Chest pain

Chest pain
Classification and external resources
ICD-10 R07
ICD-9-CM 786.5
DiseasesDB 16537
MedlinePlus 003079
MeSH D002637

Chest pain may be a symptom of a number of serious disorders and is, in general, considered a medical emergency. Even though it may be determined that the pain is noncardiac in origin (does not come from a heart problem), this is often a diagnosis of exclusion made after ruling out more serious causes of the pain. Cardiac (heart-related) chest pain is called angina pectoris. Pain in the chest wall muscles is called by other names, such as pectoralgia, stethalgia, thoracalgia, and thoracodynia.

Chest pain is a common presenting problem, as the following numbers illustrate:

[1]

Differential diagnosis

Causes of chest pain range from non-serious to serious to life-threatening.[2] DiagnosisPro lists more than 440 causes on its website.[3]

In adults the most common causes of chest pain include: gastrointestinal (42%), coronary artery disease (31%), musculoskeletal (28%), pericarditis (4%) and pulmonary embolism (2%).[4] Other less common causes include: pneumonia, lung cancer, and aortic aneurysms.[4]

Chest pain in children differs from adults in that there can be congenital causes and syndromes. In children the most common causes for chest pain are musculoskeletal and unknown.[5]

Cardiovascular

Respiratory

Gastrointestinal

Chest wall

Psychological

Others

Diagnostic approach

History taking

Knowing a patient's risk factors can be extremely useful in ruling in or ruling out serious causes of chest pain. For example, heart attack and thoracic aortic dissection are very rare in healthy individuals under 30 years of age, but significantly more common in individuals with significant risk factors, such as older age, smoking, hypertension, diabetes, history of coronary artery disease or stroke, positive family history (premature atherosclerosis, cholesterol disorders, heart attack at early age), and other risk factors. Chest pain that radiates to one or both shoulders or arms, chest pain that occurs with physical activity, chest pain associated with nausea or vomiting, chest pain accompanied by diaphoresis or sweating, or chest pain described as "pressure," has a higher likelihood of being related to acute coronary syndrome, or inadequate supply of blood to the heart muscle, but even without these symptoms chest pain may be a sign of acute coronary syndrome.[7]

Physical examination

In the emergency department the typical approach to chest pain involves ruling out the most dangerous causes: heart attack, pulmonary embolism, thoracic aortic dissection, esophageal rupture, tension pneumothorax, and cardiac tamponade. By elimination or confirmation of the most serious causes, a diagnosis of the origin of the pain may be made. Often, no definite cause will be found and reassurance is then provided.[2]

If acute coronary syndrome ("heart attack") is suspected, many people are admitted briefly for observation, sequential ECGs, and measurement of cardiac enzymes in the blood over time. On occasion, further tests on follow up may determine the cause. TIMI score performed at time of admission may help stratify risk.

Careful medical history and physical examination is essential in separating dangerous from trivial causes of disease, and the management of chest pain may be done on specialised units (termed medical assessment units) to concentrate the investigations. Occasionally, invisible medical signs will direct the diagnosis towards particular causes, such as Levine's sign in cardiac ischemia. A rapid diagnosis can be life-saving and often has to be made without the help of medical tests. However, in general, additional tests are required to establish the diagnosis.

Medical tests

On the basis of the above, a number of tests may be ordered:[8]

Management

Aspirin increases survival in people with acute coronary syndrome and it is reasonable for EMS dispatchers to recommend it in people with no recent serious bleeding.[9]

In people with chest pain supplemental oxygen is not needed unless the oxygen saturations are less than 94% or there are signs of respiratory distress.[10][11] Entonox is frequently used by EMS personnel in the prehospital environment.[12] However, there is little evidence about its effectiveness.[11][13]

When chest pain is due to a psychological cause, psychological treatments may aid in managing symptoms. Cognitive Behavioural Therapy has been found to be efficacious in diminishing symptoms of non cardiac chest pain. Non cardiac chest pain (NCCP) is characterised by recurrent angina-like substernal chest pain of noncardiac origin. Patients often present with cardiac like symptoms, including tight or pressured chest pain that begins behind the sternum and may radiate to the neck, left arm, or the back (Fass & Achem, 2011). As a result of NCCP feeling much like cardiac chest pain, sufferers tend to become increasingly anxious about their health and begin allocating attentional resources to their body. This may in turn increase their likelihood of picking up on somatic changes, which makes them more anxious. Thus, psychological treatments may reduce their anxiety related to their health symptoms and allow them to adequately manage their NCCP symptoms.

Epidemiology

Chest pain is the presenting symptom in about 12% of emergency department visits in the United States and has a one-year mortality of about 5%.[14] The rate of ED visits in the US for chest pain increased 13% from 2006-2011.[15]

References

  1. ↑ Thull-Freedman, Jennifer (2010). "Evaluation of Chest Pain in the Pediatric Patient". Medical Clinics of North America 94 (2): 327–347. doi:10.1016/j.mcna.2010.01.004. ISSN 0025-7125.
  2. 1 2 Woo KM, Schneider JI (November 2009). "High-risk chief complaints I: chest pain--the big three". Emerg. Med. Clin. North Am. 27 (4): 685–712, x. doi:10.1016/j.emc.2009.07.007. PMID 19932401.
  3. ↑ "Differential Diagnosis For Chest Pain: Poisoning (Specific Agent)".
  4. 1 2 Kontos, MC; Diercks, DB; Kirk, JD (Mar 2010). "Emergency department and office-based evaluation of patients with chest pain.". Mayo Clinic Proceedings 85 (3): 284–99. doi:10.4065/mcp.2009.0560. PMID 20194155.
  5. ↑ al.], [edited by] Jill M. Baren ... [et (2008). Pediatric emergency medicine. Philadelphia: Saunders/Elsevier. p. 481. ISBN 9781416000877.
  6. ↑ Mallinson, T (2010). "Myocardial Infarction". Focus on First Aid (15): 15. Retrieved 2010-06-08.
  7. ↑ Swap CJ, Nagurney JT (November 2005). "Value and Limitations of Chest Pain History in the Evaluation of Patients With Suspected Acute Coronary Syndromes.". JAMA 294 (20): 2623–2629. doi:10.1001/jama.294.20.2623. PMID 16304077.
  8. ↑ Hess EP, Perry JJ, Ladouceur P, Wells GA, Stiell IG (March 2010). "Derivation of a clinical decision rule for chest radiography in emergency department patients with chest pain and possible acute coronary syndrome". CJEM 12 (2): 128–34. PMID 20219160.
  9. ↑ O'Connor, RE; Brady, W; Brooks, SC; Diercks, D; Egan, J; Ghaemmaghami, C; Menon, V; O'Neil, BJ; Travers, AH; Yannopoulos, D (2 November 2010). "Part 10: acute coronary syndromes: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.". Circulation 122 (18 Suppl 3): S787–817. doi:10.1161/CIRCULATIONAHA.110.971028. PMID 20956226.
  10. ↑ "Highlights of the 2010 AHA Guidelines for CPR and ECC" (PDF). American Heart Association.
  11. 1 2 O'Connor, RE; Brady, W; Brooks, SC; Diercks, D; Egan, J; Ghaemmaghami, C; Menon, V; O'Neil, BJ; Travers, AH; Yannopoulos, D (2010-11-02). "Part 10: acute coronary syndromes: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care". Circulation 122 (18 Suppl 3): S787–817. doi:10.1161/CIRCULATIONAHA.110.971028. PMID 20956226.
  12. ↑ Castle, N (February 2003). "Effective relief of acute coronary syndrome". Emergency nurse : the journal of the RCN Accident and Emergency Nursing Association 10 (9): 15–9. PMID 12655961.
  13. ↑ "Entonox for the Treatment of Undiagnosed Chest Pain: Clinical Effectiveness and Guidelines" (PDF). Canadian Agency for Drugs and Technologies in Health. Retrieved 12 July 2011.
  14. ↑ Stephen J. Dubner; Steven D. Levitt (2009). SuperFreakonomics: Tales of Altruism, Terrorism, and Poorly Paid Prostitutes. New York: William Morrow. p. 77. ISBN 0-06-088957-8.
  15. ↑ Skiner HG, Blanchard J, Elixhauser A (September 2014). "Trends in Emergency Department Visits, 2006-2011". HCUP Statistical Brief #179. Rockville, MD: Agency for Healthcare Research and Quality.
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