Rapid assessment of chest pain. Chest pain clinics may be one step forward, two steps back.
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Angina Pectoris↗
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Practical approach to the diagnosis of unexplained chest pain.
Chest pain is a frequent medical problem causing concern for both patients and physicians. A multidisciplinary meeting recently developed algorithms for evaluating these patients in the two most common scenarios for the presentation of chest pain: (1) new onset of chest pain in the primary care setting, and (2) recurrent chest pain in the the referral setting. In both situations, the primary care physician, rather than specialists, should direct the evaluation and treatment of patients with chest pain and normal coronary angiograms.
Algorithms↗
Acute chest pain.
Chest pain is the initial symptom of many life-threatening disease processes. Pain may arise from any structure located in the thoracic cavity. Cardiac causes of chest pain usually have anginal symptoms. Noncardiac causes have a variety of chest pain characteristics. Diseases that require immediate attention and intervention are myocardial infarction/unstable angina, dissecting aortic aneurysm, pericarditis, pulmonary embolism, pneumothorax, pneumonia, and acute chest syndrome. In order to evaluate a patient with the complaint of chest pain, the advanced practice nurse must be familiar with the differential diagnosis approach to acute chest pain.
Acute Disease↗
Differential diagnosis and clinical approach to the patient with acute chest pain.
Chest pain syndromes are diverse and often enigmatic. Most chest pain is of a benign nature and poses no serious threat to life. However, when presented with the patient complaining of acute chest pain, the clinician must make decisions concerning management of potentially lethal disease while considering the emotional and financial implications of overtreatment of less serious disorders. In general, life-threatening chest pain syndromes involve some form of vascular compromise (myocardial ischemia, aortic stenosis, dissection of the aorta, pulmonary embolus), and particular emphasis must be placed on detecting these entities. We have reviewed the major causes of chest pain with a perspective on newer methods for distinguishing these entities. The skilled clinician will apply this information in a judicious, systematic manner to afford the most prudent management of the patient.
Acute Disease↗
[Symposium: frightening chest pains. Frightening chest pains of esophageal origin].
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Chest Pain↗
Hyperventilation syndrome: a frequent cause of chest pain.
Chest pain is frequently a prominent symptom of the hyperventilation syndrome (HVS) and must be distinguished from angina pectoris due to coronary atherosclerotic heart disease (CAHD). The association between hyperventilation and chest pain may be apparent if psychoneurotic traits or anxiety are present. Many patients with HVS are not overtly anxious or neurotic, but in the great majority, a careful history and physical examination will indicate whether chest pain is due to HVS or CAHD. The failure to make this clinical differential diagnosis, which often leads to unnecessary coronary angiography, should not be as frequent as generally experienced. Fifteen of 95 consecutive patients had chest pain and additional typical HVS symptoms. Reassurance and detailed explanation about the cause of the chest pain gave significant relief, so that all patients were less symptomatic 24 to 44 months later, and none had developed new signs or symptoms to suggest that symptomatic CAHD had been overlooked. The risk and expense of coronary angiography was avoided.
Adolescent↗
Acute resting myocardial perfusion imaging in patients with diabetes mellitus: results from the Emergency Room Assessment of Sestamibi for Evaluation of Chest Pain (ERASE Chest Pain) trial.
BACKGROUND: Resting myocardial perfusion imaging (MPI) improves the triage of patients presenting to the emergency department (ED) with symptoms suggestive of acute cardiac ischemia (ACI). In the ED setting the presence of diabetes mellitus (DM) is a predictor of ACI and hospitalization, but the role of resting MPI in patients with DM is unknown. METHODS AND RESULTS: A secondary data analysis of a prospective, multicenter, randomized, controlled trial of ED evaluation strategies in patients with symptoms suggestive of ACI and normal or nondiagnostic electrocardiograms was performed. In the main trial 2475 patients were randomized to receive either the usual ED evaluation strategy (n = 1260) or the usual strategy supplemented by results from resting MPI by use of single photon emission computed tomography (SPECT) technetium 99m sestamibi (n = 1215). Patients with diabetes (n = 341) were evaluated separately. Imaging results, final diagnoses, effect on triage, and prognostic value of the SPECT imaging were compared between diabetic and nondiabetic patients. Of the 341 patients with diabetes, 153 (45%) were randomized to the imaging strategy. Patients with DM had higher rates of hospitalization (66% vs 49.6%, P = .0001) and ACI (21.1% vs 12.0%, P < .001) than patients without DM. Among diabetic patients without ACI, the admission rate was 63% in the usual strategy group versus 54% in the imaging strategy group (relative risk [RR] = 0.91 [95% CI, 0.76-1.06]; P = .24). There was no difference in the magnitude of this reduced risk of admission compared with patients without DM (RR = 0.84 [95% CI, 0.77-0.92]; P = .0002 for patients without DM and P = .35 for interaction of diabetes and RR reduction). CONCLUSIONS: Acute resting MPI with Tc-99m sestamibi is associated with improved triage decision making in symptomatic ED patients with diabetes.
Acute Disease↗
Coccidioidomycosis in adolescents presenting as chest pain.
Chest pain is a relatively common complaint in adolescents and is most often attributed to anxiety or musculoskeletal conditions. Pleuritic chest pain in association with fever and cough are frequently reported in adults with primary pulmonary coccidioidomycosis. We describe three cases in which chest pain mimicking costochondritis was the predominant initial presenting symptom of pulmonary coccidioidomycosis. In addition, in each case, recent tuberculin skin test reactivity complicated the diagnostic assessment and treatment. We conclude that, in endemic areas, coccidioidomycosis should be considered in the differential diagnosis of acute chest pain in teenagers as well as in adults.
Adolescent↗
Diagnosing the cause of chest pain.
Chest pain presents a diagnostic challenge in outpatient family medicine. Noncardiac causes are common, but it is important not to overlook serious conditions such as an acute coronary syndrome, pulmonary embolism, or pneumonia. In addition to a thorough history and physical examination, most patients should have a chest radiograph and an electrocardiogram. Patients with chest pain that is predictably exertional, with electrocardiogram abnormalities, or with cardiac risk factors should be evaluated further with measurement of troponin levels and cardiac stress testing. Risk of pulmonary embolism can be determined with a simple prediction rule, and a D-dimer assay can help determine whether further evaluation with helical computed tomography or venous ultrasound is needed. Fever, egophony, and dullness to percussion suggest pneumonia, which can be confirmed with chest radiograph. Although some patients with chest pain have heart failure, this is unlikely in the absence of dyspnea; a brain natriuretic peptide level measurement can clarify the diagnosis. Pain reproducible by palpation is more likely to be musculoskeletal than ischemic. Chest pain also may be associated with panic disorder, for which patients can be screened with a two-item questionnaire. Clinical prediction rules can help clarify many of these diagnoses.
Adult↗
Oesophageal manometry in noncardiac chest pain.
Chest pain of oesophageal origin is an important differential diagnosis in patients with cardiac chest pain. A preliminary survey of 40 patients with noncardiac chest pain (NCCP) revealed oesophageal motility disorder in 47.5%; achalasia cardia being the most frequent disease (47.3%). 15.8% of these patients with motility disorder had features of progressive systemic sclerosis and another 15.8% had non specific oesophageal motility disorder (variants). Compared to barium swallow, oesophageal manometry was found to be superior in the diagnosis of oesophageal motility disorder.
Adult↗
The differential diagnosis of chest pain.
Chest pain is a frequent complaint of patients seeking urgent medical assistance. It is a serious concern for patients and practitioners because of its potentially life-threatening implications, and misdiagnosis can be fatal. The shared neurologic pathways of thoracic and abdominal visceral organs complicate the diagnosis of chest pain. It is vital that patients presenting with chest pain are rapidly and skillfully assessed so that the correct working diagnosis can be made and appropriate treatment offered.
Chest Pain↗
Diagnosis and treatment of noncardiac chest pain.
Chest pain is common: one in four of the population have an episode annually. Of those who present to hospital, nearly two-thirds have noncardiac chest pain. More than half of these cases might have gastroesophageal reflux disease. Opinion differs over what is the most appropriate application of current investigatory methods. Evidence suggests that, once cardiac disease is ruled unlikely, empiric use of a proton pump inhibitor is an option; if acid suppression fails, detailed investigations as clinically indicated can be considered. A range of esophageal investigations is available, including 24-hour or 48-hour esophageal pH testing and esophageal manometry, as well as provocative tests, but there is no consensus as to which methods are the most useful. Psychiatric evaluation is not routine, but psychiatric or psychological disorders are common. Musculoskeletal disorders are also common, but are frequently overlooked. It is possible to subject patients to a comprehensive set of investigations before empiric therapy, but recent studies have failed to demonstrate an improved outcome using this exhaustive approach. A new tactic is required, with less attention spent on absolute diagnostic accuracy and more emphasis on optimizing the long-term clinical outcome in patients with noncardiac chest pain. It is possible that the targeted use of multiple drug trials in a policy of 'therapy as investigation' might be a superior methodology.
Chest Pain↗
Adolescent chest pain.
Chest pain in adolescents rarely indicates serious organic pathology. Musculoskeletal disorders are the most common identifiable causes; psychogenic, respiratory and gastrointestinal disorders are also part of the differential diagnosis. Although cardiac disease is part of the differential diagnosis, it is very rare in this age group. Routine tests usually do not help establish a diagnosis and should be ordered only if indicated on the basis of the history and findings of the physical examination. Although most cases of chest pain are not caused by serious disease, the complaint should not be casually dismissed. An important role for primary care physicians is to provide support and adequate follow-up, because adolescent chest pain is often chronic.
Adolescent↗
Thallium myocardial scanning in the emergency department evaluation of chest pain.
Chest pain is a common complaint of patients seen in the emergency department. The causes are legion, and range from the non-life threatening to the potentially catastrophic. Thallium heart scanning was done prospectively in 20 patients with a "classic" history for myocardial infarction (eight patients) or atypical chest pain and/or associated symptoms plus an abnormal ECG (12 patients) to discern a subset of patients from whom thallium scintography may be indicated in the emergency department. Although further investigation is needed, our preliminary study suggests that myocardial scanning with thallium can be a safe, fairly rapid, and useful objective parameter in the emergency department detection of suspected myocardial infarction, and in differential diagnosis of chest pain when other data such as the history, physical examination, ECG, or enzymes are inconclusive.
Adult↗
Cocaine-associated chest pain in a chest pain center.
Chest pain is the most common cocaine-related complaint. The objective of this study was to describe an emergency department-based chest pain center for patients with cocaine-associated chest pain and to evaluate the safety of this protocol by assessing cardiac complications at 30 days.
Adult↗
Assessment and treatment of chest pain.
Chest pain is one of the main reasons for emergency admission to hospital in the UK. Jackie Tough examines the causes and treatment of chest pain and offers a structured system for taking the patient's history.
Aortic Dissection↗
Prospective multicenter evaluation of cocaine-associated chest pain. Cocaine Associated Chest Pain (COCHPA) Study Group.
OBJECTIVE: To describe a large cohort of patients who had chest pain following cocaine use, and to determine the incidence of and clinical characteristics predictive for myocardial infarction in this group of patients. METHODS: A prospective observational cohort study of consecutive patients with cocaine-associated chest pain was conducted in six municipal hospital emergency departments (EDs). Demographic variables, drug abuse patterns, medical histories, chest pain characteristics, ECG results, and laboratory data were recorded. Myocardial infarction was the primary endpoint. RESULTS: Fourteen of 246 patients (5.7%; 95% confidence interval [CI], 2.7-8.7%) had myocardial infarction, as diagnosed by elevated CK-MB isoenzyme levels. There were two deaths (0.8%). The patients had a median age of 33 years. The majority were male (71.5%), non-white (83.3%), cigarette smokers (83.3%) who used cocaine regularly. Chest pain began a median of 60 minutes after cocaine use and persisted for a median of 120 minutes. Chest pain was most frequently described as substernal (71.3%) and pressure-like (46.7%). Shortness of breath (59.3%) and diaphoresis (38.6%) were common. There was no clinical difference between patients who had myocardial infarctions and those who did not. Twelve patients had arrhythmias and four had congestive heart failure. All cases requiring intervention were evident upon presentation. An ECG revealing ischemia or infarction had a sensitivity of 35.7% for predicting a myocardial infarction. The specificity, positive predictive value, and negative predictive value of the ECGs were 89.9%, 17.9%, and 95.8%, respectively. CONCLUSIONS: Myocardial infarction in patients who have cocaine-associated chest pain is not uncommon. No clinical parameter available to the physician can adequately identify patients at very low risk for myocardial infarction. Therefore, all patients with cocaine-associated chest pain should be evaluated for myocardial infarction.
Adult↗
Investigating chest pain.
Chest pain is a common complaint that in many patients requires full investigation to exclude the possibility of heart disease. Simple tests such as ECG and chest X-ray are often unhelpful. The main investigation is an exercise test but interpretation of this is not simple and its usefulness is limited in middle-aged women. More sophisticated imaging such as thallium scanning and stress echocardiography are of limited additional benefit and have significant cost. Coronary angiography remains the gold standard for the assessment of coronary atherosclerosis.
Algorithms↗