Chest Pain

by Asaad S Shujaa

Introduction

Chest pain is one of the most common symptoms presented in the emergency department (ED), and it is worrisome because the differential diagnosis widely range between non-emergent conditions and life-threatening conditions such as acute coronary syndromes (ACS), pulmonary embolism (PE), aortic dissection, pericarditis with tamponade, pneumothorax, and esophageal rupture. Chest pain caused by non–emergent conditions include esophageal reflux, peptic ulcer, biliary colic, muscle strain, costochondritis, pleurisy, pneumonia and non-specific chest wall pain.

It is important as emergency physicians to have an approach to chest pain that enables one to recognize life-threatening conditions from non-emergent conditions. This chapter aims to discuss how to approach a patient with chest pain.

Currently, we do not have data regarding how many patients visit the ED with chest pain in the Middle East; however, in the USA, approximately 6 million patients visit ED with chest pain, which accounts for almost 9% of all ED cases. This makes it the second most common complaint in ED visits.

General Approach to Patient with Chest Pain in Emergency Department

“As a general rule, any chest pain is ischemic in origin until proven otherwise.”

Initial Approach

• Airway, Breathing and Circulation (ABC) assessment
  • Assessment of the airway by being able to talk without distress, no obvious upper airway obstruction such as tongue swelling, lip swelling, hoarseness, etc.
  • Assessment of breathing by listening to the pulmonary sounds. Is it equal or wet (basal crackles indicate CHF)?
  • Assessment of circulation by listening to heart sounds. Are there any S3,4 gallop rhythm (CHF) or new murmurs such as mitral regurgitation (papillary muscle dysfunction).
  • Checking the pulses, capillary refill to understand the shock situation.
• Vital signs should be assessed and repeated at regular intervals. For example, respiratory distress with low O2 saturation may indicate pulmonary edema, plus low BP indicates cardiogenic shock. Also, unequal BP in both arm or pulse deficient indicates aortic dissection.
• The general appearance of the patient
  • Looks sick or not sick or
  • Patient in pain or not in pain
• Electrocardiogram (ECG): To interpret myocardial ischemia, arrhythmias, pericarditis, and right ventricular strain findings for PE.
• Any abnormality found in the initial approach may need immediate actions.

History

What types of questions would you like to ask?

• Are you having discomfort, chest pain?
• How would you describe it?
• Where is it?
• Does it radiate anywhere?
• Frequency?
• Time of onset or acute worsening?
• Has there been any progression?
• Any aggravating/alleviating factors?
• Any associated symptom?
  • Diaphoresis, nausea, vomiting, cough, fever
• History of cardiopulmonary disease?
  • Risk factors for coronary disease such as hypertension, diabetes, high cholesterol, obesity, male, family history, smoker, sedentary, post-menopausal, previous history of ACS and family history of CAD.
  • Risk factors for pulmonary embolism such as travel history, oral contraceptive use etc. And risk factors for other critical diagnoses.

Table 1 – History taking for chest pain

Physical Examination

• Repeat assessment of the airway, breathing, and circulation with full examination steps.
• Assess abdomen for tenderness and pulsating mass
• Look for swelling in legs (lower limb edema), calf tenderness (deep vein thrombosis).

Bedside test

ECG

• ECG is the main bedside test for any chest pain patient.

What is your opinion about below ECGs in patients with different type of chest pain?

Case – 54 yo female presented with 3 days history of righ side chest pain (pleuritic).

Case – 46 yo male presented with central chest pain. He has nausea and diaphoresis.

• 12 lead ECG for myocardial infarction and 15 lead ECG for posterior myocardial infarction
  • Any ST elevation in 2 contiguous leads should be evaluated as S.T. Elevation M.I. However, please do remember, there are many other problems can elevate S.T. segment.
  • Any other changes such as ST depression, T inversion and Q wave should be evaluated
• ECG is more useful as ‘rule in’ than ‘rule out.’
• In Acute Myocardial Infarction ECG has 50% sensitivity, 90% specificity.
• 12 lead ECG for PE may show S1 Q3 T3 sign (prominent S wave in the lead I, Q wave and inverted T wave in the lead III). It is a sign of acute right ventricular strain (acute pressure and volume overload of the right ventricle because of pulmonary hypertension). Other ECG findings noted during the acute phase of a PE include new right bundle branch block (complete or incomplete), rightward shift of the QRS axis, ST-segment elevation in V1 and aVR, generalized low amplitude QRS complexes, atrial premature contractions, sinus tachycardia, atrial fibrillation/flutter, and T wave inversions in leads V1-V4.
• The ECG is often abnormal in PE, but findings are neither sensitive nor specific for the diagnosis of PE. The greatest utility of the ECG in a patient with suspected PE is ruling out other life-threatening diagnoses such as acute myocardial infarction.
• Some aortic dissection cases may also show ST-segment elevation as in acute myocardial infarction.
• ECG may also help to diagnose pericarditis, especially chest pain patients with fever.

Laboratory tests

• Cardiac markers
  • Troponin I or T rise within 3-6  hours and then remain elevated for about one week
  • Serial testing improves sensitivity
  • In acute coronary syndrome suspicion, an increased Troponin is a marker for increased risk of AMI and death
  • However, cardiac enzymes do not diagnose cardiac ischemia
• D-dimer
  • Only use is in a low-risk patient
  • A negative test makes PE very unlikely
  • A slightly positive test is a positive test
• Complete blood count, ESR, C reactive protein, blood culture, and lactate may help to rule out some infections such as pericarditis or mediastinitis because of esophageal rupture. But, their value in the acute setting is questionable.

Imaging modalities

• Chest X-Ray
  • To look for heart failure and evaluate for other cause of chest pain such as Aortic Dissection, pneumothorax, pneumonia etc.
  • Widened mediastinum, abnormal aortic knob, pleural effusions for aortic dissection. These findings are not sensitive for the aortic dissection. Only 25% of the patients have wide mediastinum.
  • Esophageal rupture signs in chest X-ray; Hydropneumothorax, Pneumothorax, Pneumomediastinum, Subcutaneous Emphysema, Mediastinal widening without emphysema, Subdiaphragmatic air and Pleural Effusion.

What is your opinion about below chest x-ray in a patient with chest pain?

Case – 58 yo male presented with 1 day history of sudden onset lef side chest pain radiating to left shoulder.

• Bedside ultrasound (RUSH protocol) evaluates aorta and pericardial space to rule out tamponade

• CT scan
  • CT with contrast shows large, central emboli, it is also very sensitive for aortic dissection.
  • In the suspicion of esophageal rupture, contrast-enhanced CT scan of the chest should be obtained if it is not possible to obtain a contrast esophagogram, if the esophagogram was negative, despite a high clinical suspicion, or if seeking to evaluate for a more likely alternative diagnosis. Perforation may be suggested by mediastinal air, extravasated luminal contrast, peri-esophageal fluid collections, pleural effusions, or actual communication of an air-filled esophagus with an adjacent mediastinal air-fluid collection. Definitive esophageal communication with outside structures is often difficult to visualize.
• The pulmonary angiogram is the gold standard for PE and aortic dissection but carries a risk of contrast-induced nephrotoxicity and anaphylactic contrast reaction.
• Consider Doppler ultrasound to see deep vein thrombosis in legs

• V/Q scan very sensitive but not specific for patients with suspected PE.

 

Depending on your history, physical exam and bedside investigations as well as laboratory and imaging results, the focus should be given to rule out myocardial ischemia or infarction, pulmonary embolus, pneumothorax, pericarditis with tamponade, aortic dissection, and esophageal rupture. Each of this specific disease entities has various risk stratification methods, treatment options, and dispositions. Now, it is time to look to some cases and discuss more specific management in the ED.

Case 1

A 46-year-old male with a history of diabetes mellitus, hypertension, and coronary artery disease presents to the ED. He is a smoker. He complains of chest tightness and heaviness. The symptom started gradually 3 hours ago and lasts 20 minutes when he was watching TV. The pain scale was 5/10, radiated to his jaw. The pain is associated with nausea and sweating. He took Nitroglycerin spray, and the pain was relieved. The pain started again before he reached the ED. The pain scale is 10/10. The initial assessment at triage: ABC intact, BP: 140/80, HR: 110 RR: 24, O2Sat: 98% on room air, Temperature: 37.3, Random Blood Sugar: normal.

ECG case 1

Case 1 – Critical Bedside Actions and General Approach

• Place the patient in a monitored bed, make sure security chamber established (monitor, IVs, oxygen, etc.)
• ABC intact
• Vitally stable except he has tachycardia (HR: 110)
• Quick History and Physical Examination as described in the text. Chest exam: Equal air entry, no wheeze or crackles
• CVS exam: S1+S2 no additional sound, no murmur, JVP was normal
• No lower limb edema, pulses for four limb present and equal
• 12 lead ECG shows inferior ST-elevation myocardial infarction
• Consult cardiologist as soon as possible
• Patient in pain needs analgesia
• Aspirin 300 mg was given by EMS

Case 1 – Differential Diagnoses

There are six life-threatening differential diagnoses for any chest pain patients. These consist of:

1. Myocardial ischemia or infarction (MI)
2. Pulmonary embolus (PE)
3. Pneumothorax
4. Pericarditis with tamponade
5. Aortic dissection
6. Esophageal rupture

Case 1 – History and Physical Examination Hints

• The chest pain is typical angina pain (heaviness radiating to jaw associated with nausea and sweating), the pain is not sharp such as in PE or tearing like in aortic dissection
• The patient has cardiac risk factors (DM, HTN, CAD, Smoker, and MI 1 year ago)
• No PE risk factors
• The history does not suggest any past esophageal rupture
• Physical exam not lead to cardiogenic shock or pulmonary edema
• No sign of pneumothorax in the exam
• Pulses all equal for four limbs and no inequality in BP in both arms, which does not go with aortic dissection
• ECG suggested Inferior MI, no sign of pericarditis in ECG

Case 1 – Emergency Diagnostic Tests and Interpretation

• ECG suggested Inferior MI, no sign of pericarditis in ECG
• Portable CXR: normal which rules out pneumothorax and aortic dissection (no wide mediastinum)
• Troponin I is high, which suggests Myocardia Ischemia
• In bedside echocardiography, there is hypokinetic in the inferior wall and no sign of cardiac tamponade

Case 1 – Emergency Treatment

• Aspirin should be given immediately
  • Great benefit, little risk
  • Give the minimum of 182 mg
• Rapid decisions on reperfusion
  • Based on ECG only (PCI vs. Fibrinolysis)
• Antiplatelet options:
  • Heparin (LMWH versus unfractionated)
  • Clopidogrel
• Symptomatic / pain control
  • GTN   Vasodilator also reduces preload
  • Can give SL or IV
  • Morphine for pain control and reduce anxiety and stress
• Secondary prevention
  • B-Blocker, statins and ACE inhibitor

Case 1 – Disposition Decision

Assess the risk stratification by using TIMI score

Case 1 – Admission criteria

• Establish risk level using the TIMI scoring system
• Moderate risk: Admit for further evaluation; add beta blockers, ACE inhibitors. Follow cardiac enzyme levels. If MI ruled out, exercise stress test before discharge
• High Risk: Admit for cardiac catheterization

Case 1 – Discharge criteria

• Low-risk TIMI score: May be discharged after symptom control and follow up with cardiologist outpatient for the stress test and lipid profile test

Case 1 – Referral

• Cardiology

Case 2

A 30-year-old male had an open reduction and internal fixation (ORIF) of right ankle fracture 2 weeks ago. C/O sudden onset of chest pain today. He has pleuritic sharp chest pain associated with short breath, increased during inspiration.

Initial assessment at triage

• ABC intact
• Vital signs
  • BP 120/80
  • Pulse 120
  • RR 40
  • O2 sat 88% on room air
  • T 36.5
• 12 ECG shows sinus tachycardia, T inversion V2,3 and 4, deep S lead I and Q and T inversion in the lead III, St elevation V1 and V4R suggested pulmonary embolism

Case 2 – Critical Bedside Actions and General Approach

• O2 Supply and monitor bed
• ABC intact
• Vitally stable except he is tachycardia (HR 120)
• The quick history that suggested the patient had a major surgery 2 weeks ago and was immobilized 2 weeks.
• Physical examination shows
  • Chest exam: Equal air entry, no wheeze or crackles
  • CVS exam: S1+S2 no additional sound, no murmur, JVP was normal
  • There is calf swelling in right site of surgery, pulses for 4 limbs present and equal
• To do 12 lead ECG shows sinus tachycardia, T inversion V2,3 and 4, deep S lead I and Q and T inversion in the lead III, St elevation V1 and V4R suggested pulmonary embolism
• Patient in pain need analgesia

Case 2 – Differential Diagnoses

1. Pulmonary embolus (PE)
2. Myocardial ischemia or infarction (MI)
3. Pneumothorax
4. Pericarditis with Tamponade
5. Aortic dissection
6. Esophageal rupture

Case 2 – History and Physical Examination Hints

• The chest Pain is atypical angina pain (sharp, pleuritic chest pain increased by inspiration and associated with shortness of breath, no radiation), the pain is not angina pain OR no tearing pain as in aortic dissection
• There are PE risk factors (major surgery, immobilization 2 weeks)
• The history does not suggest any previous Esophageal rupture
• Physical exam not lead to pneumonia no crackles in chest exam
• No sign of pneumothorax in the exam
• Pulses all equal for four limbs and no inequality in BP in both arms, which does not go with aortic dissection
• ECG suggested PE, no sign of pericarditis in ECG

Case 2 – Emergency Diagnostic Tests and Interpretation

• ECG suggested Pulmonary embolism, no sign of pericarditis in ECG
• Portable CXR: normal which rules out pneumothorax and aortic dissection (no wide mediastinum)
• D- Dimer is high
• Cardiac enzymes are negative
• Bedside echocardiography there is signs of right ventricle enlargement and strain and no sign of cardiac tamponade

Case 2 – Emergency Treatment

• Heparin (Will limit propagation but does not dissolve clot)
  • Unfractionated: 80 u/kg bolus, 18 h/kg/hr.
  • Fractionated (Lovenox): 1 mg/kg SC BID
• Fibrinolysis
  • Consider with large if the patient is unstable
  • No study has shown a survival benefit, but it is very difficult to study.
  • Alteplase 50–100 mg infused over 2–6 hrs (bolus in severe shock)

Case 2 – Disposition

If there is suspicious of PE, we need to do pre-test probability; there are multiple systems for doing this. Most widespread and validated is Well’s score

There is a difference in Well’s score for PE & DVT

PE – Well’s criteria

• 3 points for:
  • PE ‘most likely diagnosis
  • Signs and symptoms suggesting DVT
• 1.5 points for:
  • PR>100,
  • history (PE/DVT),
  • immobilization in 2 weeks
• 1 point for:
  • Hemoptysis or malignancy

Risk Stratification

• <2 low risk (10%), D-Dimer is good to rule out PE
• 2-6 medium risk (25%), Spiral CT chest with contrast to rule out PE
• >6 high (50%), start anticoagulation(LWMH) and Spiral CT chest with contrast

Case 2 – Referral

• ICU
  • Unstable Patient, massive PE, Bilateral PE
• Medical Ward
  • Stable patient with Small PE

Case 3

A 60-year-old male patient presented to the ED with sudden onset central chest pain, described as ripping his chest and radiating to the back, no associated symptoms and patient, previous history with HTN, CAD, and smoker. Initial assessment by EMS was ABC intact. Vitals were BP 190/95 Right arm, Pulse 110, RR 20 , T 37 , O2sat 98%.

Case 3 – Critical Bedside Actions and General Approach

• O2 Supply and monitor bed
• ABC intact
• Vitally stable except he is high BP 185/85 mmHg on the right arm and 200/100 on the left arm, tachycardia (HR 110)
• Quick history which suggested sudden onset central chest pain, described as ripping his chest and radiating to the back, no associated symptoms.
• Physical examination shows:
  • Chest exam: Equal air entry, no wheeze or crackles
  • CVS exam: S1+S2, a grade 2/6 systolic murmur, and a soft decrescendo diastolic murmur are heard at the second right intercostal space. JVP was normal
  • There is radial to radial pulsation delay
  • There are abdominal and bilateral femoral bruits, with absent distal pulses.
• 12 lead ECG shows no ST, T wave changes, no sign of MI
• Portable CXR shows wide mediastinum, no sign of CHF, pneumothorax or pneumonia
• Patient in pain need analgesia

Case 3 – Differential Diagnoses

1. Aortic dissection
2. Myocardial ischemia or infarction (MI)
3. Pulmonary embolus (PE)
4. Pneumothorax
5. Pericarditis with Tamponade
6. Esophageal rupture

Case 3 – History and Physical Examination Hints

• The chest Pain is sudden onset central ripping chest pain radiating to back as in aortic dissection; the pain is not angina pain.
• There are risk factors: HTN, CAD, smoker, and age
• The history does not suggest any previous esophageal rupture
• Physical exam not lead to pneumonia, no crackles in chest exam
• No sign of pneumothorax in the exam
• Pulses delay in radio –radio pulsation and different BP in both arm and abdominal and bilateral femoral bruits, with absent distal pulses with going with aortic dissection
• ECG no sign of ischemic changes, no sign of pericarditis in ECG
• Patient in Pain need analgesia

Case 3 – Emergency Diagnostic Tests and Interpretation

• 12 lead ECG shows no ST, T wave changes, no sign of MI
• Portable CXR shows wide mediastinum, no sign of CHF, pneumothorax or pneumonia
• The cardiac enzyme was negative rule out MI
• D-Dimer was negative
• Bedside Echo has no sign of tamponade
• CT scan is the most accurate and fastest option

Case 3 – Emergency Treatment

• Involve Cardio-Thoracic surgery as soon as possible.
• Control the blood pressure
• SBP goal is 120-130 mmHg
• Beta blockers are first-line agents (Labetalol and Esmolol), they control blood pressure and heart rate
• Depending on the patient’s vitals you can add vasodilators such as nitroprusside

Case 3 – Disposition

• Patients should be admitted to ICU,
• Emergency surgery is needed for ascending dissections
• If dissection is only descending, management is only supportive.

Case 4

A 55-year-old alcoholic with persistent vomiting presents with sudden onset of Chest Pain followed by hematemesis. The chest pain is sudden onset, sharp in nature, radiating to the back. It is associated with shortness of breath for 3 hours. Past medical history: DM, HTN, alcoholic, and smoker. Vitals: BP 120/80 equal bilateral arm, pulse 90 regular and equal on four limbs, no pulse deficit, RR 40, T 38, O2sat 96% on room air.

Case 4 – Critical Bedside Actions and General Approach

• O2 Supply and monitor bed
• ABC intact
• Vitally stable except he is febrile (T 38)
• The quick history which suggested the sudden onset of Chest Pain followed by hematemesis. The chest pain is sudden onset, sharp in nature radiating to the back; it is associated with shortness of breath for 3 hours.
• Physical examination shows
  • Chest exam: decrease air entry in the left side, and there is subcutaneous emphysema in the left side of the chest
  • CVS exam: S1+S2. No additional sound, JVP was normal, pulses equal in four limbs
• 12 lead ECG shows no ST, T wave changes, or ischemic changes
• Portable CXR shows left pleural effusion and pneumomediastinum and normal width of the mediastinum.

Case 4  – Differential Diagnoses

• Esophageal rupture
• Aortic dissection
• Myocardial ischemia or infarction (MI)
• Pulmonary embolus (PE)
• Pneumothorax
• Pericarditis with Tamponade

Case 4 – History and Physical Examination Hints

• The chest pain is sudden onset followed by hematemesis. The chest pain is sharp in nature radiating to the back; it is associated with shortness of breath for 3 hours. A history of repeated vomiting and associated with short of breath and vomiting blood (hematemesis).
• There is Risk factors, HTN, CAD, smoking, and alcohol use
• There is strong history suggested of Esophageal rupture
• Physical exam shows decreased air entry in the left side, and there is subcutaneous emphysema in the left side of the chest
• No sign of pneumothorax in the exam
• ECG no sign of ischemic changes, no sign of pericarditis in ECG

Case 4 – Emergency Diagnostic Tests and Interpretation

• 12 lead ECG shows no ST, T wave changes, no sign of MI
• Portable CXR shows left pleural effusion and right pneumomediastinum and normal width of the mediastinum. No sign of pneumothorax, no sign of CHF, no sign of pneumonia
• Cardiac enzymes were negative, which rule out MI
• D-Dimer was negative
• Bedside Echo: no sign of tamponade

Case 4 – Emergency Treatment and Disposition

• Nothing by mouth, NPO
• Broad-spectrum antibiotics – No randomized clinical trials exist for antibiotics and esophageal perforation; however, empiric coverage for anaerobic and both gram-negative and gram-positive aerobes should be initiated when the initial diagnosis is suspected.
• Parenteral nutritional support
• Nasogastric suction – This should be maintained until there is evidence to indicate that the esophageal perforation has healed, is smaller or is unchanged
• Narcotic analgesics
• Admission to a medical or surgical intensive care unit (ICU)
• Outcome: survival 65-90%, poor survival with delayed diagnosis >48hrs

References and Further Reading

• Niska R , Bhuiya F, Xu J. 2007 Emergency department summary. Natl Health Stat Report ,(26):1 2010 .
• Chan TC, Vilke GM, Pollack M, Brady WJ. Electrocardiographic manifestations: pulmonary embolism. J Emerg Med. 2001 Oct;21(3):263–70.
• Ullman E, Brady WJ, Perron AD, Chan T, Mattu A. Electrocardiographic manifestations of pulmonary embolism. Am J Emerg Med. 2001 Oct;19(6):514–9.
• Rodger M, Makropoulos D, Turek M, et al. Diagnostic value of the electrocardiogram in suspected pulmonary embolism. Am J Cardiol. 2000 Oct 1;86(7):807–9. A10
• Rosen’s Emergency Medicine – Concepts and Clinical Practice, 8th edition
• Asaad SShujaa. How to Approach a Patient with Chest Pain in Emergency Department: Case of Hypophosphatemic Osteomalacia. JOJ Case Stud. 2017; 3(3) : 555615. DOI: 10.19080/JOJCS.2017.03.555615
• Chest Pain. UNC Emergency Medicine Medical Student Lecture Series Updated 6/02/08 – BWL. Accessed May 10, 2018, from https://www.slideserve.com/palma/chest-pain
• Barbara Furry. Acute Myocardial Infarction: Differential Diagnosis and Patient Management. https://www.altru.org/app/files/public/15550/102-Furry-Differential.pdf

Links to More Information

• CDEM CURRICULUM – Chest pain
• EMERGENCY MEDICINE CASES – Chest pain related posts 
• EM DOCS – Chest pain related posts