Chest Pain












Introduction

Chest Pain Evaluation Tool Chest pain or discomfort is one of the commonest causes for presentation to the Emergency Room (ER) or physicians' office. There are many causes for chest discomfort but the serious causes need to be excluded before less serious causes can be considered. Serious causes for chest pain include:

  • Coronary syndromes (myocardial ischaemia): ACUTE: New onset angina, accelerating or crescendo angina and prolonged angina or coronary insufficiency, non ST elevation myocardial infarction (NSTEMI) and ST elevation myocardial infarction (STEMI). CHRONIC: stable angina.
  • Aortic dissection (sudden, tearing chest or back pain with weakness, dizziness, diaphoresis, pallor, new aortic regurgitation, cerebral ischaemia or pulse deficits)
  • Pulmonary embolism (sudden pleuritic chest discomfort with dyspnea, hypoxemia)
  • Pericarditis (sharp, retrosternal chest discomfort. Worse with breathing or lying down)
  • Pleurisy/pneumonia/pneumothorax (sharp thoracic discomfort associated with viral or pulmonary symptoms: fever, cough, sputum or spontaneously occurring in young people).

Less serious causes include:

  • Chest wall pain (costochondritis, pleurodynia)
  • Referred pain from cervical disc disease, brachial plexus (neuritis, scalenus anticus syndrome,
    cervical rib)
  • Gastro-esophageal reflux disease(reflux esophagitis or esophageal spasm)
  • Referred abdominal pain (biliary colic, gastritis, perforated ulcer or other viscus)
  • Zoster or shingles

Causes of chest pain or discomfort are best identified by a careful medical history. First establish the acuity or chronicity of symptoms. Acute chest pain is best evaluated in the ER to rule out ACS, NSTEMI, STEMI or other serious causes. Less acute chest pain should be evaluated using three CARDINAL FEATURES to classify the chest discomfort and establish the likelihood of angiographically significant (>70% luminal stenosis) coronary artery disease. Ischaemic chest pain or discomfort may present with typical or atypical features. Typical features include:

  • Retrosternal location of discomfort (in whole or in part)
  • Provocation by activity or stress
  • Relief by rest or nitroglycerin

If all three features are present the chest pain or discomfort is classified as TYPICAL ANGINA. If two of three features are present the chest discomfort is classified as ATYPICAL ANGINA. If only one of three features are present the chest discomfort is classified as NON ANGINAL CHEST PAIN. The angiographic likelihood of significant CAD can be derived from these three cardinal features as well as the AGE and GENDER of the patient as presented in the table at the top of the chest pain algorithm on the next page. In WOMEN, ischaemic symptoms may present atypically such as unusual fatigue, sleep disturbance and shortness of breath. Only 30% of women report chest discomfort prior to heart attack. The most frequent acute symptoms in women are shortness of breath (57.9%), weakness (54.8%), and fatigue (42.9%). Acute chest pain was absent in 43%. Evaluation of chest discomfort in women must be tempered by a lower pre-test likelihood of CAD and the atypical symptom presentation.

 

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  Version 2.0, February 2012
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