Chest pain

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Chapter 3 Chest pain

Colville Laird, Peter Driscoll, Jim Wardrope

Introduction 37
Primary survey 38
Patients with normal primary survey with obvious need for hospital admission 38
Secondary survey (including history taking) 39
The OPQRST of chest pain 39
Other factors 41
Differential diagnosis 43
Cardiac pain 44
Chest pain 44
Diagnoses for exclusion 50
Interpretation of findings 50
Treatment and disposal 50
Follow-up arrangements (if not admitted) 51

Introduction

Chest pain is the commonest reason for 999 calls and accounts for 2.5% of out-of-hours calls. Of patients taken to hospital, about 10% will have an acute myocardial infarction (AMI). Evidence suggests that up to 7.5% of these will be missed on first presentation. There are a number of other life threatening conditions which can present as chest pain and must not be overlooked. The objectives of this article are therefore to provide a safe and comprehensive system of dealing with this presenting complaint (Box 3.1).

Box 3.1 Objectives of assessment of patients with chest pain

image To undertake a primary survey of the patient and treat any immediately life threatening problems
image To identify any patients who have a normal primary survey but have an obvious need for hospital admission
image To undertake a secondary survey considering other systems of the body where dysfunction could present as chest pain
image To consider a list of differential diagnoses
image Discuss treatment based on the probable diagnosis(es) and whether home management or hospital admission is appropriate
image Consider follow up if not admitted

Primary survey

Follow the ABC principles (Box 3.2).

Box 3.2 Primary survey

If any of the following present treat immediately and transfer to hospital:

image airway obstruction
image respiratory rate <10 or >29 per minute
image O2 saturation <93%
image pulse <50 or >120
image systolic BP <90 mmHg
image Glasgow coma score <12

Patients with normal primary survey with obvious need for hospital admission

There are three immediately life threatening medical conditions that can present with chest pain:

image acute coronary syndrome (ACS)
image pulmonary embolus
image dissection of the thoracic aorta.

The history and a brief examination may lead you to suspect that one of these is the probable diagnosis. Patients may often have normal physical signs. Urgent hospital admission must be arranged if you suspect any of the above or any other life threatening diagnosis.

Fifty percent of sudden cardiac deaths occur within 1 hour of the start of a myocardial infarction and 75% within 3 hours. The benefits of thrombolysis or percutaneous intervention (PCI) are directly related to the length of time between the onset of symptoms and its delivery. Therefore if you diagnose a myocardial infarction, ensure you have immediate access to a defibrillator and consider thrombolysis or arrange rapid transportation to a facility where thrombolysis or PCI can be delivered.

Secondary survey (including history taking)

Having dealt with the potential life threatening cases you will be left with a group of patients for whom a more thorough clinical examination will be required before considering whether they can be either treated and left at home, or referred elsewhere.

Take a history of the presenting complaint, gather relevant information, and perform an examination (see Chapter 2).

For patients with chest pain, respiratory, cardiovascular, abdominal and musculoskeletal examinations are appropriate.

There is good evidence that history and examination cannot ‘rule out’ any specific diagnosis, especially acute myocardial infarction. Some types of pain are more commonly found in patients with ischaemia. However there is good evidence that history can help ‘risk stratify’ patients. In the context of acute chest pain, some other investigation will often be required.

The OPQRST of chest pain

Chest pain is often categorised into three main types (Table 3.1). It can be very difficult to place any particular patient into one of these categories, but there is evidence that the characteristics of pain can help in the diagnosis:

image typical cardiac pain
image pleuritic chest pain
image atypical chest pain.

Table 3.1 The three main types of chest pain

image

Somatic pain may arise from the chest wall (skin, ribs and intercostal muscles), pericardium (fibrous and parietal layer), and the parietal pleura. Pain from these structures is transmitted to the brain by the somatic nerve fibres that enable the brain to accurately locate the site of the problem. In the case of pleuritic chest pain, it will also be specifically related to movements of breathing.

Visceral pain in contrast originates from the deeper thoracic structures (heart, blood vessels and oesophagus) and is carried in the autonomic nerve fibres. These give a less precise location of the pain, and the pain is generally described as a discomfort, heaviness or ache. It is often referred to shoulders, arm or jaw.

TIP

Always ask about the relation of the pain to breathing, movement, exercise and rest

Onset of pain

The pain of a myocardial infarction is classically described as rapidly increasing over a few minutes but it can develop gradually or even be intermittent. In an acute coronary syndrome the pain may well be intermittent. As the platelet thrombus breaks down, blood flow is restored and the pain is relieved. Beware of pain starting at rest, or that which wakes the patient up from sleep.

Precipitating factors/palliative factors

Gain a detailed impression of how the pain started. Establish if there is any relation to exercise, breathing or food. Pain that has been provoked by exercise or wakened the patient should be regarded as significant. GTN will improve angina pain but also will improve pain from oesophageal problems. Equally there is no evidence that improvement of pain after giving an antacid can help distinguish between cardiac and oesophageal pain.

TIP

The pain due to ACS may be intermittent and appear to be responsive to antacids

Quality

Typical myocardial pain is easily recognised. It is often described as tight or squeezing. In a typical myocardial infarct it is very severe. Typical pleuritic pain is sharper and well localised. Atypical pain can take any form but is often described as ‘indigestion’ or retro-sternal burning. Such pain is also associated with inferior ischaemia and infarction.

Radiation and systemic symptoms

Typical ischaemic pain is often across the chest with radiation to the shoulders, arms or jaw. However it can be felt only in the jaw, arms, shoulder or back, or epigastrium. Pleuritic pain is well localised although it may be referred to the shoulder if the diaphragm is irritated.

Sweating, nausea, vomiting and shortness of breath are common in severe myocardial ischaemia. Ask about cough and sputum production. If the pain is pleuritic, ask about leg swelling or pain.

Timing

Typical cardiac pain that lasts less than 15 minutes is defined as angina; however, if the angina pain is of recent onset, occurring at rest, coming more often than the patient’s usual angina or if it lasts more than 15 minutes, this could indicate an acute coronary syndrome (unstable angina). It would be unusual for it to continue for over 24 hours. Chest pain lasting only a few seconds is unlikely to be cardiac.

Other factors

Previous similar symptoms

A previous history of ischemic heart disease makes it much more probable that the pain is cardiac. However, patients with heart disease do have other chest problems and the patient may say that the pain is different from the usual symptoms.

Risk factors

The presence of risk factors for cardiovascular disease should increase your suspicion as to a cardiac cause for the pain (Box 3.3).

Box 3.3 Important risk factors for angina or acute coronary syndrome

image Previous history of ischaemic heart disease
image Smoking
image Hypertension
image Diabetes
image Strong family history (that is, ischaemic heart disease onset <60 years)
image High cholesterol concentrations

Medical history/drugs allergies

It is important during the history taking to ask the patient about their medical history as they may already have had an illness that could present as chest pain. A drug history is also important; specifically ask about aspirin (you may need to give this), and if they have taken GTN, warfarin, or other cardiac medications.

TIMI scoring

TIMI risk scoring is one method of assessing the risk of a patient of having a significant cardiac event (MI, death, need for revascularisation) within the next 2 weeks. It assesses seven variables listed in Box 3.4. Cardiac markers are not routinely available at present in the community setting. If a patient has no or only one point the risk of an event is 4.7% (note even this is an appreciable risk). If they have 6 points the risk is 40%. While TIMI scoring can be used to guide therapy in the hospital setting it should not be used to ‘rule out’ ischaemic heart disease in the community setting.

Box 3.4 TIMI scoring

TIMI risk scoring assesses seven variables:

image age > 65 years
image at least three risk factors for cardiac disease
image known coronary stenosis of 50% or more
image ST segment changes on the ECG
image at least two anginal events in the previous 24 hours
image use of aspirin in the last 7 days
image elevated cardiac markers

TIMI scoring: risk of events in 14 days – score 0–1 = 4%, 2 = 8%, 3 = 13%, 4 = 19%, 5 = 26%, 6 or 7 = 41% (see Antman et al 2000)

Social history and substances

Some illegal drugs such as cocaine may cause chest pain. Patients with a history of alcohol misuse or illegal drug use are at increased risk of developing chest infections and suffering from thromboembolic disease.

Examination

See Chapter 2 for a full discussion of examination techniques.

Vital signs

Unless you are transporting the patient immediately, always measure a full set of vital signs.

General

Is the patient confused/anxious, short of breath? This may indicate a critical situation. Go back to primary survey.

Is the patient obviously in pain? Are they pale/sweaty? Have they been sick? If the answer to any of these questions is positive, there is a greater likelihood of serious disease.

Cardiovascular

Pay special attention to the rate and rhythm of the arterial pulse and the level of the jugular venous pulse. Ask the patient to take a deep breath, look for an increase in pain during inspiration. Follow this by listening to the heart sounds and the lung bases. Finish by examining the ankles, calves and foot pulses (for oedema/signs of DVT).

Chest wall tenderness reproducing the patient’s pain is suggestive of musculoskeletal pain but studies have shown this sign to be present in up to 15% of patients with confirmed myocardial infarction. Therefore this sign on its own should never be used to exclude a myocardial infarction.

Tests

An ECG is indicated in patients with chest pain. Under the age of 30, ischaemic heart disease is uncommon but if the pain is typical, obtain a 12-lead ECG. Detailed interpretation of the ECG is beyond the scope of this chapter but readers are referred to the texts in the further reading list. An abnormal ECG in a patient with chest pain is an indication for admission to hospital.

Differential diagnosis

Table 3.2 shows a list of the differential diagnoses classified by the type of pain they present with.

Table 3.2 Differential diagnoses

Cardiac ischaemic pain Pleuritic pain Atypical pain
Angina Pneumonia Non-specific chest pain
Acute coronary syndrome Pulmonary embolism Oesophageal pain
(Dissecting aortic aneurysm) Pneumothorax Cardiac pain
(Oesophageal pain) Rib injury Gastric/biliary pain
(Pericarditis) (Pericarditis) Chest wall pain
    Pericarditis
    Dissecting aortic aneurysm

Cardiac pain

Ischaemic cardiac pain originates from the myocardium when its blood supply is insufficient for its needs. It can be broadly divided into two categories – angina and acute coronary syndrome.

Angina is arbitrarily defined as lasting less than 15 minutes. It is often related to increased myocardial oxygen demand, for example, stress or exercise. If angina is of recent onset, occurring at rest, increasing in frequency or lasting more than 15 minutes, acute coronary syndrome needs to be excluded. Acute coronary syndrome includes:

image infarction with ST elevation (STEMI) – usually progresses to Q wave MI (QMI)
image MI confirmed but no Q developed (NQMI) – usually no ST elevation either (NSTEMI)
image MI occurring with left bundle branch block (LBBB) hiding ST elevation
image ACS without serological evidence of MI (unstable angina).

Chest pain

Table 3.3 provides a summary of causes and types of chest pain.

Table 3.3 Summary of causes and types of chest pain

image

Angina

Consider this diagnosis if the pain lasted less than 15 minutes or settles within 5 minutes of GTN administration and is a single episode. If it occurs at rest or is more severe than the patient’s usual angina, consider it to be acute coronary syndrome and refer. If the patient is young (35–70) and this is the first episode of typical ischaemic pain and has come on at rest, refer even with one episode.

Myocardial infarction

Carry out a full ABC assessment and provide oxygen and analgesia (appropriate to the diagnosis). A defibrillator must be taken to any patient complaining of chest pain. See Box 3.5 for the management of MI.

Box 3.5 JRCALC MI management

image Administer 400 μg GTN where systolic BP is estimated >90 mmHg
image Give high flow oxygen via a non-rebreathing mask
image Where appropriate move to the ambulance at this stage
image If pain persists consider a second dose of 400 μg GTN where systolic BP is estimated >90 mmHg
image Give aspirin 300 mg orally
image Obtain intravenous access if not already achieved
image Monitor BP for hypotension and position patient appropriately
image If pain continues, morphine 2.5–10 mg intravenously may be administered
image Pain assessment scoring should be carried out before and after analgesia has been administered
image Remove to nearest suitable receiving hospital without delay for urgent thrombolytic therapy

If trained in thrombolysis then:

image ensure the patient has the indications (typical chest pain + appropriate ST elevation; LBBB)
image ensure the patient has no contraindications
image explain risks and benefits
image obtain consent and administer thrombolysis

Who can be left at home?

Consider this option if the patient has a history of angina, and they have had a typical episode lasting less than 15 minutes, they are well and the ECG is normal. They must of course be told to call for assistance if the pain recurs. It is desirable to have a relative or carer stay with them, or to do a check by visit or telephone in a few hours.

Pericarditis

The pericardium is a double layer of tissue, which envelops the heart. It has an outer thick, fibrous layer that is attached to the base of the great vessels and the diaphragm. The gap between the heart and this fibrous layer is called the pericardial space. This is covered by a thin, serous layer, which lines the inner surface of the fibrous pericardium as well as the outer surface of the heart. Normally the two serous layers slide over one another during the movement of the heart, an action facilitated by the small amount of fluid in pericardial space. However, in pericarditis the surfaces become swollen, tender and inflamed. This usually results from infection but it can result from autoimmune reactions, after myocardial infarction and cardiac surgery. Pericarditis commonly presents as chest pain described as midline and sharp. The pain is made worse by movement and breathing, whereas sitting up and leaning forward may relieve it. The pain may radiate to the back, neck or left shoulder and is associated with dyspnoea, tiredness and fever.

Dissecting aortic aneurysm

In this condition blood breaks through the inner lining of the aorta and creates a false passage between the endothelium and the outer wall. In doing so it may occlude the branches of the aorta and give rise to a variety of conditions including strokes. It may also track proximally and burst through into the pericardium or damage the aortic valve. One of the signs of this can be disparity between the upper limb blood pressure recordings.

Typically the patient presents with severe, ‘ripping/sharp’ chest pain radiating through to the back. Diagnosis is difficult but is made easier by thinking of the condition, particularly in those with a higher risk (for example, hypertension or Marfan’s syndrome). Examination may reveal a difference in the blood pressure between the left and right arm. There may be murmurs heard over the back.

Patients with ACS, pericarditis or thoracic aortic dissection will usually have had problems identified in the primary survey. If not, correct any ABC abnormality, give pain relief and arrange immediate admission to hospital.

Cervical root pain

This occurs when one of the nerves that exits the cervical spine is irritated by structures within the vertebral column. The pain is limited to the upper chest and the neck and is usually precipitated by neck movement. These patients will not normally require admission. Treatment will be from the following options: analgesia, non-steroidal anti-inflammatory drugs, muscle relaxants, and a soft cervical collar.

Chest wall pain

This is pain originating from the ribs or chest wall musculature, or both. It may be related to trauma, in which case the area of tenderness is at the site of injury. In non-trauma cases, the pain and tenderness are usually over the anterior chest wall. Treatment is with non-steroidal anti-inflammatory drugs. If associated with major trauma, patients should be admitted.

Pneumothorax

A pneumothorax is the complete or partial collapse of a lung. There is usually a sudden onset of sharp chest pain and dyspnoea. The pain is normally one sided and may radiate to the back. Risk factors include obstructive pulmonary disease, trauma and tall thin young people. Treat any ABC abnormality and provide oxygen and analgesia. This patient will need to be sent to hospital.

Pulmonary embolism

This occurs when a clot forms within the venous system of the body and then travels to the lungs and obstructs part of the pulmonary circulation. The onset of symptoms is sudden, often unilateral and associated with dyspnoea and tachypnoea (respiratory rate >20).

Risk factors include intravenous drug abuse, a recent history of trauma or surgery, venous stasis or hypercoagulability. The pre-test probability of a pulmonary embolism can be predicted from Table 3.4.

Table 3.4 Pre-test probability of pulmonary embolism well’s criteria

Factor Risk score
Clinical signs of DVT 3.0
Other diagnosis less likely 3.0
HR >100 1.5
Stasis or operation in <4/52 1.5
History of DVT or PE 1.5
Active Ca or treatment in <6/12 1.0
Haemoptysis 1.0

Low risk 2 or less; moderate risk 2–6; high risk > 6.

The vital signs may be abnormal and hence the patient will be primary survey positive. If this is not the case, but pulmonary embolism is suspected, appropriate resuscitation should be started, if required, and the patient sent to hospital.

Infection

The patient may have a history of a current or recent upper respiratory tract infection and a productive cough. On examination there may also be fever and breathlessness. To make decisions on treatment and whether the patient can be left at home, the following guidelines from the British Thoracic Society should be used – admit if:

image Children

– Oxygen saturation <92%
– Respiratory rate >50 breath/min, under 1 year 70 breath/min
– Difficulty in breathing
– Grunting
– Signs of dehydration
– Family not able to provide appropriate observation and supervision
– Unable to take antibiotics because of vomiting

image Adults

– Confused
– Oxygen saturation <92%
– Respiratory rate >30 breath/min
– Low blood pressure (systolic <90 mmHg, diastolic < 60 mmHg)
– >50 years of age or have co-existing disease
– Unable to take antibiotics because of vomiting.

Treatment

If admission is not planned encourage the patient to rest, drink plenty of fluids and not to smoke. Pleuritic pain should be treated with simple analgesics.

Amoxicillin is the antibiotic of choice for adults, with erythromycin or clarithromycin as an alternative for patients who are hypersensitive to penicillins.

All children under 1 year should be examined by a doctor. Amoxicillin is the first choice of antibiotic for children under 5. Alternatives are co-amoxiclav, cefaclor, erythromycin, clarithromycin and azithromycin.

In children over 5, erythromycin or clarithromycin may be used as a first line treatment as mycoplasma pneumonia is more prevalent in this older age group.

Arrange review within 24 to 48 hours.

Oesophageal pain

This pain is caused by acid reflux from the stomach burning the oesophageal mucosa. The pain may be of variable onset relieved by antacids, burning in nature, radiate to between the shoulder blades, and be accompanied by swallowing difficulties. Pain may be related to eating. Beware that acute coronary syndrome may present with ‘indigestion’ or retrosternal burning.

Treatment is with antacids, H2 antagonists, or proton pump inhibitors. If it does not respond to treatment, or swallowing difficulties develop, the patient should be admitted.

Beware of labelling pain as oesophageal or chest wall pain unless you have specific reasons that support this diagnosis.

PITFALLS

It is important to remember that oesophageal pain may be relieved with GTN and that some anginal pain may appear to be relieved by antacids. This is especially true of acute coronary syndrome where the pain may well be intermittent and appears to ‘settle’.

Diagnoses for exclusion

Undertaking all of the above steps will help you reach a diagnosis. It is vital to appreciate that included in the differential diagnosis are:

image acute coronary syndrome
image pulmonary embolism
image dissection of the thoracic aorta
image pneumothorax.

Interpretation of findings

These conditions require the patient to be admitted to hospital as soon as possible so it is important that these conditions are not missed. Thus if a convincing diagnosis of a condition other than these four cannot be reached the patient should be admitted to hospital. Individual symptoms or signs are unreliable (for example, there is no guarantee that a somatic pain is not originating from the heart or that heart pain will not disappear after the administration of an antacid). It is therefore unwise to exclude the diagnosis based on a single symptom, physical sign or investigation. Instead it should be based on several supporting pieces of information.

Treatment and disposal

image Treat and Refer – ACS, dissecting aortic aneurysm, pleuritic chest pain (depending on diagnosis and condition of patient), pneumothorax, gastrointestinal pain (depending on condition of patient or not settling with appropriate treatment)
image Treat and Leave – stable angina, cervical root pain, chest wall pain, pleuritic chest pain (depending on diagnosis and condition of patient), gastrointestinal pain (depending on condition of patient or not settling with appropriate treatment).

Follow-up arrangements (if not admitted)

Arrange review if indicated before normal working hours or, if not, notify the responsible GP with appropriate information at the start of normal working hours.

Further reading

Diagnosis

Antman EM, Cohen M, Bernick PJ LM, et al. The TIMI Risk Score for unstable angina/non ST elevation MI. JAMA. 2000;284:835-842.

Klompas M. Does this patient have an acute thoracic aortic dissection? JAMA. 2002;287:2262-2272.

Panju AA, Hemmelgarn BR, Guyatt GH, et al. Is this patient having a myocardial infarction? JAMA. 1998;280:1256-1263.

Swap CJ, Nagurney JT. Value and limitations of chest pain history in the evaluation of patients with suspected acute coronary syndromes. JAMA. 2005;294:2623-2629.

ECG Interpretation

Channer K, Morris F. ABC of clinical electrocardiography: myocardial ischaemia. BMJ. 2002;324:1023-1036. Available online: http://bmj.bmjjournals.com/cgi/content/full/324/7344/1023?eaf (5 Mar 2007)

Foster B. 12-Lead electrocardiography for ACLS providers. Philadelphia: WB Saunders, 1996.

Meek S, Morris F. ABC of clinical electrocardiography: introduction. I – Leads, rate, rhythm, and cardiac axis. BMJ. 2002;324:415-418. Available online: http://bmj.bmjjournals.com/cgi/content/full/324/7334/415 (5 Mar 2007)

Meek S, Morris F. ABC of clinical electrocardiography: introduction. II – Basic terminology. BMJ. 2002;324:470-473. Available online: http://bmj.bmjjournals.com/cgi/content/full/324/7335/470?eaf (5 Mar 2007)

Meek S, Morris F. ABC of clinical electrocardiography: acute myocardial infarction – part II. BMJ. 2002;324:963-966. Available online: http://bmj.bmjjournals.com/cgi/content/full/324/7343/963?eaf (5 Mar 2007)

Morris F, Brady WJ. ABC of clinical electrocardiography: acute myocardial infarction – Part I. BMJ. 2002;324:831-834. Available online: http://bmj.bmjjournals.com/cgi/content/full/324/7341/831?eaf (5 Mar 2007)

Heart and Lung Sounds

Auscultation Assistant. http://www.med.ucla.edu/wilkes/intro.html. (5 Mar 2007)

Treatment

Boehringer Ingelheim. Thrombolysis up front version 2.2, May 2003. Bracknell: Boehringer Ingelheim, 2003.

British Thoracic Society. Guidelines for the management of community acquired pneumonia in adults. Thorax. 2001;56(suppl 4):1-64.

British Thoracic Society. Guidelines for the management of community acquired pneumonia in childhood. Thorax. 2002;57(suppl 1):1-24.

Joint Royal Colleges Ambulance Liaison Committee. Guidelines version 2. London: JRCALC Royal College of Physicians, 2002. Available online: http://www.asancep.org.uk/JRCALC/guidelines.htm (5 Mar 2007)

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