Critical Care Medicine

Chest pain

Chest Pain

Related Conditions

Acute myocardial infarction

Acute coronary syndrome

Pericarditis

Pneumonia

Pneumothorax

Pulmonary Embolism

1. Description of the problem

Chest pain may be the result of any number of pathologic and non-pathologic processes. It is important to take a thorough history, as this can often be the key factor in determining the etiology for a patient's chest pain symptoms.

Careful attention should be focused on obtaining a history that may help to establish a diagnosis for the patient's chest pain. Key features of the history include character and quality of the chest pain, location and radiation of the chest pain, precipitating/exacerbating/alleviating factors, chest pain duration, and associated symptoms.

With the history and physical examination, along with ancillary studies (including electrocardiogram, chest x-ray, and laboratory studies), the treating clinician should focus on determining the etiology of symptoms. In particular, one should determine if any high-risk conditions are present, including acute myocardial infarction, acute coronary syndrome, acute pulmonary embolism, pneumothorax, or aortic dissection.

2. Emergency Management

Management largely depends upon the etiology of a patient's chest pain presentation. As in all patients, early management should address hemodynamic stabilization and airway control as necessary. The goal is to evaluate and exclude the possibility of life-threatening diseases, including acute coronary syndrome, pulmonary embolism, and aortic dissection, in particular.

All patients with a history and/or examination concerning for acute myocardial infarction or acute coronary syndrome should get an immediate 12-lead ECG. Patients with possible pneumothorax should have an immediate chest x-ray, or tube thoracostomy if tension pneumothorax is present. Patients with presumed pulmonary embolism often require a confirmatory test, including ventilation-perfusion scan or computed tomography angiography (CTA). Those with possible aortic dissection should be further evaluated with either computed tomography or echocardiography.

Drugs and dosages

Aspirin: Aspirin should be given to all patients with presumed myocardial infarction or acute coronary syndrome; 162-325 mg orally.

Heparin: Either unfractionated or low-molecular-weight heparin should be administed to patients with presumed pulmonary embolism.

3. Diagnosis

As mentioned, an accurate and thorough history is often the key to establishing a definitive diagnosis in patients presenting with chest pain. Ancillary studies, depending upon the pre-test probability of disease, could include ECG, chest x-ray, echocardiogram, computed tomography, or angiography. Other studies often include routine laboratory tests (complete blood count, serum chemistries, creatinine, blood urea nitrogen, liver function tests, cardiac enzymes, d-dimer).

The careful accumulation of data from the history, physical examination, and ancillary studies should help the clinician establish a definitive diagnosis. Often, no diagnosis is determined.

Pathophysiology

The pathophysiology of chest pain depends upon the exact etiology.

Epidemiology

Chest pain is the presenting symptom in over 10% of emergency department visits.

Special considerations for nursing and allied health professionals.

N/A

What's the evidence?

Woo, KM. "High-risk chief complaints I: chest pain - the big three". Emerg Med Clin North Am. vol. 27. 2009. pp. 685-712.

Overview of chest pain evaluation in the emergency department

Hess, EP. "Derivation of a clinical decision rule for chest radiography in emergency department patients with chest pain and posssible acute coronary syndrome". CJEM. vol. 12. 2010. pp. 128-34.

Decision pathway used to differentiate ischemic from non-ischemic causes of chest pain in the emergency department.
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