DESCRIPTION

• One of the most frequent chief complaints in the ED
• Often the presenting symptom of a high-risk etiology:
  • Acute coronary syndrome
  • Pulmonary embolism
  • Aortic dissection
• Assume life threatening until proven otherwise.
• Categorization may suggest the underlying etiology, but the presentation of chest pain can be extremely variable and vague.
• Thoracic pain:
  • May involve the myocardium, pericardium, the ascending aorta, pulmonary artery, mediastinum, and esophagus
  • Pain is deep, visceral, and poorly localized.
  • Characteristics vary from severe and crushing to mild, burning, or indigestion.
• Epigastric pain:
  • May involve the descending aorta, diaphragmatic muscles, gallbladder, pancreas, duodenum, and stomach
  • Pain is generally referred to the xiphoid region and in the back.
• Pleuritic pain:
  • Inflammation or trauma to the ribs, cartilage, muscles, nerves, pleural or pericardial surface
  • Pain increased by breathing, laughing, coughing, sneezing
  • Tenderness to palpation may be present.
  • Diaphragmatic pleurisy:
    • Sharp shooting pains in the epigastrium, lower retrosternal area, or shoulder intensified by thoracic movement
• Chest wall pain:
  • Inflammation of skin and SC structures of the chest wall
  • Pain is reproduced by:
    • Palpation
    • Horizontal flexion of the arms
    • Extension of the neck
    • Vertical pressure on the head

ETIOLOGY

• Thoracic:
  • Acute coronary syndrome
  • Pericarditis
  • Myocarditis
  • Stress-induced cardiomyopathy
  • Cardiac syndrome X
  • Stimulant use
  • Thoracic aortic dissection
  • Esophagitis
  • Esophageal spasm
  • GERD
  • Esophageal hyperalgesia
  • Abnormal motility patterns and achalasia
  • Esophageal rupture and mediastinitis
• Epigastric:
  • Dissection of the descending aorta
  • Peptic ulcer disease
  • Pancreatitis
  • Cholecystitis
  • Splenic rupture
  • Hepatic injury
  • Subdiaphragmatic abscess
• Pleuritic pain:
  • Pulmonary embolism
  • Pneumothorax
  • Pneumonia
  • Costochondritis
• Diaphragmatic pleurisy:
  • Splenic rupture
  • Hepatic injury
  • Subdiaphragmatic abscess
• Esophageal rupture
• Intercostal myositis
• Intercostal neuralgia
• Pectoralis minor strain
• Pericarditis
• Pleuritis
• Pneumonitis
• Rib fractures
• Acute chest syndrome of sickle cell
• Chest wall twinge syndrome:
  • Brief episodes of sharp anterior chest pain lasting 30 sec–3 min, aggravated by deep breathing and relieved by shallow respirations
• Chest wall pain:
  • Chest wall hematoma
  • Chest wall laceration
  • Herpes zoster
  • Thrombophlebitis of the thoracoepigastric vein
  • Xiphisternal arthritis
  • Adiposis dolorosa
  • Breast abscess, fibroadenosis, carcinoma

[Outline]

• DESCRIPTION
• ETIOLOGY

SIGNS AND SYMPTOMS

• Coronary artery disease:
  • Pressure
  • Squeezing pain
  • Radiation to arm, jaw
  • Shortness of breath
  • Diaphoresis
  • Nausea
  • Vomiting
  • Weakness
  • Fatigue especially in women or elderly
  • Signs of CHF
  • Anxiety
• Aortic dissection:
  • Sudden onset of pain with maximal intensity early
  • Tearing pain
  • Radiation to back and/or flank
  • HTN
  • Diastolic murmur of aortic insufficiency
  • Difference in upper-extremity pulses
  • Syncope
  • Nausea
  • Vomiting
  • Associated neurologic changes (i.e., visual changes)
• Pulmonary embolism:
  • Pleuritic pain
  • Shortness of breath
  • Anxiety
  • Diaphoresis
  • Tachypnea
  • Tachycardia
  • Low-grade fever
  • Syncope
  • Localized rales
  • Wheezing
• Acute pericarditis:
  • Substernal pain
  • Varies with respiration
  • Increased with recumbency
  • Relieved by leaning forward
  • Anxiety
  • Anorexia
  • Fever
  • Pericardial friction rub
• Pneumothorax:
  • Pleuritic pain
  • Shortness of breath
  • Anxiety
  • Tachypnea
  • Decreased unilateral breath sounds
  • Can be spontaneous (young), or associated with very minor trauma (elderly)

History

• The history is the most important tool to distinguish between the various etiologies.
• Have the patient define the key features:
  • Duration
  • Location:
    • Retrosternal
    • Subxiphoid
    • Diffuse
  • Frequency:
    • Constant
    • Intermittent
    • Sudden vs. delayed onset
  • Precipitating factors:
    • Exertion
    • Stress
    • Food
    • Respiration
    • Movement
  • Timing:
    • Context of onset of pain (i.e., at rest, exertional)
    • Duration of pain
  • Quality:
    • Burning
    • Squeezing
    • Dull
    • Sharp
    • Tearing
    • Heavy
  • Associated symptoms:
    • Shortness of breath
    • Diaphoresis
    • Nausea
    • Vomiting
    • Jaw pain
    • Back pain
    • Radiation
    • Palpitations
    • Syncope
    • Fever
    • Weakness: Generalized vs. focal
    • Fatigue

Physical Exam

• Cardiac exam for murmurs, rub, decreased heart sounds, or extra heart sounds
• Chest exam for decreased breath sounds, rales, wheezing
• Extremity exam for decreased pulses, pulsus paradoxus
• Skin exam for lesions of herpes zoster
• Abdominal exam for tenderness, rebound, guarding

DIAGNOSIS TESTS & INTERPRETATION

EKG:

• Inexpensive and available
• Obtain and interpret within 10 min of arrival
• Serial EKG can be useful in patients with high concern for ACS and a negative initial EKG.
• See specific etiologies.

Lab

• Lab testing should be individualized to the patient and the presentation, based on the risk of potential life threats.
• See "Cardiac Testing."
• D-Dimer:
  • Sensitive but poor specificity for physical exam
  • Indicated for low-risk patient if there is an indication to rule out pulmonary embolus
  • Controversial use as a screening test for aortic dissection

Imaging

• CXR:
  • Pneumothorax
  • Pneumonia
  • CHF
  • Aortic dissection:
    • Widened mediastinum seen in ~55–62% of patients
    • A pleural effusion is found in ~20% of patients.
    • Apical capping
    • Aortic knob obliteration
    • A normal chest radiograph is found in 12–15% of patients.
  • Acute pericarditis:
    • Usually normal unless massive effusion enlarges cardiac silhouette
  • Esophageal rupture:
    • Usually will show mediastinal air
    • May have left pleural effusion
• Helical CT scan:
  • Pulmonary embolism
  • Sensitive for aortic dissection
• Ventilation/perfusion scan:
  • Useful in pulmonary embolus
  • Must have normal CXR
• Angiography:
  • Pulmonary embolism; although rarely done
  • Useful in dissection, especially in stable patients
• US:
  • Test of choice for pericardial and valvular disease
  • Transesophageal Echo can be used in diagnosis of aortic dissection, especially in unstable patients and those unable to tolerate contrast.
  • Right ventricular dilation and hypokinesia is suggestive for pulmonary embolus and can be used to guide therapy
  • Bedside transthoracic Echo can be used to quickly discover significant pericardial effusion, pneumothorax, and pleural effusion

DIFFERENTIAL DIAGNOSIS

See "Etiology."

[Outline]

• SIGNS AND SYMPTOMS
• DIAGNOSIS TESTS & INTERPRETATION
• DIFFERENTIAL DIAGNOSIS

PRE-HOSPITAL

• Therapeutic interventions should be guided by the patient's presentation, risk factors, and past history.
• If a cardiac life threat is suspected:
  • IV access
  • Cardiac monitoring
  • EKG
  • Oxygen
  • Baby aspirin/Full aspirin
  • Pain control:
    • Nitrates
    • Morphine

INITIAL STABILIZATION/THERAPY

As guided by the patient's presentation:

• ABCs
• IV
• Oxygen
• Cardiac monitoring

ED TREATMENT/PROCEDURES

• IV, oxygen, and monitoring
• EKG
• Treatment varies based on suspected etiologies.

MEDICATION

Dependant on etiology

[Outline]

• PRE-HOSPITAL
• INITIAL STABILIZATION/THERAPY
• ED TREATMENT/PROCEDURES
• MEDICATION

DISPOSITION

Admission Criteria

Dependent on the risk for life-threatening cardiopulmonary etiologies

Discharge Criteria

Safe if patient is deemed to have low-risk etiology of chest pain

Issues for Referral

Follow-up with primary care physician on low-risk chest pain for outpatient assessment

FOLLOW-UP RECOMMENDATIONS

Patient should be instructed to return if:

• Chest discomfort lasts > 5 min
• Chest discomfort gets worse in any way
• History of angina, and discomfort not relieved by usual medicines
• Shortness of breath, sweats, dizziness, vomiting, or nausea with chest pain or chest discomfort
• Chest discomfort moves into your arm, neck, back, jaw, or stomach

[Outline]

• DISPOSITION
• FOLLOW-UP RECOMMENDATIONS

• Caution in only ordering a single biomarker
• Using response to medications as a diagnostic tool
• Not using serial EKG in patients with suspected ACS or repeating EKGs when patients have recurrent chest pain

ICD9

• 786.50 Chest pain, unspecified
• 786.51 Precordial pain
• 786.59 Other chest pain

ICD10

• R07.2 Precordial pain
• R07.9 Chest pain, unspecified
• R07.89 Other chest pain

[Outline]

• ICD9
• ICD10

• Anderson JL, Adams CD, Antman EM, et al. 2011 ACCF/AHA Focused Update Incorporated Into the ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2011;123(18): e426–e579.
• Body R, Carley S, Wibberley C, et al. The value of symptoms and signs in the emergent diagnosis of acute coronary syndromes. Resuscitation. 2010; 81(3):281–286.
• Courtney DM, Kline JA, Kabrhel C, et al. Clinical features from the history and physical examination that predict the presence or absence of pulmonary embolism in symptomatic emergency department patients: Results of a prospective, multicenter study. Ann Emerg Med. 2010;55(4): 307–315.
• Hoffmann U, Truong QA, Schoenfeld DA, et al. Coronary CT angiography versus standard evaluation in acute chest pain. N Eng J Med. 2012;367(4):299–308.
• Upadhye S, Schiff K. Acute aortic dissection in the emergency department: diagnostic challenges and evidence-based management. Emerg Med Clin North Am. 2012;30(2):307.

Josh W. Joseph

Edward Ullman