Chest Pain

Aka: Chest Pain, Chest Pain Causes, Precordial Pain, Pleuritic Chest Pain

1. See Also
   1. Angina
   2. Angina Diagnosis
   3. Unstable Angina
   4. Chest Wall Pain
   5. Chest Wall Pain Prediction Rule
   6. Cardiac Risk Factors
   7. Framingham Score
   8. Likelihood of Coronary Disease as Cause of Chest Pain
   9. TIMI Risk Score
   10. Bosner Chest Pain Decision Rule
   11. Diamond and Forrester Chest Pain Prediction Rule
   12. Goldman Criteria for ICU Chest Pain Admission
   13. Cardiac Risk in Diabetes Score
   14. Acute Coronary Syndrome
   15. Acute Chest Pain Approach
   16. Serum Cardiac Markers
   17. Electrocardiogram in Myocardial Infarction
   18. Echocardiogram in Myocardial Infarction
2. Risk Factors
   1. See Cardiac Risk Factors
   2. See Framingham Score
3. Diagnosis: Prediction Rules
   1. See Likelihood of Coronary Disease as Cause of Chest Pain
   2. TIMI Risk Score
   3. Bosner Chest Pain Decision Rule
   4. Diamond and Forrester Chest Pain Prediction Rule
   5. Goldman Criteria for ICU Chest Pain Admission
   6. Cardiac Risk in Diabetes Score
4. Evaluation: Approach
   1. Acute Chest Pain Approach
   2. See Angina Diagnosis
   3. Focus Areas
      1. First exclude serious Chest Pain Causes
      2. Evaluate for signs of Myocardial Infarction complications (e.g. acute Congestive Heart Failure)
      3. Identify non-cardiac cause of Chest Pain
5. Precautions
   1. No single finding is absolutely pathognomonic nor completely reassuring in Chest Pain presentation
      1. Risk stratification, evaluation and management is based on an overall analysis of all clinical data
      2. Approach should be based on Chest Pain Decision Rules in combination with exam, ekg and Serum Cardiac Markers
   2. Myocardial Infarction without Chest Pain occurs in up to 50% of patients
      1. Men: 31% overall (13% under age 45)
      2. Women: 42% overall (20% under age 45)
      3. Mortality is 10-15% for painless MI (contrast with 1-2% for those with Chest Pain)
      4. Canto (2000) JAMA 283(24): 3223-9
      5. Canto (2012) JAMA 307(8): 813-22
   3. Cardiac Risk Factors only weakly predict Acute Coronary Syndrome (especially with advancing age)
      1. Age 40-65 years: 2.1 Positive Likelihood Ratio
      2. Age over 65 years: 1.1 Positive Likelihood Ratio
      3. Han (2007) Ann Emerg Med 49(2): 145-52
   4. Sudden Dyspnea may be only presenting symptom of ACS
      1. Only symptom in up to 14% of patients with MI
   5. Myocardial Infarction often presents with GI Symptoms
      1. Indigestion or burning pain (23%)
      2. Nausea (60%)
      3. Upper Abdominal Pain (20%)
   6. Esophageal pain often presents with MI type findings
      1. Pain radiates to left arm (11%)
      2. Responds to Nitroglycerin (30-50%)
   7. Relief with Nitroglycerin does not predict cause
      1. Non-cardiac pain is often relieved with Nitroglycerin
      2. Shry (2002) Am J Cardiol 90:1264-6
   8. Sharp or stabbing Chest Pain may still be cardiac
      1. Up to 22% with sharp Chest Pain have ACS
      2. Several atypical symptoms lower ACS likelihood
      3. ACS may present with Pain fully reproduced with palpation (8-10%)
   9. Intrascapular pain without Chest Pain can represent catastrophic cardiovascular events
      1. Evaluate for Acute Coronary Syndrome and Aortic Dissection
      2. Evaluate for Pulmonary Embolism
      3. Diagnosis of spinal or musculoskeletal causes are after exclusion of intra-thoracic causes
   10. Women often present atypically with Myocardial Infarctions
       1. Presentations are more similar as men and women age (contrary to prior doctrine)
          1. By age 75 years old, both men and women present without Chest Pain in 50% of cases
       2. Greatest discrepancy between male and female ACS presentations are in the under age 45 cohort
          1. Women with MI under age 45 present without Chest Pain in 20% of cases (contrast with 13% in men)
       3. Canto (2012) JAMA 307(8): 813-22
6. Symptoms
   1. See precautions above
   2. See Likelihood of Coronary Disease as Cause of Chest Pain
   3. Findings that increase the likelihood of Acute Coronary Syndrome
      1. Pain radiation to the right chest or bilateral chest
      2. Exertional pain
      3. Pain with diaphoresis
      4. Pain duration >1 hour (and less than 48 hours)
      5. Pain associated with Nausea or vomitng
      6. Central Chest Pain
   4. Findings that decrease the likelihood of Acute Coronary Syndrome
      1. Pleuritic Chest Pain
      2. Sharp Chest Pain
      3. Positional Chest Pain
      4. Pain at rest
      5. Pain fully reproducible on palpation
      6. Pain for more than 48 hours
7. Signs
   1. See Likelihood of Coronary Disease as Cause of Chest Pain
   2. Findings that increase the likelihood of Acute Coronary Syndrome (acute Congestive Heart Failure findings)
      1. New S3 Gallup Rhythm or Third Heart Sound (Positive Likelihood Ratio 3.2)
      2. Hypotension (Positive Likelihood Ratio: 3.1)
      3. New Mitral Regurgitation murmur
      4. Pulmonary Rales
      5. New Jugular Venous Distention
   3. Finding that decrease the likelihood of Acute Coronary Syndrome
      1. Pain reproducible on palpation (Negative Likelihood Ratio: 0.2 to 0.4)
8. Differential Diagnosis: General
   1. Acute Coronary Syndrome
   2. Aortic Dissection
   3. Chest Wall Pain
   4. Congestive Heart Failure
   5. Gastroesophageal Reflux
   6. Panic Attack
   7. Pericarditis
   8. Pneumonia
   9. Pulmonary Embolism
9. Differential Diagnosis: Onset
   1. Sudden Onset
      1. Angina
      2. Myocardial Infarction
      3. Aortic Dissection
      4. Pulmonary Embolus
      5. Esophageal Rupture
      6. Spontaneous Pneumomediastinum
      7. Spontaneous Pneumothorax
   2. Gradual or Variable Onset
      1. Pericarditis
      2. Musculoskeletal Chest Pain
      3. Costochondritis
      4. Epidemic Pleurodynia
      5. Mitral Valve Prolapse
10. Differential Diagnosis: Characteristic
    1. Pressure Sensation
       1. Angina
       2. Myocardial Infarction
       3. Esophageal Spasm
    2. Tearing Sensation
       1. Aortic Dissection
    3. Sharp or Stabbing Sensation
       1. Pericarditis
       2. Pulmonary Embolus
       3. Musculoskeletal Chest Pain
       4. Epidemic Pleurodynia
       5. Mitral Valve Prolapse
       6. Spontaneous Pneumothorax
       7. Esophageal Spasm
11. Differential Diagnosis: Provocative Factors
    1. Exertion or stress
       1. Angina
       2. Myocardial Infarction
    2. Hypertension
       1. Aortic Dissection
    3. Pleuritic (Deep breath or cough)
       1. See Pleuritic Chest Pain
       2. See Pleuritic Chest Pain due to Medications
       3. Pulmonary Embolus
       4. Pericarditis
       5. Spontaneous Pneumomediastinum
       6. Musculoskeletal Chest Pain
       7. Cough fracture
    4. Swallowing or Vomiting
       1. Esophageal Rupture
       2. Spontaneous Pneumomediastinum
    5. Supine Position
       1. Pericarditis
       2. Spontaneous Pneumomediastinum
    6. Movement
       1. Musculoskeletal Chest Pain
       2. Cough fracture
12. Differential Diagnosis: Radiation of pain
    1. Pain radiates to arm or Shoulder
       1. Angina or Myocardial Infarction
          1. Pain radiating to both arms strongly suggests MI (Positive Likelihood Ratio 7.1)
       2. Pericarditis
       3. Spontaneous Pneumothorax
       4. Esophageal Spasm
    2. Pain radiates to back or intrascapular
       1. Aortic Dissection
       2. Pericarditis
       3. Acute Coronary Syndrome
       4. Spontaneous Pneumothorax
       5. Esophageal Spasm
       6. Thoracic Spine radicular pain (e.g. thoracic compression Fracture, T4 syndrome)
       7. Pulmonary Embolism
    3. Pain Radiates to Neck, throat, or jaw
       1. Spontaneous Pneumomediastinum
       2. Pericarditis
       3. Acute Coronary Syndrome
       4. Esophageal Spasm
13. References
    1. Mattu (2012) EM: Rap 12(9): 4
    2. Achar (2005) Am Fam Physician 72:119-26
    3. Body (2010) Resuscitation 81(3): 281-6
    4. Goodacre (2002) Acad Emerg Med 9:203-8
    5. McConaghy (2013) Am Fam Physician 87(3):177-82
    6. Panju (1998) JAMA 280(14): 1256-63
    7. Swap (2005) JAMA 294(20): 2623-9