Approach to Chest Pain

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