The approach to the patient with chest pain, dyspnoea or haemoptysis

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Chapter 6 The approach to the patient with chest pain, dyspnoea or haemoptysis

Patricia Saccasan Whelan, Anthony J. Whelan

Chest pain, dyspnoea and haemoptysis are common and important symptoms which bring patients to the emergency department. The role of the emergency medical team is to rapidly identify high risk patients, commence resuscitation if necessary, arrive at an accurate diagnosis, initiate appropriate therapies and arrange appropriate disposition. Some therapies are extremely time-dependent (e.g. reperfusion therapy for myocardial infarction) and good outcomes depend on early recognition of these seriously ill patients. However, the clinician must be aware of the costs associated with inappropriate admissions and investigations.

CHEST PAIN

The general public is increasingly aware of the importance of chest pain and the need for early presentation with this symptom. In American emergency departments, up to 7% of all presentations are for chest pain, prompting changes in the organisation of emergency departments so that many high volume departments have specialised chest pain units where patients with this symptom are rapidly triaged and treated according to defined protocols. While there are many causes of chest pain, clinicians should be aware of disorders which are potentially life threatening (Figure 6.1). Before any chest pain patient is discharged, each of these diagnoses should at least be considered.

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Figure 6.1 Chest pain algorithm

Myocardial ischaemia

(See also Chapter 7, ‘Acute coronary syndromes’.)

History

Recognition of the symptoms of myocardial ischaemia is crucial. Modern therapies significantly improve the outcome of patients with acute ischaemia and missing this diagnosis can be disastrous. In the USA inappropriate discharge of patients who eventually are found to have acute coronary syndromes is the leading cause of litigation involving emergency physicians.

Take time to question the patient, using non-leading questions, to clarify the nature of the patient’s pain. The pain of myocardial ischaemia is classically a deep visceral pain felt in the anterior chest but not localised to any part of the chest. Patients may describe heaviness, constriction, a sensation like a heavy weight or a dull ache. Pain usually comes on gradually, reaching a peak over a few minutes, and lasts at least a few minutes. Patients prefer to lie still and the pain is not exacerbated by the respiratory cycle, posture or food intake. Classical radiation patterns include spread to the neck, jaw or arms. Pain radiating to the left arm is more common than to the right. Heaviness (rather than pain) in both arms is also very suggestive. Autonomic accompaniments such as sweating, nausea and anxiety are also concerning. While the pain of myocardial ischaemia may be severe, the severity of the pain is not consistently related to the extent of ischaemia. Angina usually lasts less than 20 minutes and there may be some benefit from oxygen and sublingual nitrates. The temporal pattern of angina is of prognostic significance (Table 6.1).

Table 6.1 Unstable angina—Braunwald classification

Class Description Risk of AMI/death in next year
I New onset exertional angina; angina with less effort; no rest pain 7%
II Angina at rest within the last month but no pain in last 48 hours 10%
III Angina at rest in the last 48 hours 11%

Atypical presentations are common. Older patients, younger patients, women and diabetics are more likely to have presentations which are not immediately suggestive of myocardial ischaemia. Pain may be felt in the abdomen, jaw or arm (without chest pain) or an acute coronary syndrome may present only with dyspnoea, vomiting or syncope. Thus a high index of suspicion is necessary and the diagnosis of myocardial ischaemia should be considered (and an ECG done) in all patients in whom this diagnosis is possible.

There may be overlap with other chest pain syndromes. Some patients describe burning pain suggestive of gastro-oesophageal reflux, and while sharp, stabbing or even pleuritic-type pain makes myocardial ischaemia unlikely, it does not exclude this diagnosis. Pope et al found up to 22% of patients with the principal complaint of sharp stabbing pain had an acute coronary syndrome.1,2

A number of diagnostic decision tools using history and ECG findings to assist with diagnosis have been proposed (e.g. the acute cardiac ischaemia (ACI) predictive instrument), which probably increase the accuracy of diagnosis.3 However a high index of suspicion is the most useful safeguard.

Risk factors

A previous diagnosis of myocardial infarction, stable angina and revascularisation procedures significantly increases the risk that a new presentation with chest pain is due to myocardial ischaemia. The presence of diabetes and increasing age are also important risks. It is not clear whether a history of other risk factors for atherosclerosis (smoking, hyperlipidaemia, family history) increases the risk that a new presentation with chest pain is due to myocardial ischaemia. This is because these findings are very common in the general population.

Other potentially life-threatening causes of chest pain

Aortic dissection

(See also Chapter 16, ‘Aortic and vascular emergencies’.)

This is an important but rare disorder leading to severe chest pain associated with a significant mortality. Typically the pain is of abrupt onset and is of maximum intensity immediately, as opposed to the pain of myocardial ischaemia which builds up over minutes. The pain of aortic dissection often radiates through to the back, which is unusual in myocardial ischaemia. The pain may be described as ‘tearing’ and can be very severe, needing large doses of narcotics for control of pain. The appearance of a patient with severe pain and a non-specific ECG who appears shocked, yet has a high blood pressure, is a strong clue to this disorder. Risk factors for aortic dissection include Marfan’s syndrome and other inherited disorders of connective tissue, hypertension, pregnancy and previous surgery involving the aorta.

Pneumothorax

(See also Chapter 8, ‘Respiratory emergencies: the acutely breathless patient’.)

Pleuritic chest pain varies with the respiratory cycle and is usually worse on inspiration. Pneumothorax (air in the pleural space) is an important cause of pleuritic chest pain and is frequently associated with dyspnoea. Primary spontaneous pneumothorax occurs most frequently in younger males who are tall and thin. Secondary spontaneous pneumothorax complicates chronic lung disease, especially COPD, asthma and cystic fibrosis.

Pulmonary embolism

(See also Chapter 10, ‘Pulmonary emboli and venous thromboses’.)

Pleuritic pain can also be caused by pulmonary embolism, where there is a complicating pulmonary infarction and pleural irritation; however, massive pulmonary embolism can also cause central chest discomfort suggestive of angina. This is often associated with dyspnoea and haemodynamic collapse, and may reflect acute right ventricular dysfunction.

Pneumonia

(See also Chapter 8.)

Pleuritic chest pain is a common feature of respiratory tract infections which involve the pleura.

Ruptured oesophagus

Severe anterior chest pain following vomiting is characteristic of oesophageal perforation (Boerhaave’s syndrome). While vomiting may occur in myocardial infarction, it usually follows the onset of chest pain rather than preceding it. Oesophageal perforation may also follow procedures, especially oesophageal dilatation.

Other causes of chest pain

Pericarditis

Pain is usually felt in the anterior or left chest. It has a pleuritic quality and varies according to posture. Pericarditis can occur at any age and the pain may be severe.

Reflux

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