Chest Pain

» Cardiology» Pulmonology

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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