Approach to Chest Pain

Question 1

60 year oldman presents to ED complaining of pain in the chest

What structures can cause pain in the chest?

Answer 1

Heart

Pericardium

Lungs

Pleura

Aorta

Oesophagua

Chest wall

Spine

Skin

Diaphragm (may cause shoulder tip pain)

Abdominal organs

Question 2

60 year oldman presents to ED complaining of pain in the chest

What are the possible mechanisms of pain in the chest?

Question 3

60 year old man presents to ED complaining of pain in the chest

DDx?

Answer 3

Cardiac: ACS, pericarditis

Vascular: dissecting aortic aneurysm

Respiratory: PE, pneumonia, pleurisy, pneumothorax

Oesophageal: oesophagitis, oesophageal spasm

Musculoskeletal: muscle injury or spasm, costochondral joint inflammation

Skin: Herpes Zoster (shingles)

Question 4

How is myocardial ischaemic pain described?

Answer 4

“Angina pectoris” = pain in the chest

Central chest pressure, tightness, squeezing, ache or discomfort with intensity increasing over a few minutes (may be mistaken for indigestion)

Radiation to shoulders, arms, neck, jaw

Worse with exertion

May be relieved by rest or GTN

Associated with sweating, nausea, dyspnoea

Question 5

Distinguish between the patterns of pain seen in stable angina, and unstable angina and myocardial infarction, in terms of the underlying pathology

Answer 5

Stable angina: chronic atherosclerotic narrowing, pain when myocardial oxygen demand > supply

Unstable angina and MI: ruptured atherosclerotic plaque and thrombus, acute narrowing or occlusion of coronary artery, pain due to acute disruption of myocardial oxygen supply

Question 6

List 3 features of pain which make myocardial ischaemic more likely

Answer 6

Radiates to shoulders

Worse on exertion

Associated dyspnoea

Question 7

List 8 features of pain which make myocardial ischaemia less likely

Answer 7

Stabbing, sharp

Pleuritic

Worse on changing position

Very localised

Reproduced by palpation or movement

Very brief (seconds)

Very prolonged (constant for days)

Radiates to legs

Question 8

When might an ACS present atypically?

Answer 8

More common in women

May be “silent” ischaemia or infarction more commonly in diabetics due to neuropathy

Question 9

What PHx is important to ask about directly when considering the possibility of ischaemic chest pain in a patient?

Answer 9

Hx of previous coronary disease: angina, infarction, bypass surgery, coronary intervention

Hx of coronary RFs: high cholesterol, smoking, HTN, DM

Question 10

Describe the clinical features of pericardial pain

Answer 10

Central or L-sided

Sharp, stabbing

Worse on movement and breathing

Question 11

Describe the clinical features of pleuritic pain

Answer 11

Pain worse on inspiration, coughing

Sharp, stabbing

Localised

May be worse on sitting up or leaning forward

Not related to exertion

Question 12

Describe the clinical features of oesophageal pain

Answer 12

Usually “burning” but may be dull ache

Worse after meals, on lying down

Relieved by antacid

Oesophageal spasm may be relieved by GTN

Question 13

Describe the clinical features of pain due to dissecting aortic aneurysm

Answer 13

Severe chest pain

Radiation to back

Question 14

Describe the key things to look for on examination of a patient with acute chest pain

Answer 14

General appearance: sweating, cyanosed, any skin rash (e.g. shingles), any tenderness over location of pain, vitals

Cardiac exam: HS, murmurs, pericardial rub

Respiratory exam: focal signs, pleural rub

Abdominal exam: tenderness

Question 15

What specific features O/E would be expected in a patient with dissecting aortic aneurysm?

Answer 15

BP different in each arm

Early diastolic murmur of AR

Question 16

What specific features O/E would be expected in a patient with pericarditis?

Answer 16

Pericardial rub

Question 17

What specific features O/E would be expected in a patient with pleurisy?

Answer 17

Pleural rub

Question 18

What changes are seen on ECG in AMI?

Answer 18

ST elevation: earliest change, resolves earliest, most specific

ST depression: recipricol to ST elevation or as only change

T wave inversion: after several hurs

Q waves: may develop early and remain permanently

Question 19

Charlie, 65 year old male truck driver, presents with 2/24 Hx of chest pain which is central and radiates to the L arm; describes it as a “tightness more than pain” and feel nauseated

Had minor chest pain for 10 mins last night

PHx: HTN (treated), smoker 20/day

FHx: father died aged 64 from AMI

O/E: HR 84, BP 110/80, temp 37.0, sweat, normal cardiorespiratory examination

Likely Dx?

Ix?

Answer 19

Cardiac ischaemia: angina or MI

Ix: ECG, CXR, cardiac enzymes

Question 20

Charlie, 65 year old male truck driver, presents with 2/24 Hx of chest pain which is central and radiates to the L arm; describes it as a “tightness more than pain” and feel nauseated

Had minor chest pain for 10 mins last night

PHx: HTN (treated), smoker 20/day

FHx: father died aged 64 from AMI

O/E: HR 84, BP 110/80, temp 37.0, sweat, normal cardiorespiratory examination

Interpret the results of his ECG

Answer 20

ST elevation in leads V1-V4

Question 21

Charlie, 65 year old male truck driver, presents with 2/24 Hx of chest pain which is central and radiates to the L arm; describes it as a “tightness more than pain” and feel nauseated

Had minor chest pain for 10 mins last night

PHx: HTN (treated), smoker 20/day

FHx: father died aged 64 from AMI

O/E: HR 84, BP 110/80, temp 37.0, sweat, normal cardiorespiratory examination

Cardiac enzymes at admission are normal - why might this be?

Answer 21

Usually take ~6 hours to increase, so they are of no help with initial Dx and Mx (as reperfusion needs to be within 6 hours to be most effective!)

High sensitivity troponin (hs-Tn) may be positive earlier

Question 22

Charlie, 65 year old male truck driver, presents with 2/24 Hx of chest pain which is central and radiates to the L arm; describes it as a “tightness more than pain” and feel nauseated

Had minor chest pain for 10 mins last night

PHx: HTN (treated), smoker 20/day

FHx: father died aged 64 from AMI

O/E: HR 84, BP 110/80, temp 37.0, sweat, normal cardiorespiratory examination

ECG changes included ST elevation

Dx: STEMI

Mx?

Answer 22

Monitor ECG

Defibrillator close by

Reperfusion by thrombolysis or PCI (preferable)

Question 25

Mary, 60 year old office manager, presents with chest pain on and off for the last day; describes it as a central “pressure but has no other Sx

PHx: hyperlipidaemia, T2DM

O/E: normal

ECG changes include ST depression in V5 and V6

Cardiac enzymes on arrival at ED were normal

Dx?

Mx?

Answer 25

Dx: ACS (ECG is suggestive of cardiac ischaemia), but not a definite myocardial infarct (could also be unstable angina)

Mx: observe, repeat ECG and enzymes, may do further tests for ischaemia later (e.g. stress testing, angiography)

Question 26

Fred, 45 year old sales representative, presents with 1/52 Hx of intermittent chest pain; he is stressed about a job promotion and did extensive work in the garden last week

No cardiac RFs

O/E: normal except for tenderness over upper L chest

ECG: normal

Dx?

Mx?

Answer 26

Dx: again, could be cardiac ischaemia but index of suspicion is lower (tenderness is against a Dx of cardiac ischaemia)

Mx: reassure (but tell to return if pain continues), or refer for outpatient stress testing, or send to hospital ED

Question 27

Joan, 67 year old retired nurse who is previously well, presents with 1/7 Hx of “feeling unwell” with productive cough and L sided chest pain, worse with breathing

Ex-smoker of 30 pack-years

O/E: temp 38.0, RR 28, no palpable LNs, chest examination showed decreased breath sounds over the L base and a pleural rub

CXR: LLL consolidation

Dx?

Answer 27

LLL pneumonia (but important to rule out lung cancer when pneumonia resolves)