Chest Pain Flashcards
Investigate
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.
History
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.
When should I suspect acute coronary syndrome? - unstable angina and myocardial infarction
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.
Dissecting thoracic aneurysm
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).
Pericarditis
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).
cardiac tamponade
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).
Acute congestive cardiac failure
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.
Arrhythmias
Symptoms
chest pain associated with palpitations
breathlessness
syncope (or near syncope).
Signs — bradycardia or tachycardia.
How should I diagnose acute coronary syndrome?
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.
Pulmonary embolism
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).
Community-acquired pneumonia
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.
Pleural effusion
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.
Lung or lobar collapse
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.
Lung cancer
Symptoms — chest or shoulder pain, haemoptysis, dyspnoea, weight loss, appetite loss, hoarseness, and cough.
Signs — finger clubbing, cervical or supraclavicular lymphadenopathy, thrombocytosis.
Asthma
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.
Acute pancreatitis
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.
Oesophageal rupture
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).
Peptic ulcer disease, gastro-oesophageal reflux, oesophageal spasm, or oesophagitis
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.
Acute cholecystitis
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).
Rib fracture
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.
Costochondritis
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.
Spinal disorders (disc prolapse, cervical spondylosis, facet joint dysfunction)
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.
Rheumatoid arthritis
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.
Psoriatic arthritis
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.
