Chest Pain

Question 1

List cardiac causes included in the differential diagnosis for chest pain.

Answer 1

• Stable angina
• Acute coronary syndromes (ACS; UA, NSTEMI, STEMI)
• Pericarditis,
• Aortic dissection

Question 2

What are pulmonary causes of chest pain?

Answer 2

• Pulmonary embolism
• Pneumothorax
• Pleuritis
• Pneumonia,
• Status asthmaticus

Question 3

Which gastrointestinal conditions can cause chest pain?

Answer 3

• Gastroesophageal reflux disease (GERD)
• Diffuse esophageal spasm
• Peptic ulcer disease
• Esophageal rupture

Question 4

What are some chest wall-related causes of chest pain?

Answer 4

Costochondritis
- muscle strain
- rib fracture
- herpes zoster

Question 5

Which psychiatric disorders can present with chest pain?

Answer 5

Panic attacks, anxiety disorders, and somatization disorder.

Question 6

How can substance use lead to chest pain?

Answer 6

Cocaine and methamphetamine use can cause angina or myocardial infarction (MI).

Question 7

What are the general steps in treating a patient with chest pain?

Answer 7

1. Rule out life-threatening causes (e.g., ACS, PE, aortic dissection).
2. Assess vital signs.
3. Perform a focused history and physical examination.
4. Order appropriate ancillary tests.
5. Develop a diagnosis based on findings.

Question 8

How should life-threatening causes of chest pain be prioritized?

Answer 8

Prioritize identifying and treating conditions like ACS, aortic dissection, tamponade, PE, and esophageal rupture. These are medical emergencies and require immediate intervention. Where as other sources of chest pain from GI, chest wall, psych, are less likely medical emergencies.

Question 9

How should the focus medical exam for chest pain be organized?

Answer 9

Gather information about:
- Character (pressure, squeezing, tearing, sharp, stabbing)
- Location
- Duration
- Setting of onset (exercise or after a meal)
- Radiation
- Aggravating or alleviating factors
- Prior cardiac history

Question 10

What details about the character of chest pain are important to elicit?

Answer 10

Pain can be described as pressure, squeezing, tearing, sharp, stabbing, or pain that radiates to the jaw or left arm. Pain radiating to the back could indicate aortic dissection.

Question 11

What should be evaluated about the location and severity of chest pain?

Answer 11

The location (e.g., retrosternal, left-sided) and severity (mild to severe) are key diagnostic clues for more emergent issues.

Question 12

How can the setting in which chest pain occurs provide diagnostic clues?

Answer 12

Pain occurring during exertion, at rest, or postprandial may indicate different conditions (e.g., ACS, GERD).

Question 13

Why is previous cardiac history essential when assessing chest pain?

Answer 13

Previous history of angina, stress tests, PCI, or CABG helps differentiate new from old pain patterns.

Question 14

What does relief of chest pain with nitroglycerin suggest?

Answer 14

Nitroglycerin relief suggests a cardiac origin, though it can also relieve diffuse esophageal spasm.

Question 15

How does pleuritic or positional chest pain guide diagnosis?

Answer 15

Pleuritic, positional, or reproducible pain with palpation is less likely cardiac in origin.

Question 16

What are the initial steps for managing unstable angina symptoms?

Answer 16

1. Obtain ECG and cardiac enzymes.
2. Administer aspirin.
3. Begin IV heparin if no contraindications.
4. Admit the patient for further evaluation.

Question 17

What are the essential ancillary tests in the workup of chest pain?

Answer 17

ECG, cardiac enzymes (troponin), chest X-ray, and specific PE workup if clinically suspected.

Question 18

How is a pulmonary embolism (PE) worked up in the context of chest pain?

Answer 18

Order D-dimer, CT angiography, or V/Q scan depending on clinical suspicion and contraindications.

Question 19

Why is it challenging to distinguish GI causes from cardiac chest pain?

Answer 19

The overlap of symptoms, such as epigastric pain and reflux, with cardiac ischemia symptoms makes distinguishing GI from cardiac causes challenging. Risk factors for CAD and clinical presentation help guide management.

Question 20

A 62-year-old man is brought to the emergency department with substernal pain and mild shortness of breath over the last 2 hours. En route, he was given sublingual nitroglycerin with significant relief of pain. He also received chewable aspirin. The patient currently rates the pain as 1–2 out of 10. His past medical history is significant for hypertension and active smoking. He has no history of bleeding. The patient’s father died of a heart attack at age 56. Blood pressure is 154/90 mm Hg, and pulse is 110/min. He is not in respiratory distress. No murmurs are heard. Lungs are clear to auscultation. The initial electrocardiogram (ECG) is shown. Which of the following is the best next step in the management of this patient?

A. Anticoagulation, second antiplatelet agent, and close monitoring
B. Cardiac catheterization within 90 minutes from first medical contact
C. CT scan of the chest with contrast
D. Intravenous adenosine
E. Transthoracic echocardiogram

Answer 20

A. Anticoagulation, second antiplatelet agent, and close monitoring

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This patient’s clinical presentation, substernal chest discomfort, relief with nitroglycerine, and electrocardiogram (ECG) findings of ST-segment depression in leads II, aVF, and V3-V6, is consistent with unstable angina/NSTEMI.

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All patients with ACS should be managed with dual antiplatelet therapy with aspirin and platelet P2Y12 receptor blockers (clopidogrel, prasugrel, or ticagrelor), as well as nitrates, beta blockers, statins, and anticoagulant therapy (unfractionated heparin, low-molecular-weight heparin, bivalirudin, or fondaparinux).