Introduction

Chest pain is a common manifestation of pathology arising from various systems therefore a thorough clinical history, examination and appropriate investigations are required.

This is a suggested format for a presentation of chest pain in an acute setting where it is important to rule out life threatening causes of chest pain, and also determining the systemic origin of the pain for optimum management.

Always approach the patient starting with the primary survey ABCDE:

A: Airway patent, able to maintain own? Airway adjunct as required.

B: Check RR, sats and breath sounds. Oxygen- 15L via non re-breather face mask.

C: Check pulse, BP, CRT and heart sounds? IV access- 2 large bore cannulas.

D: Assess consciousness with AVPU or GCS. Check pupils PEARL.

E: Expose patient, but keep covered as much as is practical.

(And D.F.G. - Don’t Forget Glucose!)

History Taking

(may need to obtain eyewitness/ ambulance hx)

Demographics: name, age, gender, race and occupation.

Presenting Complaint: SOCRATES

  • Site 
  • Onset
  • Character
  • Radiation
  • Associated Symptoms
  • Time
  • Exacerbating and Alleviating
  • Severity

Do a Relevant Systems Enquiry and ask important questions about recent travel, contact with infected people, etc.

Ask about Risk Factors for Cardiovascular Disease. The QRISK-2 criteria works out an individual's risk of having an ischaemic event (myocardial infarction or stroke) in the next ten years. It can only be used for people with no previous ischaemic history. The calculator is available at http://www.qrisk.org/

  • Patient age (35-74)
  • Patient gender.
  • Current smoker (yes/no).
  • Diabetic.
  • Family history of heart disease aged <60 (yes/no).
  • Existing treatment with blood pressure agent (yes/no).
  • Postcode (postcode-related Townsend score) - an area measure of deprivation.
  • Body mass index (height and weight).
  • Current systolic blood pressure.
  • Total and HDL cholesterol.
  • Ethnicity.
  • Rheumatoid arthritis.
  • Chronic kidney disease.
  • Atrial fibrillation.

The score has implications on a patient's further management. Those with a high risk (>20%) will be advised to start statin and anti-hypertensive medication and consider anti-platelet therapy in additionn to making changes to their lifestyle. Those with moderate risk (10-20%) and low risk (<10%) will be advised to make lifestyle alterations to further reduce their cardiovascular disease risk. 

Past Medical Hx: Any other CV disease/ conditions (if vascular likely to have other systemic vascular manifestations)? Malignancies? Past Surgical Hx?

Drug Hx: Regular medication plus herbal/ OTC/ illicit medications? Recent change to regime? Allergies or intolerances (document substance and reaction)? Smoking and alcohol hx.

Family Hx: First degree relative with CV disease? Draw family tree documenting deaths (ages and causes).

Social Hx: Occupation. Housing situation? Any dependants? Extra help or carers? Mobility aids or adaptations?

General Systems Review:

Systems Enquiry

Symptoms suggestive of ACS pathology

Examination

The examination will largely depend on the patient's conditon and whether they require resuscitation first- assess the vital signs (pulse, BP, RR, GCS, temperature and BM). When they are stable, use a systematic approach to determine if they are haemodynamically stable or not:

  • is there a palpable pulse (carotid or femoral)?
  • is there tachycardia or bradycardia?
  • is there peripheral shutdown (vasoconstriction)?
  • is there hypertension or hypotension?
  • is there a risk of haemorrhage?
  • is the patient cyanosed?
  • are there any heart murmurs or an arrhythmia?

For patients who are haemodynamically stable at this point, perform a full cardiovascular examination, following the principles of inspection, palpation and auscultation. 

Inspection

  • cyanosis
  • breathlessness
  • tobacco stains
  • alcohol abuse
  • anxious or distressed patient
  • signs of trauma
  • signs of previous cardiac surgery (scars, oacemaker)
  • signs of hyperlipidaemia (corneal arcus, xanthelasma, xanthomas)
  • skin for signs of shingles rash (erythematous swollen plaques with vesicles along the disribution of a dermatone)

Palpation

  • peripheral circulation (warmth/ coldness)
  • radial pulse rate and rhythm and radio-radial delay (co-arctation of the aorta)
  • brachial pulse volume and character
  • blood pressure
  • carotid pulse
  • femoral pulse and radio-femoral delay (co-arctation of the aorta)
  • apex beat 
  • thrills (palpable murmur)

Auscultation

  • time the heart sounds against a pulse
  • ausculatate over whole praecordium (upper right sternal edge, upper left sternal edge, lower left sternal edge and apex)
  • consider manoeuvres to accentuate certain murmurs
  • auscultate over the carotids for bruits
  • auscultate the bases of the lungs for any signs of infection etc

Once this is complete feel the abdomen for the abdominal aorta and any signs of a pulsatile, expansile mass (aneurysm). Examine the legs for any signs of a recent DVT or peripheral arterial disease. 

It may be reasonable to perform full respiratory, gastrointestinal, musculoskeletal or neurological examinations to help differentiate from cardiovascular originating chest pain. 

Differential Diagnosis

In a presentation of chest pain there are certain characteristics that make particular differential diagnoses more likely than others. Be aware of atypical presentations- diabetics and the elderly are prone to present in this manner.

Chest pain could be a manifestation of cardiac pathology but consider respiratory, gastrointestinal, musculoskeletal systems. 

Other systems from which chest pain can also originate include dermatological (e.g. shingles), endocrine (hyperthyroidism), haemotological (sickle cell crisis) and psychological (e.g. anxiety panic attacks) so remember to ask questions about symptoms of these, and look for signs on examination.

Stable Angina

Unstable Angina

Myocardial Infarction

Non ACS Cardiac Differentials

Now consider the following non ACS causes of cardiac chest pain.

Aortic Dissection

Acute Pericarditis

Cardiac Arrhythmias

Non Cardiac Differentials

Now consider the following non cardiac systemic differentials. Remember this list is not exhaustive, it is purely a reminder of the most common or life threatening conditions for each system.

Respiratory System Differentials

GastroIntestinal System Differentials

Musculoskeletal System Differentials

Initial Management

Emergency Bloods

(can be happening concurrently)

Remember MONA:

Morphine

Oxygen

Nitrites

Antiplatelet therapy.

Investigations:

  • 12 Lead ECG: current or previous changes
  • CXR: rules out any other causes
  • Emergency bloods:

 

Second Line Investigations:

  • Echo
  • Angiography
  • Exercise Testing
  • CT scan (although MRI has superior soft tissue imaging)

 

In suspected Acute Coronary Syndrome (STEMI>nonSTEMI>Unstable Angina) know your Trust guidelines for definitive treatment- angioplasty tends to be performed only at tertiary centres, whilst thrombolysis can be performed at most hospitals.

This won’t be necessary for all patients presenting with chest pain, but you should always be prepared for their condition to change!

 

To Summarise

 

Whilst this is an extensive list (following the ‘common things occur commonly’ school of mind), it is not exhaustive so remember to consider the bizarre causes and rare eponymous syndromes too!

For more information on any of the conditions mentioned on this page, see the relevant Fastbleep articles.

 

Following a structured system (like the one proposed here) will allow you to identify and manage life threatening and serious causes of chest pain first.

Further Reading and References

  1. Patient Plus Articles (http://www.patient.co.uk/patientplus Accessed 13.08.2011) particularly:
    1. ACS - Acute Coronary Syndrome
    2. Angina Pectoris
    3. Acute Pericarditis
    4. Pleuritis
    5. Tietze’s Syndrome
  2. Trauma.org
    1. Tension Pneumothorax http://www.trauma.org/index.php/main/article/199/ Accessed 13.08.2011
  3. BMJ Best Practice
    1. Chest Pain http://bestpractice.bmj.com/best-practice/monograph/301.html Accessed 13.08.2011
  4. The Medical Student’s Bible
    1. Davidson E, Foulkes A, Longmore M, Mafi A,Wilkinson I. Oxford Handbook of Clinical Medicine 8th ed. Oxford: Oxford University Press, 2010.

Kirstin McGregor

Manchester Medical School, University of Manchester

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