Chest Pain

Question 1

Investigate

Answer 1

If the person does not require immediate admission consider the following:

ECG— to look for signs of ventricular hypertrophy, arrhythmia, PE, stable angina, and acute coronary syndrome (ACS).

Blood glucose, lipid profiles, and U&E — 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.

Question 2

History

Answer 2

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.

Ask about:
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
Chest pain associated with palpitations, dizziness, or difficulty swallowing is less likely to be angina.

Also ask about a history of:
Chest pain and previous investigations (eg ECG or CXR).
A recent normal coronary angiogram is helpful to exclude coronary artery disease as a cause of chest pain.
Assess for CVS risk factors (eg older age, male sex, smoking, hypertension, diabetes mellitus, inc cholesterol and other lipid levels, and a family history of CVD) .
Respiratory and GI disease, musculoskeletal problems, and previous trauma.
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.

Question 3

When should I suspect acute coronary syndrome? - unstable angina and myocardial infarction

Answer 3

Acute coronary syndrome (unstable angina and myocardial infarction) should be suspected on the basis of the clinical features of chest pain.

Almost all people with suspected acute coronary syndrome require hospital admission or referral to confirm the diagnosis.

Suspect acute coronary syndrome, if:
Pain in the chest or other areas (for example the arms, back, or jaw) lasts longer than 15 minutes.

Chest pain is:
Dull, central, and/or crushing.
Associated with nausea and vomiting, sweating or breathlessness, or a combination of these.

Associated with haemodynamic instability (for example the person has a systolic blood pressure less than 90 mmHg).

Of a new-onset, or is the result of an abrupt deterioration of stable angina; with pain occurring frequently with little or no exertion, and often lasting longer than 15 minutes.

Question 4

Dissecting thoracic aneurysm

Answer 4

Symptoms — sudden tearing chest pain radiating to the back and inter-scapular region.
Signs — high blood pressure
blood pressure differentials (different in both arms)
inequality in pulses (carotid, radial, femoral)
a new diastolic murmur (aortic valve regurgitation)
occasionally a pericardial friction rub.
Neurological deficits may be present (such as hemiplegia).

Question 5

Pericarditis

Answer 5

Symptoms
sharp, constant sternal pain relieved by sitting forward.
Pain may radiate to the left shoulder and/or left arm and/or into the abdomen
worse when lying on the left side and on inspiration, swallowing, and coughing. Other symptoms may include fever, cough, and arthralgia.

Signs — pericardial friction rub (high pitched scratching sound, best heard over the left sternal border during expiration).

Question 6

cardiac tamponade

Answer 6

Cardiac tamponade may have associated breathlessness, dysphagia, cough, and hoarseness.

Signs
pulsus paradoxus (decrease in palpable pulse and arterial systolic blood pressure of 10 mmHg on inspiration);
hypotension
muffled heart sounds
jugular venous distention (Beck’s Triad).

Question 7

Acute congestive cardiac failure

Answer 7

Symptoms — ankle swelling,
tiredness,
severe breathlessness,
orthopnea,
coughing (rarely producing frothy, blood-stained sputum).

Signs — elevated jugular venous pressure,
gallop rhythm,
inspiratory crackles at lung bases,
(often) wheeze.

Question 8

Arrhythmias

Answer 8

Symptoms
chest pain associated with palpitations
breathlessness
syncope (or near syncope).

Signs — bradycardia or tachycardia.

Question 9

How should I diagnose acute coronary syndrome?

Answer 9

Most people require referral, to confirm the diagnosis

Offer resting 12-lead ECG
Blood sample for high-sensitivity troponin I or T measurement to confirm the diagnosis.

If the person’s pain was more than 72 hours ago and they have no complications, consider diagnosing ACS in primary care. Arrange:
An ECG — ECG changes that may indicate ischaemia or previous myocardial infarction include:
Pathological Q waves (in particular).
Left bundle branch block (LBBB).
ST-segment and T-wave abnormalities (for example T-wave flattening or elevation, or T-wave inversion).

A normal ECG does not confirm or exclude a diagnosis of ACS.

A high-sensitivity blood test for serum troponin — cardiac troponin I and T are used to differentiate unstable angina from myocardial infarction.
A detectable troponin level indicates damage to the myocardium (for example myocardial infarction).
Serum troponin is normally detectable using high-sensitivity testing within 3–6 hours following a myocardial infarction, and remains elevated for a variable time (usually several days, but it can be up to 2 weeks).

Other conditions that directly or indirectly damage heart muscle (such as arrhythmias, pericarditis, pulmonary emboli, and myocarditis) can also cause an increase in serum troponin.

When interpreting high-sensitivity troponin measurements, take into account the:
Clinical presentation.
Time from onset of symptoms.
Resting 12-lead ECG findings.
Pre-test probability of non-ST-segment-elevation myocardial infarction (NSTEMI).
Length of time since the suspected ACS.
Probability of chronically elevated troponin levels in some people.
Fact that 99th percentile thresholds for troponin I and T may differ between males and females.

Question 10

Pulmonary embolism

Answer 10

Symptoms — acute-onset breathlessness, pleuritic chest pain (worse on inspiration), cough, haemoptysis and/or syncope. Recurrent acute episodes may lead to chronic breathlessness.

Signs — tachypnoea of more than 20 breaths per minute, tachycardia, mild pyrexia, signs of deep vein thrombosis (DVT).

Question 11

Community-acquired pneumonia

Answer 11

Symptoms — cough and at least one other symptom of sputum, wheeze, dyspnoea, or pleuritic chest pain.
Signs — any focal chest sign (such as dull percussion note, bronchial breathing, coarse crackles, or increased vocal fremitus or resonance) plus at least one systemic feature (such as fever or sweating, myalgia), with or without a temperature greater than 38°C. There may be signs of an associated pleural effusion.

Question 12

Pleural effusion

Answer 12

Symptoms — localized chest pain and progressive breathlessness.
Signs — reduced chest wall movements on the affected side, stony dull percussion note, diminished or absent breath sounds, and (in people with heart or renal failure) signs of fluid overload.

Question 13

Lung or lobar collapse

Answer 13

Symptoms — localized chest pain, breathlessness, cough.
Signs — reduced chest wall movement on the affected side, dull percussion note with bronchial breathing, reduced or diminished breath sounds.

Question 14

Lung cancer

Answer 14

Symptoms — chest or shoulder pain, haemoptysis, dyspnoea, weight loss, appetite loss, hoarseness, and cough.
Signs — finger clubbing, cervical or supraclavicular lymphadenopathy, thrombocytosis.

Question 15

Asthma

Answer 15

Symptoms — wheeze, breathlessness, cough. Symptoms are variable (often worse at night, first thing in the morning, and upon exercise or exposure to cold or allergens).
Signs — there may be none when the person is feeling well. During an acute episode, the respiratory rate is increased, and wheeze is usually present.

Question 16

Acute pancreatitis

Answer 16

History — the person may have a history of gallstones or excessive alcohol consumption. (Smashed?)
Symptoms — sudden-onset pain that is typically severe, continuous, and boring in nature. Usually in the epigastric region, but it may be generalized. Pain may radiate to the right upper quadrant, chest, flanks, and lower abdomen; it is relieved by sitting upright and leaning forward, and is worse in the supine position. Typically pain increases in severity to a peak during the first few hours, before reaching a plateau that may last for several days. There is associated nausea and vomiting.
Signs — abdominal tenderness (mild tenderness in the upper abdomen to generalized peritonitis), abdominal distension, Cullen’s sign (a bluish discolouration around the umbilicus), or Grey–Turner’s sign (bluish discolouration around the flank), and low blood pressure. There may be a low-grade fever.

Question 17

Oesophageal rupture

Answer 17

History — a recent history of a medical procedure, foreign body ingestion, or oesophageal cancer.
Symptoms — thoracic oesophageal perforation leads to chest pain, dyspnoea, and odynophagia.
Signs — classical findings include fever and subcutaneous emphysema (around the neck and upper chest wall).

Question 18

Peptic ulcer disease, gastro-oesophageal reflux, oesophageal spasm, or oesophagitis

Answer 18

Symptoms — sub-sternal pain, which commonly occurs at night or after consumption of a large meal. Epigastric pain often radiates to the throat and is worse when bending or lying flat. Regurgitation of acid and food into the mouth can occur.

Question 19

Acute cholecystitis

Answer 19

History — the person may have a history of gallstones (cholelithiasis). Cholecystitis without biliary colic usually has a gradual onset.
Symptoms — sudden-onset, constant, severe pain in the upper right quadrant; and possibly anorexia, nausea, vomiting, and sweating. Low-grade fever (a high temperature is uncommon).
Signs — tenderness in the upper right quadrant, with or without Murphy’s sign (inspiration is inhibited by pain on palpation) on examination. There may also be fever (evidence of sepsis) and jaundice (stone in the bile duct or external compression of the biliary ducts).

Question 20

Rib fracture

Answer 20

History — previous history of trauma or coughing.
Symptoms — unilateral, sharp chest pain, worse with inspiration.
Signs — bruising and tenderness on palpation over the affected rib.

Question 21

Costochondritis

Answer 21

Symptoms — unilateral, sharp, anterior chest-wall pain, exaggerated by breathing, activity, or a particular posture. Usually preceded by exercise or an upper respiratory tract infection, and can last for months.
Signs — tenderness over the costochondral junction and pain in the affected area when palpating the chest wall. In Tietze’s syndrome, there is a tender, fusiform swelling of the costal cartilage at the costochondral junction.

Question 22

Spinal disorders (disc prolapse, cervical spondylosis, facet joint dysfunction)

Answer 22

Symptoms — dull and aching chest pain aggravated by particular movements of the neck. Commonly, exercise makes the pain worse and rest relieves it, but the opposite may also be true. Pain radiates in a non-segmental distribution down the arm, up into the head, into the shoulder, or across the scapulae. May be associated with headache or dizziness, or pain in the spine.
Signs — may be associated with paraesthesia or hyperaesthesia, but with no objective loss of sensation or muscle strength.

Question 23

Rheumatoid arthritis

Answer 23

Symptoms — typically causes persistent symmetrical synovitis of the small joints of the hands and feet, although any synovial joint may be affected. Pain, swelling, heat, and stiffness may be reported in affected joints. Morning stiffness (lasting at least an hour) is common. Systemic features (malaise, fatigue, fever, sweats, and weight loss) may also be present.
Signs — affected joints may feel ‘boggy’ on palpation. Hard, firm swellings over extensor surfaces may be present.

Question 24

Psoriatic arthritis

Answer 24

Symptoms — synovitis commonly involves small joints of the hands and feet, but can also affect the spine and/or entheses. Is less often symmetrical than rheumatoid arthritis. The distal interphalangeal joints may be involved.
Signs — psoriasis is present in over 90% of people with psoriatic arthritis.

Question 25

Fibromyalgia

Answer 25

Symptoms — widespread musculoskeletal pain and tenderness, poor quality sleep, fatigue, cognitive disturbances.

Question 26

Osteoporotic fracture

Answer 26

Symptoms — acute localized pain for rib fractures.
Signs — may be associated with height loss or kyphosis. More common in post-menopausal females and people using corticosteroids.

Question 27

Psychogenic or non-specific chest pain

Answer 27

History — the person has no identifiable risk factors for a physical cause of chest pain. Anxiety disorders are common, especially panic disorders. The episode is often preceded by a stressful event.
Symptoms — chest pain is usually in the left sub-mammary position (without radiation). The pain is sharp and continuous. The pain is aggravated by tiredness and stress, and may be associated with symptoms of hyperventilation (including tingling of the extremities) and palpitations.

Question 28

Herpes zoster

Answer 28

Symptoms — prodrome (1–5 days before the development of rash), abnormal sensation (for example burning, tingling, or itch) in the affected skin, there may also be headache, malaise, and photophobia.
Signs — painful maculopapular rash in a unilateral, dermatomal distribution (most commonly on the thorax) that develops into vesicular lesions, which become cloudy within 3–5 days, then crust over and heal within 2–4 weeks.

Question 29

Bornholm disease (Coxsackie B virus infection)

Answer 29

Symptoms — unilateral, knife-like chest or upper abdominal pain, following an upper respiratory tract infection.
Signs — normal examination.

Question 30

Bornholm disease (Coxsackie B virus infection)

Answer 30

Symptoms — unilateral, knife-like chest or upper abdominal pain, following an upper respiratory tract infection.
Signs — normal examination.

Question 31

Precordial catch (Texidor twinge)

Answer 31

Symptoms — brief, episodic left-sided chest pain commonly associated with bending or posture, relieved by a single deep breath or straight posture. No radiation.
Signs — normal examination.

Question 32

Which people with chest pain should be admitted to hospital?

Answer 32

Admit people with:
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.
O2 saturation less than 92%, or central cyanosis.
Altered level of consciousness.
Raised temperature

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.

Question 33

How should I manage a person with chest pain while they are waiting to be admitted to hospital? ACS

Answer 33

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 - target SpO2 of 94–98%.
If COPD Use a 28% venturi mask - 88–92%.

If the person has suspected:
Acute coronary syndrome
Treat pain with glyceryl trinitrate (GTN) and/or an opioid (eg intravenous diamorphine 2.5 mg to 5.0 mg, given slowly over 5 minutes).
Give aspirin 300 mg
Take a resting 12-lead ECG

Question 34

Acute pulmonary oedema management

Answer 34

Give an intravenous diuretic (for example furosemide 40 mg to 80 mg, given slowly).
Give an intravenous opioid (for example diamorphine 2.5 mg to 5.0 mg, given slowly over 5 minutes).
Give an intravenous anti-emetic (for example metoclopramide 10 mg). This can be mixed with diamorphine.
Give a nitrate, either sublingually or buccally (for example GTN spray, two puffs).

Question 35

Tension pneumothorax management

Answer 35

If the person’s condition is life threatening:
Consider inserting a large-bore cannula through the second intercostal space in the mid-clavicular line, on the side of the pneumothorax.

Question 36

When should I refer a person with chest pain to a specialist?

Answer 36

For people not requiring admission to hospital, appropriately refer them:

For an urgent same-day assessment, if the person has:
Suspected acute coronary syndrome (ACS) and is pain-free with:
Chest pain in the last 12 hours and a normal ECG (electrocardiogram) and no complications (such as pulmonary oedema).
Chest pain in the last 12–72 hours and no complications.

Within 2 weeks, if the person has:
Suspected ACS and is pain-free with chest pain more than 72 hours ago and no complications.
Use clinical judgement, interpretation of the 12-lead resting ECG, and blood troponin measurement to decide how urgent this referral should be
A suspected underlying malignancy (such as lung cancer).
A lung or lobar collapse or pleural effusion (if admission is not required), for investigation and treatment of the underlying cause.

Routinely, if the person has:
Suspected stable angina where the diagnosis cannot be excluded in primary care.
Consider prescribing aspirin (for example 75 mg daily) until the diagnosis is confirmed.
Chest pain where the cause is unclear.
A clear diagnosis for chest pain, but symptoms persist despite management in primary care.

Question 37

How should I manage a person with chest pain who does not require hospital admission or referral?

Answer 37

Manage the underlying cause:
Musculoskeletal chest pain — analgesia
Osteoarthritis, Osteoporosis - prevention of fragility fractures
Shoulder pain - Analgesia

Stable angina - Arrange blood tests to identify conditions which exacerbate stable angina (such as a full blood count for presence of anaemia).
Do not routinely organize a chest X-ray, unless other diagnoses are suspected (such as lung cancer).

Non-specific or psychogenic chest pain
Reassure the person that there is no underlying physical cause for their chest pain.
Explain that the chest pain may be due to underlying anxiety, and provide written information to help with the symptoms.
Consider management of any underlying anxiety disorder or depression.

Dyspepsia
Community-acquired pneumonia
Acute exacerbation of asthma or COPD
Chronic pancreatitis

Shingles — consider prescribing analgesia (for example paracetamol alone, or in combination with codeine).

Bornholm’s disease — consider prescribing analgesia (for example a nonsteroidal anti-inflammatory drug).