Chest Pain (Rosen’s)
Prevalence in emergency department
Atypical or additional aspects
1. Myocardial infarction
Discomfort is usually moderately severe to severe and rapid in onset. May be more pressure than pain. Usually retrosternal, may radiate to neck, jaw, both arms, upper back, epigastrium, and sides of chest (left more than right). Lasts more than 1530 min and is unrelieved by NTG
Diaphoresis, nausea, vomiting, dyspnea
May be precipitated by emotional stress or exertion. Often comes on at rest. May come on in early awakening period. Prodromal pain pattern often elicited. Previous history of MI or angina. Over 40 years old, positive risk factors, and male sex increase possibility
Patients are anxious and uncomfortable. Blood pressure is usually elevated but normotension and hypotension are seen. The heart rate is usually mildly increased, but bradycardia can be seen. Patients may be diaphoretic, and show peripheral poor perfusion. There are no diagnostic examination findings for MI although S3 and S4 heart sounds and new murmur are supportive
ECG changes (new Q waves or ST segment-T-wave changes) occur in 80% of patients. CK-MB and troponins are very helpful if elevated, but may be normal
Pain may present as indigestion or unable to describe. Other atypical presentations include altered mental status, stroke, angina pattern without extended pain, severe fatigue, syncope. Elderly may present with weakness, congestive heart failure, or chest tightness. 25% of nonfatal MIs are unrecognized by patient. The pain may have resolved by the time of evaluation.
2. Unstable angina
Changes in pattern of preexisting angina with more severe, prolonged, or frequent pain (crescendo angina). Pain usually lasts > 10 min. Angina at rest lasting 1520 minutes or new-onset angina (duration < 2 months) with minimal exertion. Pattern of pain change important in gauging risk for AMI. Unpredictable responses to NTG and rest
Often minimal. May have mild diaphoresis, nausea, dyspnea with pain. Increasing pattern of dyspnea on exertion.
Not clearly related to precipitating factors. May be a decrease in amount of physical activity that initiates pain. Previous history of MI or angina. Over 40 years old, presence of risk factors, and male sex increase probability
Nonspecific findings of a transient nature, may have similar cardiac findings as in MI, especially intermittent diaphoresis.
Often no ECG or enzyme changes.
May be pain free at presentation. Full history is essential. Fewer than 15% of patients hospitalized for unstable angina go on to acute MI. May respond to nitroglycerin. May manifest similarly to non-Q wave infarction.
Variant angina (Prinzmetals) has episodic pain, at rest, often severe, with prominent ST segment elevation.
3. Aortic dissection
90% of patients have rapid-onset severe chest pain that is maximal at beginning. Radiates anteriorly in chest to the back interscapular area or into abdomen. Pain often has a tearing sensation, and may migrate.
Neurologic complications of stroke, peripheral neuropathy, paresis or paraplegia. abdominal and extremity ischemia possible
Median age is 59 years. History of hypertension in 7090% of patients. 3:1 ratio males to females; Marfans syndrome and congenital bicuspid aortic valves have increased incidence.
Often poorly perfused peripherally but with elevated BP. In 5060% of cases there is asymmetric decrease or absence of peripheral pulses. 50% of proximal dissections cause aortic insufficiency. Other vascular occlusions: coronary (12%), mesentery, renal, spinal cord. New-onset pericardial friction rub or aortic insufficiency murmur supportive of diagnosis
ECG usually shows left ventricular hypertrophy, nonspecific changes. Chest film shows abnormal aortic silhouette (90%).
Rare for patient to present pain free. May present with neurologic complications. Physical examination findings may be minimal. Dissection into coronary arteries can mimic MI.
Aortic angiography has diagnostic accuracy of 9599%. Transesophageal echo, CT, MRI most useful in screening.
Ascending aortic aneurysms are approached more surgically. Descending are generally managed medically.
4. Pulmonary embolism
Pain is more often lateral-pleuritic. Central pain is more consistent with massive embolus. Abrupt in onset and maximal at beginning. May be episodic or intermittent.
Dyspnea and apprehension play a prominent role, often more than pain. Cough accompanies about half the cases.
Hemoptysis occurs in less than 20%. Angina-like pain may occur in 5%.
Often some period of immobilization has occurred, e.g., postoperative.
Pregnancy, oral contraceptives, heart disease, and cancer are all risk factors. Previous DVT or PE is the greatest risk factor.
Uncommon in ambulatory patients, but common in departments with high volumes of elderly or medically complex patients
Patients are anxious and often have a respiratory rate over 16/min. Tachycardia, inspiratory rales, and an increased pulmonic second sound are common. Fever, phlebitis, and diaphoresis are seen in 3040% of patients. Wheezes and peripheral cyanosis are less common
Arterial blood gases show PO2 <80 mm Hg in 90%. Widened A-a gradient is helpful. Chest film is usually normal, though up to 40% show some volume loss, oligemia, or signs of consolidation due to pulmonary infarction. Lung perfusion scan rules out, if truly negative
Patients may present with dyspnea with or without bronchospasm. Acute mortality rate is 10%. Emboli usually from lower extremities above knee, prostate/pelvis venous plexus, right heart. May be subtle cause of COPD exacerbation.
Pain is usually acute and maximal at onset. Most often lateral-pleuritic, but central pain can occur in large pneumothorax.
Dyspnea has a prominent role. Hypotension and altered mental states occur in tension pneumothorax.
Chest trauma, previous episode, or asthenic body type
Decreased breath sounds, increased resonance on percussion. Elevated pressure in neck veins occur in tension pneumothorax
Chest film definitive. Inspiratory and expiratory films may enhance contrast between air and lung parenchyma. Tension pneumothorax should be diagnosed on physical examination
May be subtle in COPD, asthma, cystic fibrosis. Can be complicated by pneumomediastinum
6. Esophageal rupture
Pain is usually preceded by vomiting and is abrupt in onset. Pain is persistent and unrelieved, localized along the esophagus, and increased by swallowing and neck flexion
Diaphoresis, dyspnea (late), shock
Older individual with known gastrointestinal problems. History of violent emesis, foreign body, caustic ingestion, blunt trauma, alcoholism, esophageal disease
Signs of lung consolidation, subcutaneous emphysema may be present
Chest film usually has mediastinal air, a left-sided pleural effusion, pneumothorax, or a widened mediastinum. pH of pleural effusion is <6.0. Diagnosis supported by water-soluble contrast esophagram or esophagoscopy
Patient may present in shock state. This entity often considered late in differential diagnostic process
Dull, aching recurrent pain unrelated to exercises or meals. Or it may be a sharp, stabbing, pleuritic-type pain that does not change with chest wall motion. May be severe. Not relieved by nitroglycerine.
Pain is often worse when supine, but improves sitting up. Often preceded by viral illness or underlying disease (SLE or uremia).
Friction rub may be heard, often fleeting, position dependent (50% patients).
ECG pattern typical for ST segment elevation across the precordial leads. Erythrocyte sedimentation rate may be elevated
More common in 20- to 50-year-olds. May have associated tachycardias, ventricular dysrhythmias. Idiopathic most common (80%) treated with aspirin, NSAID.
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