Chest Pain

Chest Pain: Excerpt from In a Page: Signs and Symptoms

Although most cases of chest pain are due to benign etiologies, such as gastroesophageal reflux or a muscle strain, life-threatening etiologies must be assessed and treated immediately if present. There are five primary etiologies of acute, life threatening chest pain: Aortic dissection, myocardial infarction, esophageal rupture, tension pneumothorax, and pulmonary embolism. Note that clinical improvement following use of antacids does not rule out the possibility of a cardiac etiology.

Differential Diagnosis

• Cardiovascular etiologies
  –Myocardial infarction
  –Angina
  –Acute coronary syndrome
  –Pulmonary embolus
  –Pericarditis
  –Arrhythmias
  –Mitral valve prolapse
  –Aortic stenosis
  –Aortic dissection
  –Cardiac tamponade
• Pulmonary etiologies
  –Pneumonia
  –COPD
  –Asthma
  –Pneumothorax
  –Tension pneumothorax
  –Hemothorax
  –Empyema
  –Pneumomediastinum
  –Lung cancer
• Gastrointestinal etiologies
  –Esophagitis/GERD
  –Gastritis
  –Peptic ulcer disease
  –Perforated ulcer
  –Esophageal spasm
  –Pancreatitis
  –Esophageal rupture
  –Pneumoperitoneum
• Musculoskeletal etiologies
  –Muscle strain or spasm
  –Intercostal muscle spasm
  –Costochondritis
  –Trauma (e.g., rib fracture)
• Zoster
• Cancer (e.g., lymphoma)
• Panic disorder
• Less common etiologies include Tietze's syndrome, Pott's disease (tuberculosis of the spine), xyphodenia, cholecystitis, peritonitis, liver cancer, and hepatitis

Workup and Diagnosis

• History and physical examination
  –Assess onset, duration, location, radiation, type of pain, and exacerbating and alleviating factors
  –Cardiovascular evaluation includes assessment of heart sounds, murmurs, gallops or rubs, and carotid bruit
  –All patients require a rectal exam (e.g., to assess for occult bleeding due to GI etiologies, to assess for occult bleeding before initiating anticoagulation)
  –Risk factors for coronary artery disease include smoking, hyperlipidemia, diabetes, and a personal or family history of coronary artery disease
• Initial evaluation may include pulse oximetry, CBC, electrolytes, BUN/creatinine, calcium, glucose, PT/INR/PTT, ECG, chest X-ray, and cardiac enzymes
• Patients with suspected coronary artery disease may require stress testing, echocardiogram, and/or cardiac catheterization
• Further studies to consider include arterial blood gas, liver function tests, amylase and lipase, CT of chest and abdomen, VQ scan, peak flow testing and pulmonary function tests, arteriogram, bronchoscopy, EGD, and/or esophagram
• Transesophageal echocardiogram and/or CT scan or MRI of the chest may be required to rule out aortic dissection (if widened mediastinum is present on X-ray)

Treatment

• Attention to airway, breathing, and circulation
• All patients with suspected coronary artery disease should initially be treated with supplemental O₂, aspirin, and nitroglycerin; morphine may be added if pain does not subside
• If an acute myocardial infarction is suspected, β-blockers, ACE inhibitors, heparin (usually low molecular weight heparin, enoxaparin), thrombolytic therapy or primary angioplasty (PTCA), and/or glycoprotein IIb/IIIa inhibitors (e.g., eptifibatide, abciximab, or tirofiban) may be indicated

Book Source Details

• Book Title: In a Page: Signs and Symptoms
• Author(s): Scott Kahan, Ellen G. Smith
• Year of Publication: 2004
• Copyright Details: In a Page: Signs and Symptoms, Copyright © 2004 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: In a Page: Signs and Symptoms Authors: Scott Kahan, Ellen G. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2004 ISBN: 1-4051-0368-X

 » Next page: Chest Pain (In A Page: Pediatric Signs and Symptoms)

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