Armando Hasudungan

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Chest Pain

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Cardiology» Pulmonology
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Chest Pain

Overview the most common and important cardiovascular symptom. It is also a very important symptom for the lungs and oesophagus, where the character, pattern of pain and associated symptoms differ. Initial management include oxygen, analgesia, nitrates (to rule in MI) and investigations with ECG and chest X-ray are urgent for patients who present with chest pain + grave signs and symptoms such as diaphoresis, tachycardia, hypotension, fever and sudden dyspnea. You want to rule out life-threatening causes first which are discussed below.

CAUSES OF CHEST PAIN BY BODY SYSTEMS   
Cardiac Respiratory Gastrointestinal Musculoskeletal Psychogenic
Acute Coronary Syndrome Pulmonary Embolism Oesophageal rupture Rib Fracture Anxiety
Aortic dissection Pneumothorax Pneumomediastinum Herpes Zoster Panic attack
Pericarditis Pulmonary Hypertension Cholecystitis Costochondritis
Stable Angina Pneumonia GERD/GORD
Endocarditis Lung Cancer Peptic ulcer disease
Cardiac tamponade Bronchiectasis Acute Pancreatitis

Types of chest pain

  • Pleuritic Pain - pain from parietal pleura and endothoracic fascia (the visceral pleura is insensitive to pain). It is worse on inspiration, reflecting the stretching of inflamed parietal pleura during movement of the thorax. No relief with GTN and does not radiate.
  • Pulmonary (Lung parenchymal) Pain - Dull and constant pain.
  • Diaphragmatic pain - pain referred to the shoulder tips. If pain located in costal parts of the diaphragm it radiates to the abdomen.
  • Chest wall (musculoskeletal) pain - It is rarely severe and incapacitating, is often bilateral, and generally is intensified by changes in body position or flexing the thorax. Confused with pleuritic pain. Tender to touch.
  • Burning pain - Esophageal disease, frequently after eating. Acid reflux may worsen with recumbency.
  • Cardiac pain - varies (dissecting aorta, stable angina, acute coronary syndrome and pericarditis)
Think just because chest is tender on palpation does not mean the chest pain is musculoskeletal
Life-threatening Chest Pain Clinical Features
 Conditions Pain Feature (Acute) Associated Signs and Symptoms Examination
Aortic dissection
  • Sudden substernal severe tearing pain
  • Radiating to back - classically between shoulder blades
  • Hypertensive and "marfanoid - marfan syndrome"
  • +/- syncope, hoarseness to paraplegia, altered mental status
 Prostration

Loss of pulse
Pulmonary Embolism
  • Sudden severe pleuritic chest pain
  • Can worsen overtime
  • Fever, Dyspnea (tachypnea)
  • +/- wheeze, cough, syncope, and haemoptysis
 Asymmetric extremity swelling (DVT?)
Pneumothorax
  • Sudden sharp severe pain
  • Unilateral chest pain
  • Dyspnea
  • Happening "out of the blue"
 Inspection: Asthentic habitus. Trachea deviation (only in tension pneumothorax), chest wall asymmetry (large pneumothorax)

Percussion: hyperresonant

Auscultation: reduced breath sounds and reduced vocal resonance on affected side
Cardiac Tamponade
  • Anterior precordial pleuritic pain
  • Worse when lying supine and relieved somewhat when leaning forward. It may also worsen with deep inspiration.
  • Fever
  • History of pericarditis or MI
 Inspection: Raised JVP, hepatomegaly, ascites, peripheral oedema

Palpate: impalpable apex beat

Auscultation: Telltale rub that is synchronous with the heartbeat
Acute coronary Sydnrome (Acute MI)
  • Often described as "discomfort" rather than pain
  • Constricting chest pain/ crushing/ heaviness radiating to neck and/or shoulder
  • Nausea/vomiting
  • SOB
  • Fear
  • Perspiration
 Inspection: Previous thoracic surgery

Palpapte: Heaves/Thrills

Auscultate: Tachycardia
Oesophageal rupture (Boerhaave syndrome)
  • Depend upon the location of the perforation
  • Severe, retrosternal burning pain, onset usually after eating or drinking
  • Dyspepsia and dysphagia.
  • GTN can alleviate pain (because it is a smooth muscle relaxant). However, it takes about 20min whereas in angina GTB works in a few minutes.

 

Signs and Symptoms of MI - PULSE
Persistent chest pain, Upset stomach, Lightheadedness, Shortness of breath, Excessive sweating

General Management - stabilize airway, breathing and circulation

  • Oxygen
  • Aspirin
  • Nitrates - for angina relief
  • IV access
  • Pain Relief - analgesia
  • Troponin and possibly other cardiac markers
Remember Treatment Acute MI - MONAC
Morphine, Oxygen, Nitrates, Aspirin + Clopedogril

Investigation

  • Full Blood count - White cell count may be elevated in any of the inflammatory or infectious aetiologies (ie. myocarditis, pericarditis, pneumonia)
  • EUC
  • Troponin - diagnosis of Acute MI
  • D-dimer - can help rule out PE
  • Chest X-ray
  • ECG
  • Other: B-type natriuretic peptide (heart failure), CT scan - aortic dissection and PE, Echocardiogram - pericarditis, pericardial effusion and valvular heart disease,
Remember Troponin I elevated within 3 hours peak at 12hours and remain elevated for 7-10 days

 

Life- threatening Chest Pain Features in CXR and ECG
Conditions Pain feature Chest-x - ray ECG
Aortic dissection Sudden severe tearing pain often radiating to back Widened mediastinum Can be completely normal to ST segment elevation if the dissection involes the origin of a coronary artery
Pulmonary Embolism Sudden severe pleuritic chest pain

Can worsen overtime

  Westermark's mediastinum

Hampton's hump

 "S1Q3T3" (ie, prominent S wave in lead I, Q wave in lead III, and inverted T wave in lead III) reflects right heart strain but is neither sensitive nor specific for PE
Pneumothorax Sudden severe unilateral chest pain Visceral pleural line typically identified Normal
Cardiac tamponade Anterior precordial pleuritic pain.

Worse lying supine, relieved leaning forward. Worse on inspiration

 Large globular heart (Cardiac Tamponade) Initial diffuse elevated ST segments ± depressed PR segment.
2-5 days later ST isoelectric with T wave flattening and inversion.
Acute coronary Sydnrome (Acute MI) Often described as "discomfort" rather than pain

Constricting chest pain, crushing chest pain radiating to neck/shoulder

 May show left ventricular hypertrophy,  cardiomyopathy or previous stent/pacemaker. ST elevation in leads associated with injured area of heart and reciprocal lead changes (depression) OR ST depression
Oesophageal Rupture Depend upon the location of the perforation: Mediastinal or free peritoneal air

Subcutaneous emphysema

  

 

 

Remember Approximately 90 percent of patients with aortic dissection will have some CXR abnormality. The classic findings of a widened mediastinum or aortic knob occur in up to 76 percent of patients.

Chest Pain Management Pathway - from BMJ

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