Chest pain history and symptoms: Difference between revisions

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==History ==
==History ==
The patient's history must be thoroughly investigated to exclude the life-threatening causes of [[chest pain]], such as the cardiovascular ones: [[acute coronary syndrome]], [[aortic dissection]], [[pulmonary embolism]] but also the non-cardiac such as [[tension pneumothorax]] and [[esophageal rupture]].
The patient's history must be thoroughly investigated to exclude the life-threatening causes of [[chest pain]], such as the cardiovascular ones: [[acute coronary syndrome]], [[aortic dissection]], [[pulmonary embolism]] but also the non-cardiac such as [[tension pneumothorax]] and [[esophageal rupture]].
* [[Chest pain]] in  [[myocardial ischenia]] presented as deep, difficult to localization, and diffuse.
* Point tenderness is less likelihood of [[myocardial ischemia]].
* [[Chest pain]] characterized by defining [[duration]], [[provoking factors]], [[relieving factors]], [[age]], [[cardiac risk factors]].
* [[Patient]] [[history]] is the most important basis of defining [[myocardial ischemia]].
* Because of complexity of [[cardiac symptoms]] and variable expression of [[chest pain]], [[ischemic chest pain]] may be present as non-[[cardiac]] [[chest pain]].
* [[Characteristic]] of [[chest pain]] with high likelihood of [[ischemia]] including:
*::Central
*::[[Pressure]]
*::[[Squeezing]]
*::[[Gripping]]
*::[[Heaviness]]
*::[[Tighness]]
*::[[Exertional]]
*::[[Stress related]]
*::[[Retrosternal]]
*::[[Left-sided]]
*::[[Dull]]
*::[[Aching]]
* [[Characteristic]] of [[chest pain]] with low likelihood of [[ischemia]]
*::[[Right-sided]]
*::[[Tearing]]
*::[[Ripping]]
*::[[Burning]]
*::[[Sharp]]
*::[[Fleeting]]
*::[[Shifting]]
*::[[Pleuritic]]
*::[[Positional]]
===Chest pain suggestive of cardiac ischemia as the underlying cause: <ref name="pmid20380960">{{cite journal| author=Yelland M, Cayley WE, Vach W| title=An algorithm for the diagnosis and management of chest pain in primary care. | journal=Med Clin North Am | year= 2010 | volume= 94 | issue= 2 | pages= 349-74 | pmid=20380960 | doi=10.1016/j.mcna.2010.01.011 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20380960  }}</ref><ref name="pmid34709879">{{cite journal| author=Gulati M, Levy PD, Mukherjee D, Amsterdam E, Bhatt DL, Birtcher KK | display-authors=etal| title=2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. | journal=Circulation | year= 2021 | volume= 144 | issue= 22 | pages= e368-e454 | pmid=34709879 | doi=10.1161/CIR.0000000000001029 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34709879  }} </ref>===
===Chest pain suggestive of cardiac ischemia as the underlying cause: <ref name="pmid20380960">{{cite journal| author=Yelland M, Cayley WE, Vach W| title=An algorithm for the diagnosis and management of chest pain in primary care. | journal=Med Clin North Am | year= 2010 | volume= 94 | issue= 2 | pages= 349-74 | pmid=20380960 | doi=10.1016/j.mcna.2010.01.011 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20380960  }}</ref><ref name="pmid34709879">{{cite journal| author=Gulati M, Levy PD, Mukherjee D, Amsterdam E, Bhatt DL, Birtcher KK | display-authors=etal| title=2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. | journal=Circulation | year= 2021 | volume= 144 | issue= 22 | pages= e368-e454 | pmid=34709879 | doi=10.1161/CIR.0000000000001029 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34709879  }} </ref>===



Revision as of 13:15, 23 December 2021

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Aisha Adigun, B.Sc., M.D.[2], Nuha Al-Howthi, MD[3], José Eduardo Riceto Loyola Junior, M.D.[4]

Overview

The symptoms of chest pain can help to discern whether there is an underlying cause that may be dangerous. Symptoms that should cause alarm are; chest pain radiating to the back (aortic dissection), left arm or jaw pain, nausea, vomiting, lightheadedness, and angina pain that is different from baseline (myocardial infarction). Pain that is reproduced with palpation, greatest in the abdominal region, radiating to lower extremities, brought on by inspiration, or brought on any movement or postural changes, is less characteristic of myocardial ischemia.

History

The patient's history must be thoroughly investigated to exclude the life-threatening causes of chest pain, such as the cardiovascular ones: acute coronary syndrome, aortic dissection, pulmonary embolism but also the non-cardiac such as tension pneumothorax and esophageal rupture.

Chest pain suggestive of cardiac ischemia as the underlying cause: [1][2]

Special considerations for specific groups

Class I
"1 In patients> 75 years old and chest pain, ACS should be considered, especially when accompanied with other symptoms including shortness of breath, syncope , acute delirium, unexplained fall (Level of Evidence C)"
Class I
"2 In woman with chest pain, the risk of undiagnostic cardiac etiology is more common and taking exact history about accompanying symptoms of ACS is recommended (Level of Evidence B)"
The above table adopted from 2021 AHA/ACC/ASE Guideline[2]






  • In recent studies, women are more likely to present with associated symptoms than men, and those presenting with moderate-to-severe ischemia are more symptomatic than men. Chest pain is still the predominant symptom in women.
  • Considerations for older patients: older patients presenting with chest pain require a more extensive workup for alternative diagnoses associated with chest pain, besides acute coronary syndromes. Increased age is a very important risk factor for comorbidities that predispose to other causes of chest pain.
  • Studies have showed that black patients are less likely to be treated urgently for chest pain and to be monitored than other groups. This also happens with hispanics and South Asians, which leads to worse outcomes in both of these population subgroups. It is of utmost importance to take into consideration the patient's ethnicity, race and sociocultural differences while assessing them.

Chest pain not characteristic of myocardial ischemia: [3]

  • Muscular pain; reproduced with or brought on by shoulder and/or forearm movements or postural changes,
  • Pleura related pain (pleuritic pain); a sharp or knife-like pain brought on by respiratory movements as deep breathing or cough
  • Primary or sole location of discomfort in the middle or lower abdominal region
  • Pain that may be localized at the tip of one finger, particularly over the left ventricular apex or a costochondral junction
  • Pain reproduced with movement or palpation of the chest wall or arms
  • Very brief episodes of pain that last a few seconds or less
  • Pain that radiates into the lower extremities

The relief of chest pain by administration of sublingual nitroglycerin in an outpatient setting is not diagnostic of coronary artery disease. For instance, esophageal pain can be relieved by the administration of nitroglycerin. Likewise, the relief of chest pain by the administration of liquid or chewable antacids and anti-reflux drugs does not exclude coronary artery disease as the underlying etiology of the pain.

References

  1. Yelland M, Cayley WE, Vach W (2010). "An algorithm for the diagnosis and management of chest pain in primary care". Med Clin North Am. 94 (2): 349–74. doi:10.1016/j.mcna.2010.01.011. PMID 20380960.
  2. 2.0 2.1 Gulati M, Levy PD, Mukherjee D, Amsterdam E, Bhatt DL, Birtcher KK; et al. (2021). "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines". Circulation. 144 (22): e368–e454. doi:10.1161/CIR.0000000000001029. PMID 34709879 Check |pmid= value (help).
  3. Yelland M, Cayley WE, Vach W (2010). "An algorithm for the diagnosis and management of chest pain in primary care". Med Clin North Am. 94 (2): 349–74. doi:10.1016/j.mcna.2010.01.011. PMID 20380960.