Chest pain accounts for up to 9% of all presentations to the emergency department. It has a broad differential diagnosis which include a number of life threatening conditions.
All patients with chest pain should have an ECG performed within 10 minutes of arrival and this should be read by a senior medical officer to exclude the diagnosis of STEMI (ST Elevation Myocardial Infarction).
In every patient that presents to the ED with chest pain, you must exclude a life threatening cause for the chest pain. These diagnoses include:
- Acute Myocardial Infarction / Acute Coronary Syndrome (ACS)
- Aortic Dissection
- Tension Pneumothorax
- Pulmonary Embolism
- Boerhaave's Syndrome (Ruptured Oesophagus)
The first thing to do is assess the patient and assess whether you need to intervene immediately in their management.
If the patient is stable, a focused history and clinical examination will help to determine the cause of their symptoms.
Acute Myocardial Infarction / Acute Coronary Syndrome
- Central crushing pain or a squeezing sensation.
- Radiation of pain into the arms and neck or jaw.
- Pain that is described as being burning in nature is typically associated with reflux disease, however ACS can present with this type of pain, so you need to be cautious about making the diagnosis.
- Pain that is sharp or associated with respiration or movement is less likely to be due to ACS, however you cannot exclude the diagnosis on the basis of the clinical presentation.
- Associated symptoms such as diaphoresis and nausea, vomiting and dyspnoea.
- The timing of onset of symptoms is also important as this will allow you to time the troponin in patients with ACS without ST elevation on the ECG.
- Ask about cardiac risk factors (hypertension, diabetes, smoking, family history, hypercholestrolaemia) - while it is important to ask about these, they should not be relied on to make a decision about excluding ACS.
- Clinical examination is of limited diagnostic value as there are no specific clinical findings for ACS. The examination should be used to look for evidence of other pathology in the chest causing the presentation or to look for evidence of complications related to the ACS such as arrhythmia's, heart failure and cardiogenic shock.
- 12 lead ECG is an essential investigation and should be performed as soon as possible in any patient with chest pain - you should look for evidence of ST elevation consistent with a STEMI. Patients with ACS can have non-specific ECG changes or dynamic ST and T wave abnormalities. In the patient with ongoing chest pain and unremarkable ECG, serial ECG's should be performed to look for evidence of an evolving infarction.
- Patients with chest pain who are at risk for ACS should have serum biomarkers performed (high sensitivity troponin). To exclude a NSTEMI, you need to have a serum biomarker at least 6 hours following onset of symptoms.
- Once you have excluded an acute myocardial infarction, you need to risk stratify your patient into low, intermediate and high risk for ACS. Patients who are intermediate and high risk for ACS need to be admitted to hospital for provocative stress testing. The Heart Foundation has an excellent algorithm for risk stratification of ACS.
- All patients with ACS should have analgesia given to them - sublingual GTN and intravenous morphine are the agents of choice. If there is persistent pain despite these agents, then an intravenous infusion of GTN should be started.
- Oxygen therapy is indicated for patients who are hypoxic to achieve an oxygen saturation greater than 95%.
- Aspirin 300 mg should be given to all patients with potential ACS.
- Patients with STEMI who present within 12 hours of symptom onset should have a reperfusion strategy implemented - this should be PCI (Angiography and balloon or stenting). In centres where PCI is unavailable or if there is a significant delay to PCI, then thrombolysis should be considered.
- All patients who receive a reperfusion strategy should receive clopidogrel - 600 mg for PCI and 300 mg if recieving thrombolysis.
- Antithrombin therapy should also be used concurrently with patients undergoing PCI or thrombolysis. This can be either unfractionated heparin or low molecular weight heparin (LMWH).
- In patients who have an NSTEMI, they should receive clopidogrel 300 mg and antithrombin therapy (heparin or LMWH)
- Patients with STEMI or NSTEMI should be admitted to a coronary care unit (CCU). Patients who are intermediate risk for ACS can be admitted to an observation unit for their provocative stress test. Patients who are low risk can be discharged home for an outpatient stress test.
- This is a rare condition which can be hard to diagnose and you need to have a high index of suspicion.
- Untreated this condition carries a mortality rate of 1% per hour for the first 48 hours and a 90% mortality rate at 3 months. Early diagnosis and aggressive management improves mortality rates to 20-40%.
- Pain is the most common presentation - it is classically severe in nature with a sudden onset and a tearing sensation. It can be migratory moving into the jaw and neck and down into the abdomen.
- Other types of presentation include coma and stroke from extension of the dissection into the carotids. There may be evidence of pericardial tamponade if the rupture is retrograde. Syncope may result from rupture into the pericardial sac.
- There is no single examination finding that is diagnostic for aortic dissection. Hypertension is commonly found in up to 80% of cases. Hypotension is a poor prognostic indicator and is suggestive of free wall rupture of the aorta or retrograde extension resulting in pericardial tamponade.
- The ECG should be performed to exclude STEMI. A significant number of patients will have ECG changes consistent with ischaemia. 1-2% of patients will have ECG's consistent with STEMI - the right coronary artery is more commonly affected than the left.
- Chest X-Ray abnormalities are common and include a widened mediastinum, blurred aortic knuckle, loss of the aortopulmonary window, displacement of trache to the right, displacement of the left mainstem bronchus, a calcium sign and unliateral pleural effusion. Up to 10% of patients with aortic dissection will have a normal CXR.
- In patients in whom you suspect an aortic dissection, a definitive test should be performed as soon as possible. This should be a CT aortogram. If the patient is to unstable to move to the radiology department or there is a contraindication to CTA, then bedside echocardiogram can be performed - this should be a transoesophageal echocardiogram.
- All patients should recieve analgesia - this should be titrated intravenous morphine.
- Shear stress on the aorta should be reduced - initially with a beta-blocker (esmolol or metoprolol). If a Beta-blocker is contraindicated, a calcium channel blocker can be used. If there is ongoing hypertension despite adequate beta-blockade, then a vasodilator like sodium nitroprusside or GTN can be added.
- Type A aortic dissections should be managed surgically, while type B dissections are traditionally managed medically.
- A pneumothorax is an abnormal collection of air within the pleural space. It may occur spontaneously, be iatrogenic or as the result of trauma.
- A tension pneumothorax is where there is significant respiratory distress, hypoxia and haemodynaic compromise.
- Symptoms are usually sudden in onset. Chest pain is the most common presentation and is usually localised to the side of thepneumothorax and pleuritic in nature, Dyspnoea is also common, but usually not severe.
- The classic findings are reduced or abscent sounds on the affected side and hyper-resonance on percussion. There may be evidence of subcutaneous emphysema.
- Patients with a tension pneumothorax have severe dyspnoea, distended neck veins, tachycardia, hypotension and tracheal deviation.
- The diagnosis of a tension pneumothorax is clinical and no investigations are required - it requires immediate treatment.
- In stable patients with suspected pneumothorax, a chest x-ray is the investigation of choice. Bedside ultrasound has been shown to be more sensitive and specific for pneumothorax than CXR.
- In patients with a clinical diagnosis of tension pneumothorax, immediate decompression should be performed. This should be initially be by needle thoracocentesis with a dwellcath in the 2nd intercostal space in the midclavicular line (or the 5th intercostal space in the midaxillary line). Needle thoracocentesis has a significant failure rate, and if this occurs decompression should be with an open thoracostomy. All patients with a tension pneumothorax should have a formal chest drain placed once decompression has been achieved.
- Pulmonary embolism is an important cause of chest pain. Left untreated it carries an overall mortality of 6-12%.
- There are many risk factors which are associated with PE which include surgery or trauma, malignancy, immobilization, past history of DVT or PE, hypercoagulable states, contraceptive pill, pregnancy, obesity and smoking.
- The majority of patients with PE will present with sudden onset of chest pain (usually pleuritic) or shortness of breath. Other presentations can include syncope and haemoptysis.
- Physical examination is usually non-specific, however an unexplained tachycardia or signs of a DVT may indicate the presence of a PE. Other findings can include tachypnoea, cough and fever.
- CXR is usually non-specific and is used to look for alternate pathology. A normal CXR with hypoxia is suggestive of a PE. The presence of a Hampton's Hump or Westermark sign can be diagnositic for PE, but is rarely seen.
- ECG - frequently abnormal and non-specific. The most common finding is sinus tachycardia. Other findings suggestive of PE include RBBB, TWI in V1-3 and a S1Q3T3 pattern.
- D-Dimer test - useful for excluding PE in patients who are low or intermediate risk.
- Advanced imaging - CTPA and VQ scanning. These tests are indicated in the patient who is low or intermediate risk with positive d-dimers or in patients who are high risk.
- Echocardiography - useful in detecting PE in the haemodynamically unstable patient who cannot be moved to radiology for advanced imaging. You will see right heart dilatation and dysfunction and sometimes the presence of a large pulmonary artery or atrial clot.
- In patients who are at risk of PE, the first thing to do is to risk stratify the patient using a clinical decision rule. The most common decision rule used in the Well Score for PE.
Patients who are low risk can further be risk stratified using the PERC score. If the patient is low risk for PE and PERC negative, then PE can be excluded.If the patient is PERC positive or intermediate risk, then you should perform a d-dimer.
- Patients who have positive d-dimers or who are at high risk for PE should have advanced imaging - either CTPA or VQ scanning.
- Management is generally supportive with oxygen therapy and analgesia. Patients with significant respiratory distress and hypoxia may need NIV or mechanical ventilation. Patients with a PE should be anti coagulated if there are no contraindications. This is with unfractionated heparin or low-molecular heparins followed by warfarin or NOAC's.
- In the haemodynamically unstable patient, thrombolysis should be given. If there are contraindications to thrombolysis, then mechanical clot disruption or surgical thrombectomy can be performed.
- This is an uncommon cause of chest pain from a ruptured oesophagus.
- Forceful and protracted vomiting usually causes the tear - commonly from heavy eating or drinking alcohol.
- Physical examination includes tachypnoea, tachycardia and hypotension. There may be evidence of subcutaneous emphysema or air in the mediastinum which produces a crunching sound known as Hamman's sign.
- The CXR may show a unilateral pleural effusion, widened mediastinum, pneumothorax or pneumomediastinum.
- An oesophagram with water soluble contrast is the definitive test.
- Initial management of the patient includes fluid resuscitation for shock, oxygen therapy and broad spectrum antibiotics (ampicillin, gentamicin and metronidazole). The use of a nasogastric tube should be avoided as this can exacerbate gastric reflux and worsen the mediastinitis.
- The patient should be fasted. Operative therapy is standard for these patients, although in some select patients with a small contained rupture a non-operative approach can be an option.
Once you have excluded the life threatening causes for chest pain, you need to consider other causes for chest pain. The differential diagnosis is wide in patients with chest pain and can include;
Investigation and treatment of these patients should be directed towards the likely cause.
- Muscular Strain
- Tietzes Syndrome (costochondritis)
- Oesophageal Spasm
- Anxiety Attacks
- Hyperventilation Syndrome
- Cardiac Neurosis
- Nerve root compression (cervical or thoracic)
- Herpes Zoster
- Peptic Ulcer Disease
- Biliary Colic / Cholecystitis
Investigation and treatment of these patients should be directed towards the likely cause.
- Chest Pain - Chapter 5.1 Textbook of Adult Emergency Medicine. Cameron et al.
- Chest Pain - Chapter 26 Rosens Emergency Medicine - 8th Edition. Marx, Hockberger and Walls et al.
Below is a podcast on the approach to the patient with chest pain.