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chest pain

Etiology: 1) Cardiovascular a) myocardial ischemia* - pressure or squeezing pain - radiation to left arm - precipitated by exertion# - exercise - meals - emotion - straining on defecation - relieved by rest & nitroglycerin# b) Prinzmetal's angina (coronary vasospasm) - chest pain at night or at rest [5] - cocaine or amphetamines may induce coronary vasospasm in young patients with normal coronary arteries c) myocardial infarction* - STEMI & NSTEMI - stress cardiomyopathy (broken heart syndrome) - post-menopausal women with severe emotional or physical stress - STEMI with normal coronary angiography d) acute pericarditis - steady, crushing, substernal pain - pleuritic pain component aggravated by cough or deep inspiration - positional, relieved by sitting up, worse when supine - pericardial tamponade* e) valvular heart disease - mitral valve prolapse - aortic stenosis f) aortic dissection* - very severe pain, midline, radiation to back - ripping, tearing pain - not affected by changes in position - weak or absent peripheral pulses - especially Marfan syndrome [5] g) coronary artery dissection - peripartum chest pain [5] h) hypertrophic cardiomyopathy 2) Pulmonary a) pulmonary embolism* - pleuritic chest pain - hemoptysis - hypoxia, dyspnea - tachycardia - risk factors for venous thromboembolism b) pneumothorax - tall, thin, young, male, smoker - sudden pleuritic chest pain, dyspnea c) mediastinal emphysema - chest wall trauma, bronchoscopy, esophagoscopy - sharp, intense, substernal pain - audible crepitus d) pleurisy - secondary to inflammation, less commonly tumor or pneumothorax* - generally sharp, unilateral, superficial - aggravated by cough & respirations e) pneumonia f) tracheobronchitis g) lung cancer 3) Esophageal pain: a) esophagitis, GERD, esophageal spasms b) esophageal rupture* & mediastinitis c) additional symptoms of dysphagia, vomiting d) may be relieved by antacids 4) Rheumatologic (musculoskeletal) a) costochondral pain - pain reproduced by pressure over painful area b) chest wall pain - muscle or ligament strain from exercise - rib fracture - local tenderness c) fibromyalgia d) Tietze's syndrome (costochondritis) e) arthritis: rheumatoid, osteoarthritis 6) spinal disease f) subacromial bursitis 5) Neurologic a) cervical or thoracic spine nerve root compression b) intercostal neuritis (Herpes) 6) Referred pain from abdominal disorders a) peptic ulcer b) hiatal hernia c) pancreatitis d) biliary colic due to cholecystitis or choledocholithiasis e) colonic distension 7) Inflammation or tumor of the breast 8) Psychiatric disorders a) panic disorder b) anxiety c) phobias, especially agoraphobia d) depression e) somatization f) conversion g) malingering h) Munchausen's syndrome i) hyperventilation 9) idiopathic - most patients presenting with chest pain for the 1st time do not receive a diagnosis within 6 months [25] * potentially lethal conditions # relief of pain with nitroglycerin NOT helpful in establishing etiology [6,7] History: - duration, location, radiation, character, intensity, rate of onset, relationship to activity, relief by nitroglycerin, rest, or antiacids, changes in frequency or severity of chest pain, occurrence during rest or sleeping, diaphoresis, nausea/vomiting, dyspnea at rest or on exertion, orthopnea, edema, palpitation, hemoptysis, dysphagia, cough, sputum, paresthesia, syncope, fever/chills, use of cocaine effect of: inspiration, cough, position, arm, chest or neck movement, eating, NSAIDs, alcohol, exertion Clinical manifestations: 1) non cardiac chest pain may coexist with coronary artery disease 2) features associated with likelihood of cardiac ischemia a) exertional chest pain* b) radiation of pain to either of both arms or shoulder pain c) diaphoresis d) nausea/vomiting e) pressure-like pain [5] 3) features associated with a low risk of cardiac ischemia a) age < 40 years b) no new ST segment changes on EKG c) pain reproduced by palpation d) radiation of the pain to the back, abdomen or legs e) pleuritic chest pain f) a pain that is stabbing or sharp in nature g) positional chest pain h) inframammary chest pain i) not associated with exertion [5] 4) findings helpful in establishing diagnosis a) 4th heart sound b) systolic click c) murmur d) friction rub with pericarditis e) pain relief with change in position with pericarditis f) cardiac risk factors: smoking, hypertension, diabetes, hyperlipidemia g) chest pain occurring after meals or upon reclining suggests of gastroesophageal reflux h) cough or respiratory tract symptoms suggestive of pulmonary disease i) pain exacerbated by upper body movements in rheumatologic disease j) pain characteristics suggesting aortic dissection - tearing or ripping sensation - pain starting at maximum intensity - radiation to back, abdomen or legs k) pain, pressure, or tightness in the chest, shoulders, arms, neck,back, upper abdomen, or jaw, dyspnea & fatigue should all be considered equivalents of angina pectoris [32] * accuracy of most chest pain characteritics in the diagnosis of acute myocardial infarction (AMI) is low [14] - the association with exertion is a stronger indicator of AMI than association with dyspnea, pressure, or stress [14] Laboratory: 1) complete blood count (CBC) 2) markers of myocardial infarction - emergency department or inpatient setting - sensitivity of negative markers is 98.8% for rule out MI increased to 99.6% for a 2nd set of markers 6 hours later [16] - high-sensitivity cardiac troponins preferred standard [32] - high-sensitivity cardiac troponin T in serum may reduce risk of major cardiac events in patients discharged from the emergency department [26] - obtain cardiac troponin initially & after 1 hour - if cardiac troponin level does not significantly change after 1 hour admit/hold for observation* 3) erythrocyte sedimentation rate if indicated 4) rheumatoid factor if indicated * if high-risk, treat as acute coronary syndrome Special laboratory: 1) electrocardiogram (EGG) - would seem indicated in all patients presenting to the emergency department with chest pain [20] - likelihood of an acute coronary syndrome in patients with chest pain & a normal ECG is the same whether or not chest pain was present when the ECG was obtained [9] 2) percutaneous coronary intervention when ECG or biomarker testing is positive [20] 3) stress tests a) graded exercise test with or without thallium or sestamibi scintigraphy b) dipyridamole thallium test c) exercise echocardiography d) stress testing not beneficial in low-risk patients [27] 4) coronary CT angiography with better outcomes than stress testing [31] 5) psychometric testing if indicated * non-invasive testing for acute chest pain in the ED (coronary CT angiography, treadmill test, stress echocardiography) is associated with longer hospital stays, but no better clinical outcomes beyond ECG & serum troponin-I [29] Radiology: 1) chest radiograph 2) echocardiogram rarely appropriate [20] 3) coronary computed tomography angiography - suspected NSTEMI [20] - cost-effective in 60 year old patients with non-acute chest pain & low to intermediate probability of coronary artery disease [17] - not beneficial in low-risk patients [27] 4) triple-rule-out CT [22] - evaluates coronary arteries, thoracic aorta, & pulmonary arteries - better sensitivity for pulmonary embolism, aortic aneurysm, & pneumonia than CT angiography [22] - higher radiation dose (mean, 4.84 mSv higher) - larger contrast bolus (mean, 38.0 mL higher) Differential diagnosis: - 6 potentially lethal conditions - acute coronary syndrome - aortic dissection - pericarditis with pericardial tamponade - pulmonary embolism - pneumothorax - esophageal rupture - see etiology & also chest pain syndrome Complications: - patients presenting with chest pain for the 1st time who do not receive a diagnosis within 6 months are at increased cardiovascular risk in subsequent years [25] Management: 1) general - directed at underlying etiology - shared decision-making [32] 2) a normal physical exam, electrocardiogram, & laboratory results do not rule out coronary artery disease 3) identification of emergency room patients with chest pain eligibile for early discharge [10,16,18] a) TIMI risk score = 0 b) no new ischemic changes on electrocardiogram - no left bundle branch block - no cardiac pacemaker c) normal laboratory markers of myocardial infarction (at least two measurements 3 hours apart) [18] 1] serum troponin-I 2] serum creatine kinse MB 3] serum myoglobin d) normal vital signs [18] e) hospital admission & cardiac stress testing not indicated [18] 4) exercise testing before discharge - not yet feasible in all hospitals - may increase downstream testing & treatment without reducing hospitalization for myocardial infarction [27,29] - may not improve outcomes [27,29] 5) patients with coronary artery disease should be followed periodically for an indefinite period to assess progression of disease 6) most patients with chest pain & angiographically normal coronary arteries continue to complain of chest pain 7) proton pump inhibitor for unexplained chest pain effective in a minority of patients (NNT = 8) [11] but recommended as empiric therapy for non-cardiac chest pain [5] 8) remove cardiac monitor if patient is pain-free with normal or nonspecific electrocardiogram [24] - false alarms lead to alert fatigue & negatively impact patient safety & satisfaction [24] 9) several scoring systems & web-based tools described a) emergency department assessment of chest pain score accelerated diagnostic pathway (EDACS-ADP) [21] - uses age, sex, patient history, presenting signs & symptoms, electrocardiogram, serum troponin I or serum troponin T at 0 & 2 hours - score range: -10 to 34 - score < 16 in a stable patient with a nonischemic ECG & nonelevated serum troponin I or serum troponin T is considered low risk [21] b) Heart score performs well (free online calculator) [30] c) for low-risk chest pain in the emergency department (normal ECG & initial serum troponin-I) shared decision-making usinga web-based tool can help reduce admissions for cardiac testing [23] Notes: - rate of MI is 2% within 6 months of emergency department visit for chest pain [15] - rate of MI does not differ according to whether or not a cardiac stress test is done [15] - patients having a cardiac stress test are more likely to undergo coronary angiography [15] - non-cardiac chest pain rather than atypical chest pain is the preferred descriptor if heart disease is not suspected [32]

Related

chest pain syndromes Women's Heart Attack Signs/Symptoms

Specific

angina pectoris pleuritis (pleurisy) pleurodynia sternalgia (sternodynia) xiphoidynia (xiphoidalgia)

General

pain [odyn-]

References

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