CHEST PAIN

Ask the following questions:

1. Is the chest pain acute or chronic? If it is acute, one must consider acute myocardial infarction, pulmonary embolism, pneumothorax, pericarditis, and fractures. If the chest pain is chronic, one must consider chronic coronary insufficiency, esophagitis, hiatal hernia, and various chest wall conditions.
2. Is the pain constant or intermittent? Constant pain suggests acute myocardial infarction, pulmonary infarction, dissecting aneurysm, and pneumonia. Intermittent pain would suggest coronary insufficiency, Tietze's disease, and DaCosta's syndrome.
3. Is there associated significant hypertension? Significant hypertension would make one think of dissecting aneurysm, but it is also found occasionally in acute myocardial infarction.
4. Is the pain relieved by antacids? Relief by antacids should prompt one to consider esophagitis and hiatal hernia.
5. Is the pain precipitated or increased by breathing? The pain of pleurisy, costochondritis, rib fractures, and pneumothorax is precipitated or increased by breathing.
6. Is there associated hemoptysis? Hemoptysis should make one consider a pulmonary embolism.
7. Is there fever and purulent sputum? Fever and purulent sputum should make one consider pneumonia.
8. Is there dyspnea? Dyspnea should make one consider pneumothorax, pulmonary embolism, and pneumonia, as well as congestive heart failure secondary to acute myocardial infarction.
9. Is it aggravated by movement? Aggravation of the chest pain by movement should suggest pericarditis. Remember, myocardial infarctions may also have extension into the pericardium and must be considered at times.
10. Is it relieved by nitroglycerin? Relief by nitroglycerin should suggest a coronary insufficiency, but esophagospasm may be relieved by nitroglycerin also.

DIAGNOSTIC WORKUP

All patients should have a CBC, sedimentation rate, chemistry panel, VDRL test, chest x-ray, and EKG. If there is sputum, a smear and culture should be done as soon as possible.

If a myocardial infarction is suspected, then serial EKGs and tests for the isoenzyme of creatine kinase (CK-MB) should be done if the initial EKG and enzymes do not show any significant changes. Serum cardiac troponin levels may also be diagnostic of a myocardial infarct. Thallium-201 scintigraphy is useful in diagnosing both myocardial infarction and coronary insufficiency. Exercise tolerance tests may help diagnose coronary insufficiency. Immediate coronary angiography should be undertaken if the condition deteriorates. This can be followed by immediate balloon angioplasty, reperfusion therapy, or bypass surgery.

If a pulmonary embolism is suspected, arterial blood gases and a ventilation-perfusion scan should be done. d -dimer testing of whole blood is a sensitive test of pulmonary embolus. Pulmonary angiography may need to be done if these are negative and pulmonary embolism is still strongly suspected.

If esophageal disease is suspected, an upper GI series with esophagogram should be done; this can be followed with esophagoscopy and gastroscopy if needed. A Bernstein test (acid perfusion of the esophagus) may reproduce the exact pain and distinguish esophageal reflux from a cardiac source of the pain. Ambulatory pH monitoring may also diagnose reflux esophagitis.

If pericarditis is suspected, echocardiography and possibly a CT scan of the chest and pericardium may be necessary. Coronary angiography may be necessary to diagnose coronary insufficiency. Echocardiography is also helpful in diagnosing mitral valve prolapse and the various myocardiopathies. Twenty-four-hr Holter monitoring is useful in diagnosing many causes of intermittent chest pain.

Referral to a cardiologist or pulmonologist may be appropriate at any point in this workup. Dissecting aneurysm may be confirmed by a CT scan or MRI of the chest.

Book Source Details

• Book Title: Algorithmic Diagnosis of Symptoms and Signs
• Author(s): R. Douglas Collins
• Year of Publication: 2003
• Copyright Details: Algorithmic Diagnosis of Symptoms and Signs, Copyright © 2003 Lippincott Williams & Wilkins.

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