Approach to Chest Pain

Approach to Chest Pain 2018-01-30T16:37:03+08:00

Differential diagnosis

  • Cardiac
    • Angina
    • Acute coronary syndrome
      • Familial hypercholesterolaemia
    • Pericarditis
    • Tamponade
      • Infective
      • Inflammatory
      • Malignancy
      • Hypothyroidism
      • Rheumatoid arthritis
  • Respiratory
    • Pulmonary embolism
      • Anti-phospholipid syndrome
      • Long flights
      • OCP
      • SLE
    • Pneumothorax
      • Catamenial pneumothorax
      • Marfan’s syndrome
    • Empyema
    • Pneumonia
    • Pleurisy
  • Gastrointestinal
    • Gastro-oesophageal reflux disease
    • Peptic ulcer disease
    • Oesophagitis
    • Oesophageal candidiasis
    • Oesophageal stricture
  • Vascular
    • Aortic dissection
    • Aortic aneurysm rupture
  • Musculoskeletal
  • Anaemia
  • Neuropathic pain
    • Malignant infiltration of vertebral body
    • Herpes zoster

Relevant points in the history

  • Chest pain
    • Are you in pain at the moment?
    • Tell me about the chest pain
    • Can you point with one finger where the pain is?
    • What were you doing when you first noticed it?
    • Does it come on suddenly or slowly?
    • What does the pain feel like?
    • Does the pain spread anywhere?
    • When the pain comes on, are there other symptoms like sweating or nausea?
    • Does anything make the pain better?
    • Does anything make it worse?
    • How long does each episode last?
    • On a scale of 1 – 10, 10 being the worst pain ever, how bad is it?
    • Has the pain ever happened before?
    • What do you think may be causing it?
  • Cardiac
    • Do you ever get chest pain on walking?
    • How many pillows do you sleep on at night?
    • Do you ever wake up in the middle of the night feeling breathless?
    • Have you noticed any leg swelling?
    • Have you had a flu recently?
  • Respiratory
    • Is the pain worse when you breathe in?
    • Have you been on any long-haul flights recently?
    • Do you feel short-of-breath when the pain happens?
    • Do you have a fever?
    • Do you have a cough?
  • Gastrointestinal
    • Do you ever get a feeling of heartburn or a sour taste in your mouth from reflux?
    • Do you have any tummy pain?
    • Is there any pain on swallowing?
    • Do you feel like food sticks on the way down your food pipe?
    • Does the pain get worse when you lie down?
    • Does it get worse on an empty stomach?
  • Vascular
    • Does the pain go to the back?
    • Did you notice it suddenly?
  • Anaemia
    • Have you noticed that you are unusually tired recently?
    • Have you or any of your friends noticed that you are unusually pale?
    • Have you noticed any change in the frequency of going to the toilet to pass motion?
    • Have you noticed a change in the colour of your stools?
    • Have you noticed any blood in your stools?
    • Have you lost any weight?
  • Neuropathic
    • Have you noticed a rash over the area of the pain?
    • Any blisters?

Examination

  • General
    • Well or unwell
    • Habitus – Marfanoid?
    • Pulse – tachycardic or irregular rhythm
  • Cardiovascular
    • Radio-radial delay, radio-femoral delay
    • Raised jugular venous pulsation on inspiration (Kussmaul’s sign)
    • Apex beat – displaced or not
    • Heart sounds and murmurs – ischaemic mitral regurgitation, aortic regurgitation
      • Pulsus paradoxus: cannot palpate radial pulse on inspiration but heart sounds present
    • Respiratory
      • Tracheal deviation
      • Breath sounds – equal on both sides
    • Offer:
      • Digital rectal examination to look for PR bleeding
      • Vitals chart to look for fever, desaturation, haemodynamic compromise
      • Blood pressure in each arm
      • Blood pressure difference during inspiration (drop > 10mmHg = pulsus paradoxus)
      • If unwell: urgent admission

Investigations

  • Full blood count: anaemia (symptomatic anaemia, GI bleeding / malignancy)
  • Renal panel (contrast if cardiac catheterization required, dose-adjustment for LMWH)
  • Amylase (acute pancreatitis)
  • Serum troponin measurement to look for myocardial injury
  • Consider arterial blood gas if tachycardic and hypoxic
  • Electrocardiogram looking for ischaemic changes (ST segment deviation in contiguous leads)
  • Chest radiograph looking for pneumothorax, widened mediastinum, wedge infarction
  • Consider:
    • Urgent coronary angiogram if ECG changes evident
    • Computed tomography pulmonary angiogram to look for PE
    • Computed tomography of the aorta to look for dissection
    • Bedside echocardiogram to look for cardiac tamponade
    • Oesophagogastroduodenoscopy to look for Barret’s oesophagus, peptic ulcer disease

Management

  • Basic resuscitative measures
    • Oxygen supplementation
    • Obtain intravenous access
  • Immediate medical therapy for acute coronary syndrome
    • Aspirin 300mg STAT + 100mg OM
    • Plavix 600mg STAT (STEMI) or 300mg STAT (NSTEMI) + 75mg OM
    • In NUH: prasugrel 60mg STAT + 10mg OM; ticagrelor 180mg STAT + 90mg BD (NSTEMI)
    • NSTEMI: treatment dose of low-molecular weight heparin (1mg/kg BD)
    • Analgesia
  • STEMI: activate cardiac catheterization lab for urgent percutaneous coronary intervention
  • NSTEMI: admit, early coronary angiogram, ± percutaneous coronary intervention. TIMI predicts mortality:
    • Age ≥ 65
    • Aspirin use in last 7 days
    • At least 2 anginal episodes in last 24 hrs
    • ST changes of at least 0.5mm in contiguous leads
    • Elevated serum cardiac markers
    • Known coronary artery disease
    • At least three CAD risk factors
    • ≥ 2 = more than 8% chance of all-cause mortality at 14 days; 5 = 25% risk
  • Secondary prevention
    • Statins
    • Angiotensin-converting enzyme inhibitor
    • Beta blocker
    • Control of cardiovascular risk factors: smoking, diabetes, hypertension, dyslipidaemia
  • No driving for one month following event
  • Pulmonary embolism
    • Massive: immediate thrombolysis
    • Sub-massive / other PE: LMWH 1mg/kg BD, then warfarin / NOAC if no contraindications
    • Provoked PE: anticoagulation for three months
    • Unproved PE: re-assess after three months; if low risk of bleeding, may need long-term

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This Sliding Bar can be switched on or off in theme options, and can take any widget you throw at it or even fill it with your custom HTML Code. Its perfect for grabbing the attention of your viewers. Choose between 1, 2, 3 or 4 columns, set the background color, widget divider color, activate transparency, a top border or fully disable it on desktop and mobile.