Chest Pain, Emergency Medicine

Basics

Description

One of the most frequent chief complaints in the ED
Often the presenting symptom of a high-risk etiology:
- Acute coronary syndrome
- Pulmonary embolism
- Aortic dissection
Assume life threatening until proven otherwise.
Categorization may suggest the underlying etiology, but the presentation of chest pain can be extremely variable and vague.
Thoracic pain:
- May involve the myocardium, pericardium, the ascending aorta, pulmonary artery, mediastinum, and esophagus
- Pain is deep, visceral, and poorly localized.
- Characteristics vary from severe and crushing to mild, burning, or indigestion.
Epigastric pain:
- May involve the descending aorta, diaphragmatic muscles, gallbladder, pancreas, duodenum, and stomach
- Pain is generally referred to the xiphoid region and in the back.
Pleuritic pain:
- Inflammation or trauma to the ribs, cartilage, muscles, nerves, pleural or pericardial surface
- Pain increased by breathing, laughing, coughing, sneezing
- Tenderness to palpation may be present.
- Diaphragmatic pleurisy:
  - Sharp shooting pains in the epigastrium, lower retrosternal area, or shoulder intensified by thoracic movement
Chest wall pain:
- Inflammation of skin and SC structures of the chest wall
- Pain is reproduced by:
  - Palpation
  - Horizontal flexion of the arms
  - Extension of the neck
  - Vertical pressure on the head

Etiology

Thoracic:
- Acute coronary syndrome
- Pericarditis
- Myocarditis
- Stress-induced cardiomyopathy
- Cardiac syndrome X
- Stimulant use
- Thoracic aortic dissection
- Esophagitis
- Esophageal spasm
- GERD
- Esophageal hyperalgesia
- Abnormal motility patterns and achalasia
- Esophageal rupture and mediastinitis
Epigastric:
- Dissection of the descending aorta
- Peptic ulcer disease
- Pancreatitis
- Cholecystitis
- Splenic rupture
- Hepatic injury
- Subdiaphragmatic abscess
Pleuritic pain:
- Pulmonary embolism
- Pneumothorax
- Pneumonia
- Costochondritis
Diaphragmatic pleurisy:
- Splenic rupture
- Hepatic injury
- Subdiaphragmatic abscess
Esophageal rupture
Intercostal myositis
Intercostal neuralgia
Pectoralis minor strain
Pericarditis
Pleuritis
Pneumonitis
Rib fractures
Acute chest syndrome of sickle cell
Chest wall twinge syndrome:
- Brief episodes of sharp anterior chest pain lasting 30 sec-3 min, aggravated by deep breathing and relieved by shallow respirations
Chest wall pain:
- Chest wall hematoma
- Chest wall laceration
- Herpes zoster
- Thrombophlebitis of the thoracoepigastric vein
- Xiphisternal arthritis
- Adiposis dolorosa
- Breast abscess, fibroadenosis, carcinoma

Diagnosis

Signs and Symptoms

Coronary artery disease:
- Pressure
- Squeezing pain
- Radiation to arm, jaw
- Shortness of breath
- Diaphoresis
- Nausea
- Vomiting
- Weakness
- Fatigue especially in women or elderly
- Signs of CHF
- Anxiety
Aortic dissection:
- Sudden onset of pain with maximal intensity early
- Tearing pain
- Radiation to back and/or flank
- HTN
- Diastolic murmur of aortic insufficiency
- Difference in upper-extremity pulses
- Syncope
- Nausea
- Vomiting
- Associated neurologic changes (i.e., visual changes)
Pulmonary embolism:
- Pleuritic pain
- Shortness of breath
- Anxiety
- Diaphoresis
- Tachypnea
- Tachycardia
- Low-grade fever
- Syncope
- Localized rales
- Wheezing
Acute pericarditis:
- Substernal pain
- Varies with respiration
- Increased with recumbency
- Relieved by leaning forward
- Anxiety
- Anorexia
- Fever
- Pericardial friction rub
Pneumothorax:
- Pleuritic pain
- Shortness of breath
- Anxiety
- Tachypnea
- Decreased unilateral breath sounds
- Can be spontaneous (young), or associated with very minor trauma (elderly)

History

The history is the most important tool to distinguish between the various etiologies.
Have the patient define the key features:
- Duration
- Location:
  - Retrosternal
  - Subxiphoid
  - Diffuse
- Frequency:
  - Constant
  - Intermittent
  - Sudden vs. delayed onset
- Precipitating factors:
  - Exertion
  - Stress
  - Food
  - Respiration
  - Movement
- Timing:
  - Context of onset of pain (i.e., at rest, exertional)
  - Duration of pain
- Quality:
  - Burning
  - Squeezing
  - Dull
  - Sharp
  - Tearing
  - Heavy
- Associated symptoms:
  - Shortness of breath
  - Diaphoresis
  - Nausea
  - Vomiting
  - Jaw pain
  - Back pain
  - Radiation
  - Palpitations
  - Syncope
  - Fever
  - Weakness: Generalized vs. focal
  - Fatigue

Physical Exam

Cardiac exam for murmurs, rub, decreased heart sounds, or extra heart sounds
Chest exam for decreased breath sounds, rales, wheezing
Extremity exam for decreased pulses, pulsus paradoxus
Skin exam for lesions of herpes zoster
Abdominal exam for tenderness, rebound, guarding

Diagnosis Tests & Interpretation

EKG: á

Inexpensive and available
Obtain and interpret within 10 min of arrival
Serial EKG can be useful in patients with high concern for ACS and a negative initial EKG.
See specific etiologies.

Lab

Lab testing should be individualized to the patient and the presentation, based on the risk of potential life threats.
See "Cardiac Testing."Ł
d-Dimer:
- Sensitive but poor specificity for physical exam
- Indicated for low-risk patient if there is an indication to rule out pulmonary embolus
- Controversial use as a screening test for aortic dissection

Imaging

CXR:
- Pneumothorax
- Pneumonia
- CHF
- Aortic dissection:
  - Widened mediastinum seen in ~55-62% of patients
  - A pleural effusion is found in ~20% of patients.
  - Apical capping
  - Aortic knob obliteration
  - A normal chest radiograph is found in 12-15% of patients.
- Acute pericarditis:
  - Usually normal unless massive effusion enlarges cardiac silhouette
- Esophageal rupture:
  - Usually will show mediastinal air
  - May have left pleural effusion
Helical CT scan:
- Pulmonary embolism
- Sensitive for aortic dissection
Ventilation/perfusion scan:
- Useful in pulmonary embolus
- Must have normal CXR
Angiography:
- Pulmonary embolism; although rarely done
- Useful in dissection, especially in stable patients
US:
- Test of choice for pericardial and valvular disease
- Transesophageal Echo can be used in diagnosis of aortic dissection, especially in unstable patients and those unable to tolerate contrast.
- Right ventricular dilation and hypokinesia is suggestive for pulmonary embolus and can be used to guide therapy
- Bedside transthoracic Echo can be used to quickly discover significant pericardial effusion, pneumothorax, and pleural effusion

Differential Diagnosis

See "Etiology."Ł á

Treatment

Pre-Hospital

Therapeutic interventions should be guided by the patients presentation, risk factors, and past history.
If a cardiac life threat is suspected:
- IV access
- Cardiac monitoring
- EKG
- Oxygen
- Baby aspirin/Full aspirin
- Pain control:
  - Nitrates
  - Morphine

Initial Stabilization/Therapy

As guided by the patients presentation: á

ABCs
IV
Oxygen
Cardiac monitoring

Ed Treatment/Procedures

IV, oxygen, and monitoring
EKG
Treatment varies based on suspected etiologies.

Medication

Dependant on etiology á

Follow-Up

Disposition

Admission Criteria
Dependent on the risk for life-threatening cardiopulmonary etiologies á
Discharge Criteria
Safe if patient is deemed to have low-risk etiology of chest pain á
Issues for Referral
Follow-up with primary care physician on low-risk chest pain for outpatient assessment á

Followup Recommendations

Patient should be instructed to return if: á

Chest discomfort lasts >5 min
Chest discomfort gets worse in any way
History of angina, and discomfort not relieved by usual medicines
Shortness of breath, sweats, dizziness, vomiting, or nausea with chest pain or chest discomfort
Chest discomfort moves into your arm, neck, back, jaw, or stomach

Pearls and Pitfalls

Caution in only ordering a single biomarker
Using response to medications as a diagnostic tool
Not using serial EKG in patients with suspected ACS or repeating EKGs when patients have recurrent chest pain

Additional Reading

Anderson áJL, Adams áCD, Antman áEM, et al. 2011 ACCF/AHA Focused Update Incorporated Into the ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2011;123(18): e426-e579.
Body áR, Carley áS, Wibberley áC, et al. The value of symptoms and signs in the emergent diagnosis of acute coronary syndromes. Resuscitation. 2010; 81(3):281-286.
Courtney áDM, Kline áJA, Kabrhel áC, et al. Clinical features from the history and physical examination that predict the presence or absence of pulmonary embolism in symptomatic emergency department patients: Results of a prospective, multicenter study. Ann Emerg Med. 2010;55(4): 307-315.
Hoffmann áU, Truong áQA, Schoenfeld áDA, et al. Coronary CT angiography versus standard evaluation in acute chest pain. N Eng J Med. 2012;367(4):299-308.
Upadhye áS, Schiff áK. Acute aortic dissection in the emergency department: diagnostic challenges and evidence-based management. Emerg Med Clin North Am. 2012;30(2):307.

Codes

ICD9

786.50 Chest pain, unspecified
786.51 Precordial pain
786.59 Other chest pain
786.52 Painful respiration
786.5 Chest pain

ICD10

R07.2 Precordial pain
R07.9 Chest pain, unspecified
R07.89 Other chest pain
R07.1 Chest pain on breathing
R07.81 Pleurodynia
R07.82 Intercostal pain
R07.8 Other chest pain

SNOMED

29857009 Chest pain (finding)
102587001 Acute chest pain
426396005 cardiac chest pain (finding)
274668005 non-cardiac chest pain (finding)
281245003 Musculoskeletal chest pain (finding)
3368006 Dull chest pain (finding)
59139008 Crushing chest pain (finding)

Home

Erectile Dysfunction

Doctor123.org