Chest pain
Questionnaire/history:
C/o chest pain (CP)? Onset? - Acute? Location? - Poorly localised, substernally, central or band-like across the anterior chest? - Localised, eg exclusively in right or left chest? Radiation? - Radiation to jaw, shoulders, arms, hands or back? - Radiating to both arms or the back (aortic dissection?)?
Quality?
- Pressing, squeezing, bank like, dull, tightness, heaviness (as if someone has a heavy object sitting on the chest), constricting discomfort or crushing?
- Sharp, stabbing, burning, or pleuritic?
Duration?
- Seconds? - 5-15 minutes - >15 minutes? - >1 hour? - >12 hours? Currently painfree? Last episode of pain? - Within 12 hours? Worse or better with exercise? Relieved by rest within about 5 minutes? Relieved by glyceryl trinitrate (GTN) within about 5 minutes?
Worse on deep inspiration (pleuritic)?
Change of pain by moving the arms or torso, or in certain positions?
Tender to touch where pain is localised?
Worse after eating a large meal?
Associated symptoms? - Autonomic symptoms?
- (Cold) sweating/diaphoresis? - Nausea?
- Vomiting? - Lightheadedness/dizziness? - Palpitations?
- Breathless - Overwhelming anxiety or sense of doom? - Sudden onset of indigestion, heartburn, or abdominal pain? - Cough? - Fever?
- Difficulty in swallowing?
- Other?
Previous investigations?
- ECG?
- Chest X-ray?
- Coronary angiogram?
Clinical diagnosis of angina (driven mainly by the characteristics of chest pain):: Characteristics of chest pain: 1. Central, lasting about 1-15 minutes? 2. Provoked by exertion or emotional stress? 2. Relieved promptly by rest or nitrates? <= 1 characteristics: non-anginal pain 2 characteristics: atypical angina
All 3 characteristics: typical angina Other causes of chest pain? Non-coronary causes of angina (eg severe aortic stenosis)? PMH?
- Cardiovascular history? Current medication?
Drug allergies?
Risk factors for CVD?
Marburg Heart Score (MHS)?
- Female ≥65 or male Female ≥55 (+1)?
- Known CAD, CVD, or PAV (+1)?
- Pain worse with exercise (+1)?
- Pain reproducible with palpation (+0)?
- Patient assumes pain is cardiac (+1)?
0-2 points: low risk
≥ 3 points: intermediate/high risk
4-5 points: high risk
Examination:
General appearance?
- Pallor?
- Sweating?
BP in both arms?
- Hemodynamic instability (SBP < 90, HR > 130)? Pulse?
Temperature?
SpO2? < 92%?
JVP?
Neck?
Chest wall?
RR? > 30 bpm?
Chest?
Heart sounds?
Abdomen?
Legs/calves/ankles?
- Swelling?
- Tenderness?
Skin?
- Rash?
- Bruising? Signs of other CVD?
Investigations:
ECG? Changes consistent with coronary disease? - Pathological Q waves? - Left bundle branch block (LBBB)? - Regional ST/T changes (eg T-wave flattening or elevation, or T-wave inversion=? Blood tests? To rule out conditions exacerbating angina (eg anaemia)? Hs-cTnI and hs-cTnT? (Troponin normally detectable using high-sensitivity testing within 3-6 hours following a MI, and remains elevated for a variable time (usually several days, but can be up to 2 weeks)
Diagnosis:
For differential diagnosis see NICE CKS Retrosternal: Myocardial ischemic pain Pericardial pain Esophageal pain Aortic dissection Mediastinal lesion Pulmonary embolization Interscapular: Myocardial ischemic pain Musculoskeletal pain Gallbladder pain Pancreatic pain Right lower anterior chest: Gallbladder pain Distention of the liver Subdiaphragmatic abscess Pneumonia/pleurisy Gastric or duodenal penetrating ulcer Pulmonary empolization Acute myositits Injuries Epigastric: Mycocardial ischemic pain Pericardial pain
Esophageal pain Duodenal-gastric pain Pancreatic pain
Gallbladder pain Distension of the liver Diaphragmatic pleurisy Pneumonia Shoulder: Myocardial ischemic pain Pericarditis Subdiaphragmatic abscess Diaphragmatic pleurisy Cervical spine disease Acute musculoskeletal pain Thoracic outlet syndrome Arm: Myocardial ischemic pain Cervical/dorsal spine pain Thoracic outlet syndrome Left lower anterior chest: Intercostal neuralgia Pulmonary embolization Myositis Pneumonia/pleurisy Splenic infarction Splenic flexure syndrome Subdiaphragmatic abscess Precardial catch syndrome Injuries Management?
Hospital admission as clinical features suggesting a serious cause:
While waiting for ambulance: -
Sat patient up
- Offered oxygen as SpO2 < 94% (with face mask and flow rate to 5-10 L/min to achieve target SpO2 of 94-98% as not at risk of hypercapnic respiratory failure)
- As chronic obstructive pulmonary disease with risk of hypercapnic respiratory failure, used 28% Venturi mask with flow rate at 4 L/min to achieve target SpO2 of 88-92%
- As ACS suspected gave GTN and aspirin 300 mg
- As acute pulmonary oedema suspected gave furosemide 40-80 mg slowly IV, metoclopramide 10 mg IV and GTN
- As tension pneumothorax suspected and person's condition life threatening inserted large-bore cannula through 2nd ICS in the MCL on the side of the pneumothorax
Urgent same-day assessment if:
Suspected ACS
+ Pain-free with CP in the last 12 h + normal ECG OR
+ Pain-free with CP in the last 12-72 h + no complications
Assessment within 2 weeks if:
Suspected ACS
+ Pain-free with CP more than 72 h ago + no complications
(Urgency decided on the basis of ECG, high-sensitivity blood troponin (and advice from cardiologist)) Suspected underlying malignancy
Lung or lobar collapse or pleural effusion and admission not required
Routine assessment if:
Suspected stable angina where diagnosis cannot be excluded in primary care (to consider aspirin 75 mg od) CP with unclear cause
Clear diagnosis of the cause of the CP, but symptoms persist despite management in primary care
Clinical chest pain description:
Typical chest pain: retrosternal sensation of pressure or heaviness ('angina') radiating to the left arm (less frequently to both arms or to the right arm), neck or jaw, which may be intermittent (usually lasting for several minutes) or persistent, additional sxs such as sweating, nausea, abdominal pain, dyspnoea and syncope maybe present
Atypical presentation include epigastric pain, indigestion-like symptoms and isolated dyspnoea
The relief of sxs after nitrates is not specific for anginal pain as it is repoted also in other cause of acute chest pain
Reference(s): Braunwald, E.: The history. In Zipes, D.P. et al.: Heart disease. Ed. 7, Philadelphia, Saunders, 2005, p.68) Hickam, D. A.: Chapter 9. Chest Pain or Discomfort, Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition. 1990