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Chest Pain

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Chest Pain, Chest Pain Causes, Precordial Pain

  • Risk Factors
  • Epidemiology
  1. Acute Myocardial Infarction and Chest Pain are the two most commonly litigated ED Malpractice claims
    1. Brown (2010) Acad Emerg Med 17(5):553-60 +PMID:20536812 [PubMed]
  • 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 combination of factors
      1. Chest Pain Decision Rules
      2. Exam, ekg and Serum Cardiac Markers
    3. Consider atypical presentations of coronary syndromes in atypical patients
      1. Younger patients with Chest Pain
      2. Women with Chest Pain (see below)
      3. Non-diagnostic initial Electrocardiograms
      4. Atypical symptoms
      5. Rusnak (1989) Ann Emerg Med 18(10): 1029-34 +PMID:2802275 [PubMed]
  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 [PubMed]
    5. Canto (2012) JAMA 307(8): 813-22 [PubMed]
  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 [PubMed]
  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 gastrointestinal 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 (or lack of relief) with Nitroglycerin does not predict cause
    1. Non-cardiac pain is often relieved with Nitroglycerin (e.g. Esophageal Spasm)
    2. Cardiac Chest Pain not relieved with Nitroglycerin may be an indication for emergency catheterization (PCI)
    3. Shry (2002) Am J Cardiol 90:1264-6 [PubMed]
  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 (e.g. Dyspnea, weakness Nausea, Palpitations, Syncope) with Myocardial Infarctions
    1. Even prior stress testing may have been falsely reasuring
      1. Non-occlusive CAD is twice as common in women
      2. Non-occlusive Plaque may embed within artery wall, erode and cause acute thrombus or vasospasm
    2. 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
    3. 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)
    4. References
      1. Canto (2012) JAMA 307(8): 813-22 [PubMed]
      2. Pepine (2015) J Am Coll Cardiol 66(17): 1918-33 +PMID:26493665 [PubMed]
  • Symptoms
  1. See precautions above
  2. See Likelihood of Coronary Disease as Cause of Chest Pain
  3. Findings that most increase the likelihood of Acute Coronary Syndrome
    1. Pain radiation to the right chest or bilateral chest or Shoulder (LR+ 4.7) or both Shoulders (LR+ 4.1 to 7.1)
    2. Exertional pain (LR 2.4)
    3. Pain with diaphoresis (LR 2.0)
    4. Pain associated with Nausea AND Vomiting (LR+ 1.9)
    5. Pain that is similar to prior MI or worse than previous Angina pain (LR+ 1.8)
  4. Other findings that increase the likelihood of Acute Coronary Syndrome
    1. Pain duration >1 hour (and less than 48 hours)
    2. Central Chest Pain
  5. Findings that decrease the likelihood of Acute Coronary Syndrome
    1. Fully reproducible Chest Pain on palpation (LR+ 0.3)
    2. Positional Chest Pain (LR 0.3)
    3. Pleuritic Chest Pain (LR+ 0.2)
    4. Sharp Chest Pain (LR+ 0.3)
    5. Pain at rest
    6. Pain for more than 48 hours
    7. No radiation to arm, Shoulder, neck or jaw
  • 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)
  • 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
  1. See EKG in Cardiac Ischemia
  2. Consider subtle findings on EKG that could indicate ischemia
  3. Repeat Electrocardiograms with ongoing symptoms
  • 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
  • Management