Approach to the Patient with Chest Pain

Overview

Chest pain is the most frequent complaint in the emergency department, and the most common cause is reflux. Nevertheless, approach these patients with an index of suspicion (especially if older)

As with any complaint of pain, you need to fully describe it using the mnemonic:

S – Site

O – Onset

C – Character

R – Radiation

A – Associated symptoms

T – Time

E – Exacerbating and relieving factors

S – Severity

Make sure to ask about risk factors for the differentials you are thinking of:

• ACS risks: prior myocardial infarction(MI), family history of cardiac disease, smoking, hypertension (HTN), hyperlipidemia (HLD), and diabetes
• Pulmonary embolism (PE) risks: prior deep venous thrombosis (DVT) or PE, hormone use (including oral birth control), recent surgery, cancer, or periods of non-ambulation
• Recent gastrointestinal (GI) procedures like scopes
• Drug abuse (cocaine and methamphetamines)

Differential diagnoses and how to rule each out clinically

Cardiovascular

• Angina
  • Retrosternal
  • Progressive build up in intensity over 1-2 minutes
  • Constricting and heavy
  • Radiates to the neck, jaw, shoulder, arm sometimes to the back and epigastrium
  • Associated with breathlessness
  • Intermittent; episodes last 2-10 minutes
  • Triggered by exertion, emotion, large meal, cold wind; relieved by rest
• Myocardial ischemia
  • Central (retrosternal), diffuse pain
  • Rapid onset; over a few minutes
  • Radiates to the neck, jaw, shoulder, arm sometimes to the back and epigastrium
  • Tight/squeezing/choking in character
  • Precipitated by exertion/ emotion/ a large meal/ cold wind
  • Exertion is a rare trigger, usually spontaneous. Not relieved by rest or nitrates
  • Associated with sweating, pallor, breathlessness, nausea and vomiting, a feeling of impending death (Angor animi)
• Aortic dissection
  • Interscapular/ retrosternal in site
  • Very sudden onset
  • Tearing/ ripping in character
  • Radiates to the back
  • Associated with sweating, syncope, focal neurological deficits, signs of limb ischemia, mesenteric ischemia; feeling of impending death (Angor animi)
  • Spontaneous i.e no trigger; not relieved by any factor
  Neurological symptoms occur because of occlusion of carotid, vertebral, or spinal arteries, and vasa nervorum of peripheral nerves
• Pericardial pain
  • Retrosternal or left-sided in site
  • Gradual in onset
  • Sharp, stabbing pleuritic pain
  • Radiates to left shoulder or back
  • Associated with flu-like prodrome, breathlessness, fever
  • Exacerbated by POSTURAL change (sitting up or lying down); relieved by NSAIDS
  Remember Pericardial Pain is associated with Postural change.
• Other causes
  • Myocarditis
  • Mitral valve prolapse syndrome
  • Aortic aneurysm

Respiratory

• Pulmonary embolus
  • Central or lateral (area of pulmonary infarction)
  In central PE, chest pain may be from underlying right ventricular ischemia and needs to be differentiated from an acute coronary syndrome or aortic dissection.
  • Pleuritic – sharp, stabbing pain that worsens when breathing in
  • Sudden onset in acute PE. Subacute may be gradual
  • No classical radiation
  • Associated with dyspnea, hemoptysis, cough, syncope, leg swelling and pain
  • Worsened by deep inspiration, coughing, or movement (pleuritic pain); Not relieved by rest or nitroglycerin
• Pneumothorax
  • Unilateral pain; localised
  • Sharp; pleuritic
  • Sudden in onset
  • Radiates to ipsilateral shoulder
  • Associated with dyspnea, dry cough, tachycardia, mediastinal shift, hyper-resonant percussion, absent lung sounds, trauma
  • Worsened by breathing in, coughing; not relieved by any factors
• Pneumonia
  • Can be localised or generalised; Unilateral or bilateral
  • Gradual onset
  • Dull; pleuritic pain
  • Associated with fever, chills, productive cough, dyspnea, hemoptysis, fatigue, malaise
  • Not relieved by any factors
  • Improves when on antibiotics
• Malignancy
  • Dull, persistent, unilateral pain
  • Insidious onset
  • Dull, aching, pleuritic (if pleura is involved); gnawing, continuous local pain (if invading chest wall)
  • Radiation depends
  • Associated with cough, hemoptysis, dyspnea, night sweats, unintentional weight loss
• Tuberculosis

Gastrointestinal

• Gastroesophageal reflux disease
  • Retrosternal
  • Burning in nature
  • Gradual onset
  • Radiates to neck
  • Recurrent
  • Typically occurs after a meal; lying down
  • Relieved by antacids, PPIs, sitting upright
  • Associated with chronic cough, asthma, laryngitis, dental erosions, dysphonia, and hoarseness, and globus sensation
• Esophageal perforation (Boerhaave’s Syndrome) The classic presentation of spontaneous esophageal rupture is that of a middle-aged man with a history of dietary overindulgence and overconsumption of alcohol who experiences chest pain and subcutaneous emphysema after recent vomiting or retching (Mackler triad)
  • Severe retrosternal/ epigastric pain
  • Sudden onset; may follow excessive vomiting, esophageal instrumentation, trauma
  • Tearing, ripping in character
  • Radiates to back, left shoulder, neck
  • Associated with vomiting, subcutaneous emphysema, dysphagia, dyspnea, hematemesis, melena
  • Worse with swallowing, breathing; ****No relief without surgical intervention
  • Catastrophic – considered an emergency
• Esophagitis
  • Retrosternal
  • Gradual onset
  • Associated with odynophagia, dysphagia, nausea, vomiting ( with blood – hematemesis), oral thrush
  • Worsens with feeding; relieved by PPIs, antacids,
• Esophageal spasm
  • Retrosternal
  • Intermittent
  • Squeezing like character (mimics angina)
  • Radiates to arm, jaw, back (mimics angina)
  • Associated with dysphagia, regurgitation,
  • Triggered by very hot and cold drinks and stress; relieved by CCBs and nitrates (mimics angina)
• Mallory Weiss syndrome

Neurological

• Prolapsed intervertebral disc
• Herpes zoster
• Thoracic outlet syndrome

Musculoskeletal

• Osteoarthritis
• Intercostal muscle injury
• Rib fracture
• Acute vertebral fracture