Chest pain resident survival guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Rim Halaby, M.D. [2]; Alejandro Lemor, M.D. [3]

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Chest Pain Resident Survival Guide Microchapters
Overview
Causes
FIRE
Complete Diagnosis Cardiac Non-Cardiac
Treatment
Do's
Don'ts

Overview

Chest pain is defined as a discomfort or pain felt anywhere along the front of the body between the upper abdomen and the neck. The most common causes of chest pain include diseases of cardiac, pulmonary, and gastrointestinal systems. Chest pain is one of the most common complaints in the ER and it is extremely important to rule out life-threatening conditions that need to be managed immediately such as acute myocardial infarction, aortic dissection, esophageal rupture, pulmonary embolism, and tension pneumothorax. To guide the diagnosis and therapy, it is important to characterize the location, intensity, quality, onset, radiation, the alleviating and aggravating factors and the associated symptoms of chest pain. An electrocardiography (ECG) is the most important initial test to diagnose or rule out acute myocardial infarction. The treatment of chest pain depends upon the underlying etiology.

Causes

Life-Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.

• Acute myocardial infarction
• Aortic dissection
• Esophageal rupture
• Pericardial tamponade
• Pneumothorax
• Pulmonary embolism

Common Causes

Cardiac

• Acute myocardial infarction
• Aortic dissection
• Aortic stenosis
• Coronary vasospasm

• Cocaine induced coronary vasospasm

• Prinzmetal's angina

• PCI-induced coronary vasospasm

• Pericarditis
• Pericardial tamponade
• Stable angina

Pulmonary

• Asthma exacerbation
• Bacterial pneumonia
• Pleurisy
• Pneumothorax
• Pulmonary hypertension
• Pulmonary embolism
• Pulmonary TB

Gastrointestinal

• Acute cholecystitis
• Esophageal rupture
• Esophageal spasm
• GERD
• Pancreatitis
• Peptic ulcer

Other

• Costochondritis
• Herpes zoster
• Panic attacks

Click here for the complete list of causes.

FIRE: Focused Initial Rapid Evaluation

A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention.

Boxes in red signify that an urgent management is needed.

Abbreviations: CAD: coronary artery disease; DVT: deep venous thrombosis; ECG: electrocardiogram; ICU: intensive care unit; JVD: jugular venous distension; LBBB: left bundle branch block; NSTEMI: non-ST elevation myocardial infarction; STEMI: ST elevation myocardial infarction; TEE: transesophageal echocardiography

❑ Order ECG ❑ Order serial cardiac biomarkers (troponins) and CK MB ❑ Perform a bedside echocardiography (if available)

Does the patient fulfill the criteria of myocardial infarction? ❑ Rise and/or fall of cardiac biomarker, preferably troponin, with at least one of the measurements >99th percentile of the upper limit of normal PLUS at least one of the following ❑ Symptoms of ischemia ❑ New ST-T wave changes ST-T wave changes in STEMI: ❑ ST elevation in at least 2 contiguous leads of 2 mm (0.2 mV) in men or 1.5 mm (0.15 mV) in women in leads V2–V3 and/or of 1 mm (0.1mV) in other contiguous chest leads or the limb leads, OR ❑ ST depression in at least two precordial leads V1-V4 (suggestive of posterior MI), OR ❑ ST depression in several leads plus ST elevation in lead aVR (suggestive of occlusion of the left main or proximal LAD artery) ST-T wave changes in NSTEMI: ❑ No changes ❑ Non specific ST- T wave changes ❑ T wave inversion ❑ ST depression in at least 2 contiguous leads ❑ New LBBB ❑ New Q wave ❑ New regional wall abnormality or new myocardial loss

Yes

No

Click here for STEMI resident survival guide Click here for NSTEMI resident survival guide

Rule out the following life-threatening conditions

Aortic dissection

Pulmonary embolism

Tension pneumothorax

Esophageal rupture

Look for supportive symptoms and signs: ❑ Sudden onset of chest pain radiating to the back or interscapular pain ❑ Acute heart failure ❑ Syncope ❑ Low pitched early diastolic murmur best heard at the 2nd right intercostal space ❑ Asymmetric blood pressure in the upper extremities ❑ Coma ❑ Diminution or absence of pulse ❑ Altered mental status ❑ Evidence of ischemia ❑ Splanchnic ischemia ❑ Renal insufficiency ❑ Lower extremity ischemia ❑ Focal neurologic deficits

Look for supportive symptoms and signs: ❑ Pleuritic chest pain ❑ Dyspnea ❑ Anxiety ❑ History of: ❑ DVT ❑ Recent surgery ❑ Malignancy ❑ Immobility

Look for supportive symptoms and signs: ❑ Sudden onset of shortness of breath ❑ Cyanosis ❑ Penetrating chest wound ❑ Flopping sound ❑ Recent medical procedure ❑ Patient on mechanical ventilation ❑ Tracheal deviation towards the unaffected side ❑ Absent heart sound on the affected side ❑ Hyperresonance on the affected side

Look for supportive symptoms and signs: ❑ Vomiting ❑ Lower chest pain ❑ Hematemesis ❑ Cervical subcutaneous emphysema ❑ Overindulgence in alcohol ❑ Overindulgence in food

Click here for the detailed management

Click here for the detailed management

Click here for the detailed management

Click here for the detailed management

Complete Diagnostic Approach

A complete diagnostic approach should be carried out after a focused initial rapid evaluation is conducted and following initiation of any urgent intervention.

Abbreviations: ABG: Arterial blood gases; ALT: Alanine transaminase; AST: Aspartate transaminase; CAD: Coronary artery disease; CBC: Complete blood count; COPD: Chronic obstructive pulmonary disease; CXR: Chest X-ray; DVT: Deep venous thrombosis; ECG: Electrocardiogram; GERD: Gastroesophageal reflux disease; GGT: Gamma-glutamyl transpeptidase; HF: Heart failure; JVD: Jugular venous distention; LBBB: Left bundle branch block; LVH: Left ventricular hypertrophy; MI: Myocardial infarction; NSTEMI: Non-ST elevation myocardial infarction; P2: Second heart sound, pulmonary component; PE: Pulmonary embolism; S1: First heart sound; S2: Second heart sound; S3: Third heart sound; SLE: Systemic lupus erythematosus; STEMI: ST elevation myocardial infarction; TB: Tuberculosis; TEE: Transesophageal echocardiography; TTE: Transthoracic echocardiography

Characterize the chest pain ❑ Onset (sudden or gradual) ❑ Duration ❑ Frequency ❑ Location (retrosternal, epigastric, chest wall, diffuse) ❑ Type (sharp, pleuritic, heaviness, colicky) ❑ Radiation (shoulder, neck, back, trapezius) ❑ Worsening factors (exertion, position, respiration, drugs) ❑ Alleviating factors (exertion, position, drugs)

Characterize associated symptoms Non-specific symptoms ❑ Altered mental status ❑ Shortness of breath ❑ Nausea ❑ Vomiting ❑ Dizziness ❑ Syncope ❑ Fatigue ❑ Lethargy Symptoms suggestive of cardiac etiology ❑ Heaviness or crushing sensation (suggestive of MI) ❑ Radiatiion of the pain to left arm, neck and/or jaw (suggestive of MI) ❑ Interscapular pain (suggestive of aortic dissection) ❑ Epigastric pain (suggestive of inferior MI) ❑ Sweating ❑ Palpitations ❑ Pain associated with exertion ❑ Loss of consciousness Symptoms suggestive of pulmonary etiology ❑ Pleuritic pain ❑ Sharp or knife-like ❑ Increases with respiratory movements ❑ Dyspnea ❑ Cough ❑ Hemoptysis ❑ Unilateral pain and swelling of lower extremity (suggestive of DVT) ❑ Chills (suggestive of pneumonia) Symptoms suggestive of gastrointestinal etiology ❑ Burning sensation (suggestive of GERD) ❑ Colic (suggestive of cholelithiasis) ❑ Epigastric pain ❑ Pain is associated with: ❑ Meals (suggestive of GERD or peptic ulcer) ❑ Medication intake (eg: NSAIDs) ❑ Swallowing ❑ Changes in position ❑ Wakening during night (suggestive of GERD) ❑ Relieved by antacids ❑ Not related to exercise

Inquire about past medical history and risk factors ❑ Previous episodes of chest pain ❑ Cardiovascular disease ❑ Previous MI ❑ DVT ❑ Hypertension ❑ Family history of CAD ❑ Recent medical procedures ❑ Central venous catheter placement (suggestive of pneumothorax) ❑ Bronchoscopy (suggestive of pneumothorax) ❑ Pleural biopsy (suggestive of pneumothorax) ❑ Pulmonary disease ❑ Previous PE ❑ COPD ❑ Asthma ❑ Malignancy ❑ Recent viral infection (suggestive of pericarditis or pneumonia) ❑ Recent trauma ❑ Recent surgery (<3 months) (suggestive of PE) ❑ Psychiatric disorders ❑ Alcohol intake ❑ Smoking ❑ Cocaine use ❑ Methamphetamine use ❑ Hyperlipidemia ❑ Rheumatic disorders ❑ SLE ❑ Rheumatoid arthritis

Examine the patient Vitals ❑ Fever (non-specific) ❑ Heart rate ❑ Tachycardia (non-specific) ❑ Bradycardia ❑ Blood pressure in both arms ❑ Hypertension ❑ Hypotension ❑ Narrow pulse pressure (suggestive of aortic stenosis) ❑ Asymmetric blood pressure in extremities (suggestive of aortic dissection) ❑ Tachypnea (non-specific) General appearance ❑ Pale ❑ Diaphoretic ❑ Severe distress Neck ❑ JVD (suggestive of pericarditis or pulmonary hypertension) ❑ Kussmaul sign (suggestive of pericarditis) Cardiovascular examination Palpation ❑ Pain on palpation of chest wall (suggestive of costochondritis) ❑ Apical impulse (suggestive of LVH in aortic stenosis) Pulses ❑ Pulsus parvus et tardus (suggestive of aortic stenosis) ❑ Pulsus paradoxus (suggestive of pericarditis) Auscultation ❑ Carotid or femoral bruits (suggestive of vascular disease) ❑ Presence of S3 and/or S4 ❑ Paradoxical splitting of S2 (suggestive of aortic stenosis) ❑ Muffled heart sounds (suggestive of pericarditis) ❑ Pericardial friction rub (suggestive of pericarditis) ❑ Systolic murmur (suggestive of aortic stenosis or hypertrophic cardiomyopathy) ❑ Diastolic murmur (suggestive of aortic dissection) Respiratory examination ❑ Shift of the trachea from midline (suggestive of tension pneumothorax) ❑ Hyperresonance over the affected side (suggestive of tension pneumothorax) Auscultation of the lungs ❑ Absent breath sounds in one hemithorax (suggestive of pneumothorax) ❑ Rales (suggestive of HF or pneumonia) ❑ Wheezing (suggestive of asthma or COPD) ❑ Pleural rub (pleuritis Abdominal examination ❑ Positive Murphy's sign (suggestive of acute cholecystitis) ❑ Resonant percussion over the liver (suggestive of perforated peptic ulcer) ❑ Tenderness over the epigastrium (suggestive of gastrointestinal etiology) ❑ Rectal examination that shows occult bleeding (peptic ulcer) Neurological examination ❑ Focal abnormalities (suggestive of stroke due to aortic dissection) ❑ Hemiparesis ❑ Vision loss ❑ Aphasia ❑ Hypertonia Skin ❑ Unilateral vesicular rash located in one or two adjacent dermatomes (suggestive of herpes zoster) ❑ Jaundice (suggestive of acute cholecystitis) ❑ Xanthoma (suggestive of dyslipidemia)

Order labs and tests according to the suspected etiology In high suspicion of MI, do not delay initial management ❑ ECG, consider serial ECG's (most important initial test) ❑ Troponin and CK-MB, serial measurements: at presentation, and 6 to 12 hours after onset of symptoms ❑ CBC ❑ Amylase / Lipase ❑ AST and ALT ❑ Alkaline phosphatase and GGT ❑ Bilirubin ❑ ABG ❑ D-dimer

Order imaging studies According to the suspected etiology ❑ Chest X-ray (to rule out pneumothorax or pneumonia) ❑ Echocardiography (to rule out aortic stenosis or aortic dissection) ❑ CT angiography (to rule out pulmonary embolism) ❑ Upper endoscopy (to rule out peptic ulcer or GERD) ❑ RUQ ultrasound (to rule out acute cholecystitis)

Does the chest pain have any of the following findings suggestive of cardiac etiology? ❑ Pain described as a heaviness or crushing sensation ❑ Radiation of the pain to the left arm, neck and/or jaw ❑ Associated symptoms of: ❑ Diaphoresis ❑ Dyspnea ❑ Nausea ❑ Vomiting

YES

NO

Click here for the cardiac chest pain approach

Click here for the non-cardiac chest pain approach

Cardiac Chest Pain

Click on each disease shown below to see a detail approach for every cardiac cause of chest pain.

Does the ECG show any of the following: ❑ ST- T wave changes, OR ❑ New LBBB, OR ❑ New Q wave

Yes

No

Are the ECG changes confined to an anatomic area?

Does the TTE show valve or aortic abnormalities?

Yes

No

Yes

No

Consider the following: Myocardial infarction* ❑ Pain described as a substernal pressure or crushing sensation ❑ Pain radiation to the left arm, neck and/or jaw ❑ Dyspnea ❑ Associated with diaphoresis, nausea or vomiting ❑ Not alleviated by rest or medications ❑ CK-MB and troponin elevation ❑ ECG changes ❑ New ST-T wave changes ST-T wave changes in STEMI: ❑ ST elevation in at least 2 contiguous leads of 2 mm (0.2 mV) in men or 1.5 mm (0.15 mV) in women in leads V2–V3 and/or of 1 mm (0.1mV) in other contiguous chest leads or the limb leads, OR ❑ ST depression in at least two precordial leads V1-V4 (suggestive of posterior MI), OR ❑ ST depression in several leads plus ST elevation in lead aVR (suggestive of occlusion of the left main or proximal LAD artery) ST-T wave changes in NSTEMI: ❑ Non specific ST- T wave changes ❑ T wave inversion ❑ ST depression in at least 2 contiguous leads ❑ New LBBB ❑ New Q wave Coronary vasospasm ❑ Prinzmetal's angina ❑ PCI-induced coronary vasospasm ❑ Cocaine induced

Consider the following: Pericarditis ❑ Sharp and pleuritic pain ❑ Pain radiation to trapezius ❑ Pain increase on inspiration ❑ Pain improved by sitting up and leaning forward ❑ Pericardial friction rub ❑ Diffuse, non-specific ST elevation ❑ PR depression ❑ PR elevation in lead aVR ❑ Fever ❑ Cough ❑ Pericardial friction rub Myopericarditis ❑ Similar symptoms and signs to pericarditis ❑ Symptoms of heart failure ❑ Elevated troponins

Consider the following: Myocardial infarction* ❑ Elevated cardiac enzymes, PLUS ❑ New regional wall abnormality or new myocardial loss Aortic stenosis ❑ Systolic ejection murmur with ejection click ❑ Best heard at the upper right sternal border ❑ Bilateral radiation to the carotid arteries ❑ TTE findings of stenosis ❑ Exertional dyspnea ❑ Syncope Aortic dissection ❑ Acute mid-scapular knifelike, tearing pain ❑ Discrepancy of blood pressure (> 20mmHg) between two arms ❑ Decreased pulses ❑ Low or high blood pressure ❑ Focal neurological deficit ❑ Low pitched early diastolic murmur best heard at the 2nd right ICS ❑ Widened mediastinum on chest X-ray ❑ TEE findings of: ❑ Intimal tear ❑ Aortic regurgitation ❑ History of: ❑ Hypertension ❑ Marfan syndrome

Consider the following: Myocardial infarction* ❑ Elevated cardiac enzymes, PLUS ❑ Symptoms of ischemia Stable angina ❑ Pain described as a heaviness or crushing sensation ❑ Normal value of cardiac enzymes ❑ Pain usually lasts < 10 min ❑ Provoked by exertion or stress ❑ Improves with rest or nitroglycerin

• Myocardial infarction is defined as positive biomarkers (rise and/or fall) plus at least one of the following: ischemia symptoms, ST-T wave changes confined to a regional territory, new LBBB, new pathological Q wave, and new regional myocardial wall abnormality or loss.

Non-Cardiac Chest Pain

Click on each disease shown below to see a detail approach for every non-cardiac cause of chest pain.

Determine the non-cardiac etiology based on the physical examination and tests findings

Pulmonary

Gastrointestinal

Other

Is the onset sudden?

Yes

No

Consider the following: Pulmonary embolism ❑ Sudden chest pain ❑ Dyspnea ❑ History of DVT, surgery, malignancy, immobility ❑ Increase respiratory rate ❑ Increase heart rate ❑ Elevated D-dimer ❑ Hypoxia Pneumothorax ❑ Sharp pleuritic pain ❑ Sudden onset of dyspnea ❑ Tracheal deviation towards the unaffected side ❑ Hyperresonance on the affected side ❑ Hyperresonance ❑ Hypoxia Asthma exacerbation ❑ Acute shortness of breath ❑ Wheezing ❑ History of asthma

Consider the following: Pulmonary hypertension ❑ Dyspnea on exertion ❑ Increased P2 ❑ History of gradual onset of shortness of breath ❑ R3 or R4 ❑ JVD ❑ Lower extremity edema Bacterial pneumonia ❑ Productive cough ❑ Fever ❑ Dyspnea ❑ Increased respiratory rate ❑ Crackles ❑ New infiltrate on the CXR Pulmonary TB ❑ Cough ❑ Hemoptysis ❑ Night sweats ❑ Weight loss ❑ Cavitary lesion on CXR Pleurisy ❑ Sharp pain associated with inspiration and expiration ❑ Shallow breathing ❑ Pleuritic friction rub ❑ Search for an underlying cause

Consider the following: Pancreatitis ❑ Severe epigastric pain radiating to the back ❑ Nausea and vomiting ❑ Increased levels of amylase or lipase ❑ History of alcohol intake or gallstones Acute cholecystitis ❑ RUQ pain associated with meals ❑ Radiation to right shoulder ❑ Nausea and vomiting ❑ Jaundice ❑ Positive Murphy's sign GERD ❑ Burning sensation from the epigastrium towards the throat ❑ Symptoms occur following meals ❑ Duration of symptoms: minutes to hours Peptic ulcer ❑ Epigastric pain: ❑ Starts 5-15 min after a meal (suggestive of gastric ulcer) ❑ Alleviated by meals (suggestive of duodenal ulcer) ❑ Alleviated by antacids Esophageal spasm ❑ Intermittent intense substernal pain ❑ Worsen by swallowing ❑ Alleviated by nitroglycerin or CCB ❑ Dysphagia Mallory-Weiss syndrome ❑ Epigastric ± back pain ❑ History of vomiting ❑ Hematemesis

Consider the following: Musculoskeletal pain ❑ Localized pain ❑ Reproducible pain on palpation of costochondral joints ❑ Exacerbated by chest wall movements ❑ History of rheumatoid arthritis Herpes zoster ❑ Burning pain localized in a dermatome ❑ Unilateral vesicular rash ❑ History of immunosuppresion or severe stress Psychiatric conditions ❑ Anxiety ❑ Hypochondriasis ❑ Panic attack

Treatment

The management of chest pain will depend on the underlying cause. Click on each disease shown below to see a detail management for every cause of chest pain.
Abbreviations: GERD: Gastroesophageal reflux disease; NSTEMI: Non-ST elevation myocardial infarction; STEMI: ST elevation myocardial infarction

CARDIAC	PULMONARY	GASTROINTESTINAL	OTHER
❑ STEMI / LBBB ❑ NSTEMI / Unstable angina ❑ Stable angina ❑ Pericarditis ❑ Aortic dissection ❑ Aortic stenosis ❑ Prinzmetal's angina ❑ PCI-induced coronary vasospasm ❑ Cocaine induced coronary vasospasm	❑ Pulmonary embolism ❑ Pneumothorax ❑ Asthma exacerbation ❑ Pulmonary hypertension ❑ Pneumonia ❑ Pleuritis	❑ Pancreatitis ❑ Acute cholecystitis ❑ GERD ❑ Peptic ulcer ❑ Esophageal spasm ❑ Mallory-Weiss syndrome	❑ Musculoskeletal pain: ❑ Costochondritis ❑ Rheumatoid arthritis ❑ Rib fracture ❑ Herpes zoster ❑ Anxiety ❑ Panic disorder

Do's

• Treat patients with cocaine induced coronary vasospasm like any other patient being evaluated for a possible acute coronary syndrome and administer a benzodiazepine and aspirin (Class I; Level of Evidence: B).

• Suspect tension pneumothorax in the case of blunt and penetrating trauma to the chest.

Don'ts

• Don't administer beta-blockers to patients with cocaine induced coronary vasospasm as it could worsen the vasospasm (Class III; Level of Evidence: C).

• Don't perform pericardiocentesis in aortic dissection and ruptured ventricular aneurysm and avoid it in cases of uncorrected coagulopathy, anticoagulant therapy, thrombocytopenia < 50,000/mm 3 , small, posterior, and loculated effusions.

• Don't delay treatment when cardiac tamponade is suspected.

References