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
Diagnostic Tests & Interpretation
ECG:
- Inexpensive and available
- Obtain and interpret within 10 min of arrival
- Serial ECG can be useful in patients with high concern for ACS and a negative initial ECG
- Leads V7-V9 may reveal posterior infarction in higher-risk patients whose initial ECG is nondiagnostic
- 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
- Threshold can be adjusted in patients over 50 yr of age
- Limited utility 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 CXR 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
- CT angiography:
- 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”
Prehospital
- 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
- ECG
- Oxygen
- Baby aspirin/full aspirin
- Pain control:
- Nitrates
- Morphine (caution if confirmed ischemia or comorbid heart failure)
Initial Stabilization/Therapy
As guided by the patient's presentation:
- ABCs
- IV
- Oxygen (if needed for hypoxia)
- Cardiac monitoring
ED Treatment/Procedures
- IV, oxygen, and monitoring
- ECG
- Treatment varies based on suspected etiologies
Medication
Dependent on etiology
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
- AmsterdamEA, WengerNK, BrindisRG, et al. 2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes: Executive Summary: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines . Circulation. 2014;130(25):2354-2394.
- FanaroffAC, RymerJA, GoldsteinSA, et al. Does this patient with chest pain have acute coronary syndrome? The rational clinical examination systematic review . JAMA. 2015;314(18):1955-1965.
- HofmannR, JamesSK, JernbergT, et al. Oxygen therapy in suspected acute myocardial infarction . N Engl J Med. 2017;377(13):1240-1249.
- PapeLA, AwaisM, WoznickiEM, et al. Presentation, diagnosis, and outcomes of acute aortic dissection: 17-year trends from the international registry of acute aortic dissection . J Am Coll Cardiol. 2015;66(4):350-358.
- PoldervaartJM, LangedijkM, BackusBE, et al. Comparison of the GRACE, HEART and TIMI score to predict major adverse cardiac events in chest pain patients at the emergency department . Int J Cardiol. 2017;227:656-661.
The authors gratefully acknowledge Edward Ullman for his contribution to the previous edition of this chapter.