Chest pain is a common condition. Its presence usually heralds concerns about the presence of ischemic heart disease. Reports have consistently showed that while most of the clinical efforts are exhausted in excluding ischemic heart disease they represent a small proportion of the causes. In one report more than 60% of cases were attributed to nonorganic causes.
Careful examination of chest pain requires taking note of the onset, course and duration of the chest pain episodes. The character of pain should also be noted according to the patient's description, this includes dull aching, heaviness, chest tightness, sharp or tearing, pricking or stitching in character.
I. Exclude causes with a CHARACTERISTIC clinical presentation
The best approach to chest pain is to first exclude the 'easier' causes which have a characteristic presentation. These include:
- Exertional chest pain: Patients usually present with typical symptoms of central/retrosternal chest tightness or heaviness which is brought on by exertion or stress and relieved by rest or nitrates. It may radiate to the arms, the neck, jaw or teeth. The additional presence of risk factors enhances the diagnosis (old age, males more than females, hypertension, diabetes, hypercholesterolemia, hypertension, smokers as well as other risk factors). These patients are found to have IHD in 90% of cases. Patients with non-typical symptoms, who have no risk factors are found to have IHD in <25% of cases.
- Pleuritic chest pain: Pain arising from the pleura characteristically increases with inspiration. This is seen in pleurisy (inflammation of the pleura) but is also seen in pericarditis (which is both pleuritic and positional). Sometimes musculoskeletal causes (e.g. muscle strain) of chest pain can also increase on inspiration.
- Positional chest pain: Pain arising from the pericardium is characteristically positional. It increases on lying down (supine). Pericarditis is both positional and pleuritic. Positional chest pain is sometimes seen in both pleuritic and musculoskeletal diseases, as patients describe being more comfortable by sleeping on one side more than the other (the opposite side in pleuritic pain).
- Tender chest pain: This type of pain is characteristic of chest wall disease such as costochondritis and other musculoskeletal conditions. Touching the site of pain elicits tenderness. Musculoskeletal causes of chest pain are common especially if there is a history of trauma, muscle strain or sprain.
- Dermatomal chest pain: Pain that arises spinal disease that affects the nerve radicles causes a pain that affects a specific dermatome on one side of the chest wall. Herpes zoster infection also causes unilateral dermatomal chest pain.
- Referred chest pain from the neck: As described above, this can be dermatomal in distribution. It is accompanied by a history of neck pain or diseases of the cervical vertebrae such as spondylosis. There may also be some tingling due to affection of the nerves.
- Chest pain associated with food intake: This characterizes pain that arises from gastrointestinal causes. The pain is usually in the epigastrium but may appear as central lower chest wall pain causing confusion. GERD, peptic ulcer disease and gall bladder disease are amongst the most common causes. Chest pain associated with intermittent dysphagia is suggestive of diffuse esophageal spasm (DES)
II. Exclude the FOUR KILLER causes
After excluding the characteristic types, it's important to remember and carefully exclude the FOUR KILLERS of chest pain. These include:
- Ischemic heart disease (IHD) as described above.
- Pulmonary embolism: Patients usually present with sudden onset of dyspnea (in a matter of seconds) accompanied by chest pain. They may have a risk factor for pulmonary embolism such as a history of DVT.
- Pneumothorax: Tension pneumothorax is a medical emergency. It presents with sudden onset of dyspnea and chest pain. On examination there is tympanitic hyperresonance on percussion of the chest wall.
- Ruptured aortic aneurysm: Ruptured aortic aneurysm may present with sudden onset of tearing chest pain which may radiate to the inter-scapular region. The patient may be known to have a history of aortic aneurysm.
III. Consider psychogenic chest pain
It is worth noting that more than 60% of all chest pain cases presenting in the primary care setting were reported to have "unorganic causes". After excluding the above list of causes, it may be that the cause of the chest pain is psychological (such as hysterical). This is more commonly seen in women and those with a history of psychological illness. However, this should be a diagnosis that is reached by exclusion.
Initial management depends on whether the patient arrives during the episode of chest pain or after the episode. For those seen during the painful episode, they should be suspected as acute coronary syndrome. These cases should be treated as an emergency with appropriate measures taken within 10 minutes.
- Airway, breathing, and circulation assessed
- 12-lead ECG obtained
- Resuscitation equipment brought nearby
- Monitor attached
- Oxygen given
- Access and blood work obtained
- Aspirin: All patients should be given 162 to 325 mg to chew or swallow (unless C/I such as history of anaphylaxis to aspirin).
- Nitrates (unless contraindicated - viagra, inferior MI of right ventricle) and morphine given (reduce sympathetic stim by pain, anxiety --> decrease catechol & cardiac work). In such cases sublingual nitroglycerin: 0.4 mg every five minutes for a total of three doses, after which an assessment of blood pressure and pain relief should guide the need for intravenous nitroglycerin. IV morphine sulfate at a dose of 2 to 4 mg, with increments of 2 to 8 mg, repeated at 5 to 15 minute intervals, should be given for the relief of chest pain and anxiety.
On the other hand, if the patient arrives after the chest pain event, a stress EKG should be requested. Normal stress testing measure achieves 85% of max HR for age (220 - patient age). If normal findings consider noncardiac causes of chest pain. If it shows ST depression consider ischaemia and if it shows ST segment elevation then consider myocardial infarction.
High risk treadmill features include
1. Development of symptoms / hypotension that limits the ability to conclude the test
2. ST depression > 2 mm / diffuse / longer than 5 mints into the recovery period
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