Assessment of Chest Pain Flashcards
Investigations in chest pain
-FBC
-Fasting blood glucose
-Troponin
-Lipids
-TFT
-Stress testing
-Stress echocardiography
-Magnetic resonance perfusion imaging
-CT coronary angio= angina due to CHD
-ECG: to look for signs of ventricular hypertrophy, arrhythmia, pulmonary embolism, stable angina, and acute coronary syndrome (ACS).
=An ECG does not give a definitive diagnosis of angina, but provides information on heart rhythm (for example to check for arrhythmias [such as atrial fibrillation] or conduction defects [such as heart block and bundle-branch block]) and identifies signs of myocardial ischaemia, hypertrophy, and previous myocardial infarction.
-Blood glucose, lipid profiles, and urea and electrolyte levels — to review the person’s cardiovascular risk profile.
-Full blood count — to check for anaemia which may be exacerbating stable angina.
-Thyroid function tests — to check for thyroid disease.
-Liver function tests and amylase — to check for cholecystitis and pancreatitis.
-C-reactive protein or erythrocyte sedimentation rate (ESR) — for evidence of infection or inflammation.
-Chest X-ray — to look for signs of heart failure and pulmonary pathology (including pleural effusion, lobar collapse, lung cancer).
=Do not routinely request a chest X-ray for people with angina.
-Organize further investigations depending on the suspected underlying cause of chest pain.
History taking in chest pain
-Check whether the person currently has chest pain.
=If they are pain-free, ask when their last episode of pain was, and in particular if it was within the last 12 hours.
-The nature, onset, duration, site, and radiation of chest pain.
=An acute onset, with central or band-like chest pain which radiates to the person’s jaw, arms, or back, is strongly suggestive of cardiac chest pain.
=Persistent, localized chest pain is more suggestive of a pulmonary or musculoskeletal cause.
-Exacerbating and relieving factors of chest pain.
=Chest pain related to exertion is typical of angina.
=Chest pain that is related to inspiration (pleuritic) may suggest a musculoskeletal or pulmonary cause.
-Associated symptoms.
=Breathlessness can be seen with cardiac or pulmonary causes of chest pain.
=Chest pain associated with palpitations, dizziness, or difficulty swallowing is less likely to be angina.
-History of Chest pain and previous investigations (for example ECG [electrocardiogram] or chest X-ray).
=Do not rule out stable angina on the basis of a normal resting 12-lead ECG.
=An abnormal ECG makes the diagnosis of coronary artery disease more likely, but does not confirm that the chest pain is stable angina.
=A recent normal coronary angiogram is helpful to exclude coronary artery disease as a cause of chest pain.
-Stable angina or myocardial infarction, and assess for cardiovascular risk factors (such as older age, male sex, smoking, hypertension, diabetes mellitus, increased cholesterol and other lipid levels, and a family history of cardiovascular disease) — risk factors increase the likelihood of significant coronary artery disease.
-Respiratory and gastroenterological disease, musculoskeletal problems, and previous trauma — musculoskeletal and gastrointestinal disorders are common causes of chest pain in primary care and are often overlooked.
-Anxiety and depression — psychogenic or non-specific chest pain is a common cause of chest pain in primary care and should be considered if there are clinical features suggesting the diagnosis.
Examination in chest pain
-A cardiovascular examination.
=Heart sounds (for murmurs and pericardial rub).
=Blood pressure in both arms (possible aortic dissection).
=Pulse rate and rhythm (shock and arrhythmias).
Jugular venous pressure.
=Carotid pulse.
=Ankles (for oedema, indicating heart failure).
-Chest wall examination — palpate for tenderness, and assess whether movement of the chest wall reproduces the pain (indicating musculoskeletal chest pain).
=Listen to the person’s lung fields for signs of infection.
=Measure the respiratory rate and carry out pulse oximetry (low oxygen saturation).
-General appearance — check for pallor and sweating (shock).
-Abdomen — check for tenderness (gallstones, pancreatitis, or peptic ulceration).
-Neck — check for localized tenderness and stiffness (cervical spondylosis or osteoarthritis).
-Legs — check for swelling or tenderness (deep vein thrombosis).
-Skin — check for rashes (shingles) and bruising (rib fracture).
-Temperature — check for raised temperature, especially over 38.5ºC (infection, pericarditis, or pancreatitis).
Immediate management of suspected ACS
-Glyceryl trinitrate and/or opioid
-Aspirin 300mg. NICE do not recommend giving other antiplatelet agents (i.e. Clopidogrel) outside of hospital
-Do not routinely give oxygen, only give if sats < 94%*
-Perform an ECG as soon as possible but do not delay transfer to hospital. A normal ECG does not exclude ACS
-Sit the person up.
-Do not routinely administer oxygen. Only offer supplemental oxygen to people with:
=Oxygen saturation (SpO2) of less than 94% who are not at risk of hypercapnic respiratory failure.
==Use a simple face mask. Adjust the flow rate to 5–10 L/min to achieve a target SpO2 of 94–98%.
=Chronic obstructive pulmonary disease, who are at risk of hypercapnic respiratory failure.
==Use a 28% venturi mask. Keep the flow rate at 4 L/min to achieve a target SpO2 of 88–92%.
Referral for chest pain
-Current chest pain or chest pain in the last 12 hours with an abnormal ECG: emergency admission
-Chest pain 12-72 hours ago: refer to hospital the same-day for assessment
-Chest pain > 72 hours ago: perform full assessment with ECG and troponin measurement before deciding upon further action
Oxygen therapy in ACS
-Do not routinely administer oxygen, but monitor oxygen saturation using pulse oximetry as soon as possible, ideally before hospital admission. Only offer supplemental oxygen to:
-People with oxygen saturation (SpO2) of less than 94% who are not at risk of hypercapnic respiratory failure, aiming for SpO2 of 94-98%
-People with chronic obstructive pulmonary disease who are at risk of hypercapnic respiratory failure, to achieve a target SpO2 of 88-92% until blood gas analysis is available.
Definition of anginal pain
- constricting discomfort in the front of the chest, or in the neck, shoulders, jaw or arms
- precipitated by physical exertion
- relieved by rest or GTN in about 5 minutes
-patients with all 3 features have typical angina
-patients with 2 of the above features have atypical angina
-patients with 1 or none of the above features have non-anginal chest pain
Investigations for stable angina cannot be excluded by clinical assessment alone/ symptoms consistent with typical/atypical angina or ECG changes
1st line: CT coronary angiography
2nd line: non-invasive functional imaging (looking for reversible myocardial ischaemia)
3rd line: invasive coronary angiography
Examples of non-invasive functional imaging
-Myocardial perfusion scintigraphy with single photon emission computed tomography (MPS with SPECT) or
-Stress echocardiography or
-First-pass contrast-enhanced magnetic resonance (MR) perfusion or
-MR imaging for stress-induced wall motion abnormalities
Who to admit with chest pain
-Clinical features which suggest a serious cause of chest pain, such as:
=Respiratory rate of more than 30 breaths per minute.
=Tachycardia greater than 130 beats per minute.
=Systolic blood pressure less than 90 mmHg, or diastolic blood pressure less than 60 mmHg (unless this is normal for them).
=Oxygen saturation less than 92%, or central cyanosis (if the person has no history of chronic hypoxia).
Altered level of consciousness.
=Raised temperature (especially if it is higher than 38.5°C).
-Suspected acute coronary syndrome (ACS), who:
=Have current chest pain.
=Have signs of complications (such as pulmonary oedema).
=Are pain-free, but have had chest pain in the last 12 hours and have an abnormal electrocardiogram (ECG) or an ECG is not available.
-A recent history of ACS, who have developed further chest pain.
