Chest pain

Exam Cram

• Chest pain can be caused by cardiovascular, respiratory, gastro intestinal, musculoskeletal or vascular body systems

• Chest pain is most commonly caused by reflux or musculoskeletal sources

• Chest pain red flag differentials include: acute coronary syndrome, pericarditis, aortic dissection, pulmonary embolism, pneumothorax, pneumonia, and oesophageal rupture

• Chest pain red flag features include: hyperacute onset < 1 minute, hypotension, severe hypoxia

Assessment

History

• Cardiac ischaemia: central dull ache radiating down left arm/ jaw, autonomic - nausea, sweaty, lightheaded

• Pleuritic- worse with breathing suggests respiratory- pulmonary embolism, pneumonia, pneumothorax; or rib fracture/ musculoskeletal or pericarditis

Examination

Observations

Basic Work Up 

Investigations

• ECG- all patients require ECG ?ACS ?pericarditis

• Troponin- low threshold ?ACS

• Chest XR- low threshold ?PE, ?pneumothorax ?pneumonia, ?oesphageal rupture

• FBC, EUC- ?ACS from T2MI

• D-dimer ? PE (often can send coagulation studies and add on D-dimer)

• Consider proBNP, ECHO if signs of heart failure

Management

1. Stabilise via A-E

2. Treat underlying cause

3. Symptomatic relief

   • Paracetamol

   • Opioids- if severe

   • NSAIDs- contraindicated in ACS

   • GTN- reasonable in ACS however contraindicated in right heart failure

Differentials 

Chest pain differentials can be divided into pathologies with findings on investigations (hard chest pain) in the acute setting and those that do not (soft chest pain).  Pneumonia is a surprisingly common differential. 

Hard chest pain:

1. NSTEMI, STEMI, unstable angina

2. Pulmonary embolus

3. Pneumonia

4. Pneumothorax

5. Pericarditis

6. Aortic dissection

7. Esophageal rupture

'Soft' chest pain

1. Angina

2. Reflux

3. Musculoskeletal injuries: rib fracture, costochondritis, pulled muscle

4. Idiopathic- chest wall syndrome

Chest pain work up in the emergency department involves ruling out the 'hard' chest pains and unless concerning angina/ unstable angina, discharging home

Chest pain

1. Settings: GP, A&E, medical assessment unit & inpatient

2. History

3. Examination

4. Observations

5. Investigations

   1. 1. 1. 
            

6. Differentials

   1. 1. 1. Heart

            1. 1. 1. Coronary artery disease: angina -> unstable angina -> NSTEMI -> STEMI

         2. Lungs

            1. 1. 1. Pneumonia

                  2. Pneumothorax

                  3. Pulmonary embolus

         3. Vascular: Aortic dissection

         4. Musculoskeletal

            1. 1. 1. Rib #

                  2. Intercostal muscle sprain

7. Management

This presentation is managed largely with information within the history but also with a few key investigations. 

Setting

The setting provides context to the pain and the patient's perception of its severity. Medicine often boils down to probabilities and the rates of myocardial infarction are different in a cohort presenting with chest pain to the GP vs to A&E vs to medical assessment unit vs as an inpatient. Some GP practices as part of their phone service will state all chest pains require assessment at hospital. As someone working in hospital I can both understand the difficulty of assessing chest pain without an ECG or troponin (there are sometimes surprises), on the other hand it would feel sensible to take a quick history to ensure the patient truly has chest pain before sending them to hospital (rather than simple reflux, for example. 

On the other hand if an individual is happy to wait in A&E for four hours then they likely feel the pain is significant enough to justify this expense. Surgeons will have a low threshold for asking for medical input for a chest pain, a common scenario is a type II MI secondary to biliary sepsis or an NSTEMI presenting with ?biliary colic. 

Assessing chest pain at the GP

A history should be taken and if true chest pain this is normally assessed at the hospital 

Indications for referral into hospital:

1. ?acute stemi 999 ambulance to A&E, preferably hospital with primary PCI

2. ?Nstemi, unstable angina Medics/ A&E

3. ?Pneumothorax Medics /A&E

4. ?Pulmonary embolus Medics

History

Pleurisy is pain with breathing in, this is caused by a rib#, muscle damage, pneumothorax, pulmonary embolus and pneumonia. 

Examination

This is usually unhelpful however a focused examination is integral to a thorough assessment.

1. Full A-E

   1. 1. B- auscultate, RR, sats, 

      2. C- auscultate HS, pulse regular, WWP? (warm and well perfused)

      3. D- GCS, temp, BM

      4. E- abdo + calf ?tenderness, any markings on chest wall ?bruise

2. Extra Tips:

   1. 1. Palpate the area that is painful

Palpating the area that is painful can suggest a musculoskeletal problem or rib #. 

Investigations

Personally I believe all chest pains require an ecg, full set of bloods (FBC, UEs, CRP +/- LFTs) with a troponin and chest x-ray as standard (differing views exist!). 

Management

1. Symptom control

2. Therapeutic

Chest pain symptom control follows core principles for pain management. See Analgesia for further information.