Chest pain


 * Associate Editor-In-Chief:

Overview
Chest pain is a common clinical symptom.
 * Several life threatening disorders should be excluded upon presentation.
 * The first diagnostic study to be ordered within 10 minutes is the 12 lead electrocardiogram.
 * A full medical history may assist in the prompt management of the patient with chest pain.

Chest pain that suggest cardiac ischemia as the underlying cause

 * Describing the pain as heaviness, a pressure or a band like tightness
 * Radiation of the pain to neck, jaw or left arm
 * Sweating
 * Nausea
 * Palpitations
 * Pain with exertion
 * Dizziness
 * Shortness of breath
 * A sense of impending doom.

Chest pain that are not characteristic of myocardial ischemia

 * Muscular pain; reproduced with or brought on by shoulder and/or forearm movements or postural changes,
 * Pleura related pain (pleuritic pain); a sharp or knifelike pain brought on by respiratory movements as deep breathing orcough
 * Primary or sole location of discomfort in the middle or lower abdominal region
 * Pain that may be localized at the tip of one finger, particularly over the left ventricular apex or a costo chondral junction
 * Pain reproduced with movement or palpation of the chest wall or arms
 * Very brief episodes of pain that last a few seconds or less
 * Pain that radiates into the lower extremities

The relief of chest pain by administration of sublingual nitroglycerin in outpatient setting is not diagnostic of coronary artery disease. For instance, esophageal pain can be relieved by administration of nitroglycerin. Likewise, the relief of chest pain by the administration of liquid or chewable antacids and anti reflux drugs does not exclude coronary artery disease as the underlying etiology of the pain.

5 Life Threatening Diseases to Exclude Immediately

 * Aortic Dissection
 * Esophageal Rupture
 * Myocardial Infarction
 * Pulmonary Embolism
 * Tension Pneumothorax

History and Symptoms
Levine's sign


 * Thorough history including:
 * Onset
 * Duration
 * Type of pain
 * Location
 * Exacerbating factors
 * Alleviating factors
 * Radiation


 * Risk factors for coronary artery disease:
 * Family history
 * Smoking
 * Hyperlipidemia
 * Diabetes

Physical Examination

 * Complete physical examination including the following:
 * Temperature
 * Pulse
 * Jugular venous pulse (JVP)
 * Auscultation of the chest
 * Palpation of the chest

Heart: Cardiovascular examination including assessment of murmurs, gallops or rubs,carotid bruit and heart sounds

Extremities: Evidence of lower limb tenderness or pain

Other: Rectal examination is required to assess for occult bleeding

Laboratory Findings
On the basis of the above, a number of tests may be ordered:
 * Electrocardiogram (ECG): usually required for initial evaluation. ST elevation should require further urgent evaluation for reperfusion therapy.


 * 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)


 * X-rays of the chest and/or abdomen:
 * A chest X-ray can be useful in the initial evaluation of the patient to ascertain if there is cardiomegaly, pulmonary edema and aortic dissection.
 * CT scanning may be better but is often not available


 * Echocardiography or Ultrasound:
 * Echocardiogram usually required for patients with suspected coronary artery disease
 * To rule out aortic dissection, transesophageal echocardiogram of the chest may be indicated


 * MRI and CT:
 * CT scan of abdomen and chest may be helpful in ruling out pulmonary embolism
 * To rule out aortic dissection, a CT scan or MRI of the chest may be indicated


 * Other Imaging Findings:
 * V/Q scintigraphy or CT Pulmonary angiogram (when a pulmonary embolism is suspected)
 * For patients who are suspected to have coronary artery disease may require stress testing or cardiac catheterization
 * Peak flow studies and pulmonary function tests may be indicated for patients requiring further evaluation


 * Other Diagnostic Studies:
 * Upper gastrointestinal endoscopy if esophagitis is suspected

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 (e.g.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 therapies.

Treatment
Immediate Management:
 * Special attention to: airway, breathing, and circulation
 * Treat all underlying etiologies as clinically indicated
 * Supplemental O2 should be administered to patients with suspected coronary artery disease

Acute Pharmacotherapies:
 * For patients with coronary artery disease:
 * Aspirin
 * Nitroglycerin
 * Morphine (if necessary)
 * For patients with myocardial infarction:
 * Heparin
 * Beta-blockers
 * ACE inhibitors
 * Thrombolytic therapy
 * Glycoprotein IIb/IIIa inhibitors

Surgery and Device Based Therapy:
 * For patients in which myocardial infarction is suspected, angioplasty may be indicated
 * For patients with aortic dissections, emergent surgery may be required.