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In medicine, chest pain is a number of serious conditions and is generally considered a medical emergency. Even though it may be determined that the chest pain is non-cardiac in origin, this is often a diagnosis of exclusion made after ruling out more serious causes of the pain.

Causes

Cardiovascular

• Acute coronary syndrome
  • Unstable Angina Pectoris - requiring emergency medical treatment but not primary intervention as in a myocardial infarction
  • Myocardial infarction ("heart attack")
• Aortic dissection
• Pericarditis and cardiac tamponade
• Arrhythmia - atrial fibrillation and a number of other arrhythmias can cause chest pain.
• Stable Angina Pectoris - this can be treated medically and although it warrants investigation, it is not an emergency in its strictest sense

Pulmonary

• Pulmonary embolism
• Pneumonia
• Hemothorax
• Pneumothorax and Tension pneumothorax
• Pleurisy - an inflammation which can cause painful respiration

GI

• Upper gastrointestinal ailments
  • Gastroesophageal reflux disease (GERD) and other causes of heartburn
  • Hiatus hernia (which may not accompany GERD)
  • Achalasia, nutcracker esophagus and other neuromuscular disorders of the esophagus
  • Functional dyspepsia

Chest wall

• Problems of chest wall structures
  • Costochondritis or Tietze's syndrome - a benign and harmless form of osteochondritis often mistaken for heart disease
  • Spinal nerve problem
  • Fibromyalgia
  • Chest wall problems
  • Radiculopathy
  • Precordial catch syndrome
  • Breast conditions
  • Herpes zoster commonly known as shingles

Psychological

• Psychological
  • Panic attack
  • Anxiety
  • Clinical depression
  • Somatization disorder
  • Hypochondria

Others

• Others
  • Hyperventilation syndrome often presents with chest pain and a tingling sensation of the fingertips and around the mouth
  • Da costa's syndrome
  • Bornholm disease - a viral disease that can mimic many other conditions
  • Precordial catch syndrome - another benign and harmless form of a sharp, localised chest pain often mistaken for heart disease
  • Carbon Monoxide Poisoning
  • Sarcoidosis
  • Lead Poisoning
  • High abdominal pain may also mimic chest pain

Analysis

As in all medicine, a careful medical history and physical examination is essential in separating dangerous from trivial causes of disease, and the management of chest pain is often done on specialised units (termed medical assessment units) to concentrate the investigations. A rapid diagnosis can be life-saving and often has to be made without the help of X-rays or blood tests (e.g. aortic dissection). Occasionally, invisible medical signs will direct the diagnosis towards particular causes, such as Levine's sign in cardiac ischemia. Generally, however, additional tests are required to establish the diagnosis.

An emergency medicine doctor will also focus on recent health changes, family history (premature atherosclerosis, cholesterol disorders), tobacco smoking, diabetes and other risk factors.

Features of the pain suggest of cardiac ischaemia are describing the pain as heaviness; radiation of the pain to neck, jaw or left arm; sweating; nausea; palpitations; the pain coming upon exertion; dizziness; shortness of breath and a "sense of impending doom."

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)
  • serum amylase to exclude acute pancreatitis

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 ("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

References

From Wikiversity

Physicians will typically keep asking a patient about chest pain even after they have identified it as pressure. ER Physicians need to consider whether pain is esophageal acid reflux [burning], musculoskeletal [stabbing or with movemment] or cardiac [at rest or exertional], the latter requiring a 'chest pain protocol' evaluating cardiac enzymes creatine kinase and toponin and ending with a stress test or cardiac catheterization in the hospital. It may help for the evaluator to write out 'chest pain' or 'chest pressure' and refer back to this to expedite the interview. Associated symptoms are pain in the neck, jaws, shoulders, arms or hands; breathlessness [dyspnea], inappropriate sweating, nausea, or exertional dizziness or exhaustion. It is important to memorize this list so that you can say you have reviewed a complete set with the patient. Diabetes reduces or obliterates symptoms because of autonomic neuropathy. Associated physical signs of an impending heart attack [angina, ischemia] or heart attack [myocardial infarction] are high or low blood pressure, pulse and respiratory rate. Dyspnea and/or Pain on inspiration [pleurisy] should be evaluated by computed tomography for pulmonary embolus, another fatal treatable process.

ID

• name, AGE

SOAP

-HPI- Subjective

• O = onset
  • Sudden or gradual onset?
• P = precipitating
  • What were you doing when pain came on?
  • palliation
    • NO, antacids, rest, positional
  • provocative
    • exercise, food, emotion, deep breaths
• Q = quality
  • sharp, dull, heavy, squeezing, tearing
• R = radiation
  • Point to where pain is and goes. (neck, jaw)
• S = symptoms, severity
  • sweating, SOB, palpitations, cough, syncope/presyncope, anxiety, sour-taste, nausea
• T = timing
  • Describe the course of the pain. (worsening, intermittent, better)
  • Timing of day.
• V = déjà vu
  • Have you felt similar symptoms before?

Objective -PMHx-

• Previous similar episodes? (past therapy, investigations)

• Hx: MI, documented CAD, angioplasty, CABG
• Important historical risk factors
  • Smoking
  • Hypertension
  • Diabetes mellitus
  • hypercholesterolemia
  • positive family history

Medication/allergies

Assesment

ROS

• syncope, exercise intolerance, PND/orthopnea, angina, CVA

Impression

• Is the chest pain typical or atypical for angina?
  • look at the ECG, cardiac enzymes, CXR

Differential Diagnosis

• CV: stable or unstable angina (< 10 min, worsened by cold air, stress)
• IHD (> 30 min, unrelieved)
• aortic dissection
• pericarditis (hrs to days, relieved by sitting up and leaning forward)

• RESP: pneumothorax, PE, pleuritis
• GI: GERD, PUD, esophageal spasm
• MSK: costochondritis, rib fracture
• MISC: panic attack, herpes zoster

Plan

Canadian Cardiovascular Society (CCS) Classification

1. Angina only with strenuous, rapid or prolonged activity
2. Angina only slightly limiting ordinary activity, such as walking up-hill, climbing stairs rapidly, or climbing more than 2 blocks on the level, at a normal pace.
3. Angina with level walking at normal pace for less than 1-2 blocks, or less than 1 flight of stairs
4. Inability to carry on any physical activity without developing angina

Other OSCE modules