Chest Pain Diagnosing Chest Pain

Chest pain rightly frightens patients. It may reflect life-threatening

illness: always take the complaint seriously. In the emergency depart-
ment these patients are almost always triaged as ‘urgent’ to ensure
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that they are seen within the first few minutes of their arrival. The
frequency of ischemic heart disease is such that it is understandably
the first diagnosis to spring to mind in the middle-aged or elderly.
However, remember that chest pain may result from a variety of
other disease processes, many of which are also potentially life-
threatening.
History
Ask about the site (central, bilateral or unilateral), severity, the time of
onset, and duration of the pain. Then ask about the character (stab-
bing, tight/gripping, or dull/aching) and whether there was any radia-
tion (especially to the arms and neck, which is common in myocardial
ischemia). Were there any precipitating and relieving factors, such as
exercise, rest, foods, or medications such as nitroglycerin? If the patient
2 has a history of similar pain, compare the present attack to those in the
past—is this as bad, or worse? Enquire about associated symptoms:
breathlessness, nausea and vomiting, diaphoresis, cough, hemoptysis,
palpitations, dizziness or loss of consciousness. Ask about the patient’s
ability to walk uphill or upstairs over the last few days or weeks, as well
as any exercise that the patient does on a regular basis.
Then ask about and document any cardiac risk factors. Specifically,
ask about a history of angina or coronary artery disease, hyperten-
sion, hypercholesterolemia, parents or siblings with a history of CAD, a
smoking history, and a history of diabetes. Ask if the patient has had any
prior tests such as an exercise stress test (a treadmill test), a cardiac
ECHO or catheterization, and any prior ED visits for similar complaints.
Ask about risk factors for a pulmonary embolus: These are any previ-
ous DVT or PE, smoking, an underlying malignancy, oral contraceptive
use, trauma (specifically long bone fractures), any known hematologi-
cal abnormalities and any prolonged immobilization, including recent
plane or road trips. Review any available old records and prior EKGs.
For hospitalized patients review the history of their current admission,
and put this episode of chest pain into that context.
Associated Physical Signs
Unstable angina and acute MI (p. 42) Note the pulse (either
tachycardia or bradycardia can occur) and blood pressure. Pay atten-
tion for any signs of heart failure. Since things can change quickly, it
is important to document normal and negative findings clearly so
that new problems will be immediately apparent. Record the heart
sounds including any added sounds and the nature or absence of
murmurs. A rapid survey for neurological deficits is appropriate
(as anticoagulation or thrombolysis may be indicated) with a more

Chest Pain
detailed examination reserved for those where relevant abnormali-
ties are identified.
Pulmonary embolism (p. 162) Look for a sinus tachycardia,
hypotension, cyanosis, tachypnea, low grade fever, palpable right

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ventricle, loud pulmonary component of second heart sound (loud
P2), pleural rub, and signs of deep vein thrombosis.
Pericarditis (p. 154) Listen for a pericardial friction rub. Check
the pulse character, and measure the blood pressure yourself (look
especially for pulsus paradoxus, in which the systolic pressure differ-
ence through respiratory cycle is greater than 10 mmHg). Look for
other signs of tamponade, e.g., hypotension, Kussmaul’s sign (where
the JVP rises on inspiration) and quiet or absent heart sounds.

Patterns of Presentation
Angina pectoris (p. 56) is typically ‘tight,’ ‘heavy’ or ‘compressing’ in
quality in the substernal area, often (but not always) associated with
radiation to the (left) arm or throat and occasionally to the back or
epigastrium. It may also be experienced in the right arm. The
severity is highly variable from barely perceptible to severe and 3
frightening.
• Chronic stable angina is typically provoked by physical exertion,
cold (leading to peripheral vasoconstriction), and emotional
stress, and is relieved by rest. Sublingual nitroglycerine will usually
work within a couple of minutes.
• Unstable angina (p. 56) occurs at rest or on minimal exertion and
is more likely to be severe and sustained. There may be associated
autonomic features such as sweating, nausea, and vomiting.
There may have been a period of stuttering or rapidly increasing
symptoms leading up to the acute presentation. Sharp stabbing
pains, or pains that are well localized, of fleeting duration (usually
less than 30 seconds), are unlikely to reflect myocardial ischemia.
l Remember that angina does not necessarily indicate coronary
artery disease. Aortic stenosis, left ventricular outflow tract obstruc-
tion, and anemia are possible causes of angina too.
Thoracic aortic dissection (p. 144) typically has abrupt, even
instantaneous, onset. A tearing sensation from anterior to posterior
in the chest may be described. The pain is severe and often terrifying.
Other features may supervene, depending on which vascular terri-
tories are affected (e.g., angina) and neurological symptoms manifest
due to carotid or spinal artery involvement. The usual cause is hyper-
tension, which may be previously undiagnosed. Marfan syndrome is
an important predisposition.
Pulmonary embolism (p. 162) may present with pleuritic chest
pain (sharp, localized pain, intensified by inspiration). There may be
associated breathlessness or hemoptysis. Large pulmonary emboli
Chest Pain may diminish cardiac output to the extent that syncope occurs. Ask
about risk factors such as a previous DVT or PE (the most common
risk factor), prolonged immobility (travel and recent surgery), malig-
nancy, post-partum, personal or familial tendency to thrombosis,
smoking, and oral contraceptive use.
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Pericarditis (p. 154) may also cause pleuritic pain. The pain is
often relieved by leaning forward, most likely by easing the apposi-
tion of the inflamed pericardial layers. There may be associated ‘viral-
type’ symptoms or features of the underlying disease. Breathlessness
may indicate the accumulation of pericardial fluid, and suggests the
possibility of tamponade (p. 156).
Esophageal pain can mimic angina, in that it may present with
similar symptoms and be similarly relieved with nitroglycerine (which
relaxes the esophageal muscles, so relieving the spasm). An associa-
tion with acid reflux, exacerbation of the discomfort when supine, or
with food or alcohol, and relief with antacids all suggest esophageal
pain, but the distinction can be difficult and investigation is often
required. Remember that meals can also provoke angina.

4
Causes of Chest Pain

Table 1.1 Causes of Chest Pain

Cardiovascular Aortic Gastrointestinal
dissection* Myocardial Esophagitis Biliary
ischemia or infarction* colic Cholecystitis
Myocarditis Pancreatitis
Pericarditis Esophageal rupture*
Pulmonary Other
Pneumonia
Pneumothorax* Musculoskeletal**
Pulmonary embolus* Herpes zoster

*Potentially rapidly fatal

**Very common

Investigations
The tests needed will reflect the possible diagnoses and complica-
tions based on the history and physical examination and are shown
in the table below. Unless the diagnosis is musculoskeletal pain in a
young patient, an EKG is usually required. Remember that the EKG
may initially appear to be normal in MI, PE and aortic dissection.
Ensure that all patients are monitored. Radiological tests will be
 Chest Pain
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Table 1.2 Investigation of Chest Pain Based on Etiology
Suspected Cause Lab or EKG Test Radiographic Tests
Aortic dissection CBC CXR
Type and cross CT angiogram of chest
EKG TEE
Biliary colic or CBC, electrolytes US of RUQ
cholecystitis LFTs
Myocardial ischemia or CBC, electrolytes CXR (if CHF
infarction EKG suspected or required
Serial cardiac enzymes for admission)
(If an admitted patient, ECHO
send a total cholesterol Coronary angiography
and HDL cholesterol)
Pericarditis CBC, electrolytes ECHO
(Most patients require Cardiac enzymes
none of these tests, EKG
which should be (In select patients send
reserved for special ANA, viral titers and
cases only.) pericardial fluid for
microscopy and culture)
Pneumothorax CXR in expiration
Pneumonia CBC, electrolytes (for CXR
PORT score)
Pulmonary embolism CBC CT angiogram of chest
Electrolytes V/Q if CT unavailable
D-dimer or contraindicated
EKG (will also require a
(If an admitted patient, CXR)
send a thrombophilia US of legs
screen)