcian and surgeon. In most cases, a thorough medical history will provide a clue to the diagnosis. The key is to not miss a life threatening disorder like an acute MI or an aortic dissection. When the cause of chest pain remains unknown, it is recommended that the patient be referred to the specialist for care. The outcomes for patients with chest pain depend on the cause.


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Chest Pain - Questions

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A 56-year-old man presents with persistent, severe chest pain after repeated bouts of vomiting over the past 24 hours. Which of the following is most appropriate for the management of this patient?



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A patient comes to the Emergency Department complaining of chest pain. The patient has a hemoglobin of 7.5 gm/dl. Which of the following would be administered?



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Which of the following types of chest pain is most indicative of ischemic heart disease?



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What is the first test to perform in an adult patient presenting with unrelenting substernal chest pain?



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A 67-year-old patient with chest pain and a possible myocardial infarction presents to the emergency department. Which of the following should be performed first in management of this patient?



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Which of the following is not a common pediatric cause of chest pain?



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An OT takes a group from a day program on a community outing. One of the group members complains of chest pain. The OT checks the patient's vital signs and determines the patient's heart rate is 125 bpm and the blood pressure is 220/130 mm Hg. What should be done?



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A pregnant woman at 34 weeks presents with transient substernal chest pain? Exam shows a grade 2/6 systolic murmur heard loudest at the left sternal border, a loud S3, normal ECG, and normal sinus rhythm at a rate of 90 bpm with left axis deviation and nonspecific ST change. What is the most likely cause?



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A 60-year-old man experienced substernal chest pain 3 days ago while camping. Select the test that would best detect myocardial damage.



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An obese diabetic patient is being evaluated for vague chest pain. He is to have an elective repair of an inguinal hernia. The patient has bilateral foot ulcers with neuropathy. Which of the following non-invasive tests would best help screen for myocardial ischemia?



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A 40-year-old female presents with a 1-month history of burning substernal chest pain. This occurs mainly at night after going to bed. It resolves spontaneously and does not interfere with sleep. She has no other relevant past medical history or family history of coronary artery disease. Vital signs are normal. Her BMI is 35. EKG shows normal sinus rhythm with no ST or T wave abnormalities. What is the next step in this patient's treatment?



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A client presents to the emergency department with chest pain. What are potential causes of chest pain? Select all that apply.



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A client checks into the emergency department with a complaint of chest pain. A standard treatment protocol has been enacted by the triage nurse until the provider can examine the client. As part of the initial workup, what diagnostic tests are typically part of the standard evaluation and treatment protocols for a client with chest pain? Select all that apply.



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Chest Pain - References

References

Frequency of pulmonary embolism in patients admitted with chest pain and suspicion of acute myocardial infarction but in whom this diagnosis is ruled out., Fruergaard P,Launbjerg J,Hesse B,, Cardiology, 1996 Jul-Aug     [PubMed]
The diagnoses of patients admitted with acute chest pain but without myocardial infarction., Fruergaard P,Launbjerg J,Hesse B,Jørgensen F,Petri A,Eiken P,Aggestrup S,Elsborg L,Mellemgaard K,, European heart journal, 1996 Jul     [PubMed]
Multislice spiral CT angiography for evaluation of acute aortic syndrome., Zhao DL,Liu XD,Zhao CL,Zhou HT,Wang GK,Liang HW,Zhang JL,, Echocardiography (Mount Kisco, N.Y.), 2017 Oct     [PubMed]
Hydropneumothorax Due to Esophageal Rupture., Shiber JR,Fontane E,Ra JH,Kerwin AJ,, The Journal of emergency medicine, 2017 Jun     [PubMed]
Point-of-care ultrasound leads to diagnostic shifts in patients with undifferentiated hypotension., Shokoohi H,Boniface KS,Zaragoza M,Pourmand A,Earls JP,, The American journal of emergency medicine, 2017 Aug 26     [PubMed]
Performance of a simple robust empiric timing protocol for CT pulmonary angiography., Hsu KA,Levsky JM,Haramati LB,Gohari A,, Clinical imaging, 2017 Sep 14     [PubMed]
Effective diagnosis and treatment of pulmonary embolism: Improving patient outcomes., Meyer G,, Archives of cardiovascular diseases, 2014 Jun-Jul     [PubMed]
Comparison of 30-day mortality and myocardial scar indices for patients treated with prehospital reduced dose fibrinolytic followed by percutaneous coronary intervention versus percutaneous coronary intervention alone for treatment of ST-elevation myocardial infarction., Solhpour A,Chang KW,Arain SA,Balan P,Zhao Y,Loghin C,McCarthy JJ,Vernon Anderson H,Smalling RW,, Catheterization and cardiovascular interventions : official journal of the Society for Cardiac Angiography & Interventions, 2016 Nov     [PubMed]
Managing emergency hypertension in aortic dissection and aortic aneurysm surgery., Khoynezhad A,Plestis KA,, Journal of cardiac surgery, 2006 Mar-Apr     [PubMed]
Jänig W, [Neurobiology of visceral pain]. Schmerz (Berlin, Germany). 2014 Jun;     [PubMed]
de Bliek EC, ST elevation: Differential diagnosis and caveats. A comprehensive review to help distinguish ST elevation myocardial infarction from nonischemic etiologies of ST elevation. Turkish journal of emergency medicine. 2018 Mar;     [PubMed]
Habibi B,Achachi L,Hayoun S,Raoufi M,Herrak L,Ftouh ME, [Management of spontaneous pneumothorax: about 138 cases]. The Pan African medical journal. 2017;     [PubMed]
Alzubaidi M,Gabbard S, GERD: Diagnosing and treating the burn. Cleveland Clinic journal of medicine. 2015 Oct;     [PubMed]

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