Patients that present with chest pain

Patients that present with chest pain or discomfort can create a real dilemma for the clinician. I have worked in A&E for many years now and have seen young people that presented with chest pains that ended up being heart attacks, blood clots on the lungs and aortic aneurysms.

So how do I decide where to start?

The history take is the most essential part of the chest pain dilemma.

It is important to use a tool such as S.O.C.R.A.T.E.S. which will enable you to make a more thorough and objective history take.

Site:

Where is the pain? This is important because we know cardiac pain is non-specific or ‘visceral pain’, which usually radiates across the whole chest or into the throat or back. If the patient is able to point at the pain with one finger it is very unlikely to be cardiac in nature. If they use their whole hand this is more significant.

Onset:

The time of onset of pain is essential to establish because it will enable us to risk assess the patient. If the pain started years ago it is less likely to be serious but still warrants further investigation by their GP. If it is acute then this will effect our decision making and how reliable the blood tests can be. For example a troponin to check for cardiac damage is more sensative after a few hours of the onset than soon after. But a d-dimer becomes less sensitive after 7 days of the onset of pain and could even provide a false negative result.

Character of pain:

Research has shown that patients presenting with cardiac pain typically describe it as a pressure, fullness, burning sensation or tightness of the chest.

Pleuritic chest pain is often referred to as sharp or stabbing in nature.

Gastric chest pain is usually caused by wind or acid reflux that causes a burning sensation up the centre of the chest and can often be mistaken for a heart attack or angina. However the alleviating or relieving factors of this such as belching or bloating often give us clues to its origin.

Musculoskeletal pain can be described as dull, aching or sharp in nature.

In my experience patients that present with aortic dissection often describe it as a ripping type pain or sharpness. One patient I had in her 40’s with a type B aortic dissection even described it as a ‘searing’ pain every time her heart beats.

Radiation of pain:

Cardiac chest pain can radiate across the chest, down the arms, into the throat or even into the back depending on what part of the heart is ischaemic.

Pleuritic chest pain is usually radiating either anterior to posterior chest or visa-versa.

Gastric pain tends to radiate from the epigastric region up the centre of the chest or even to the left side of the chest. However, an esophageal spasm can cause sharp shooting pains radiating from the front to back of the central chest.

Musculoskeletal pain is often very specific but can radiate across the muscle/bone that is effected.

A sudden onset of chest pain radiating front to back or visa versa should always ring ‘alarm bells’ for an aortic dissection. I would suggest a senior review for anyone that presents with this as it can be very difficult to diagnose unless you CT Angio or Ultrasound scan everyone’s aorta. A hospital I worked in recommended a bedside ultrasound scan for everyone that presented with sudden onset of chest or abdominal pain after a missed aortic dissection lead to a patient dying.

Associated symptoms:

Symptoms that are associated with cardiac chest pain include sweating, palpitations, nausea, vomiting, feeling faint, feeling of imminent doom and shortness of breath with exertion.

Pleuritic chest pain usually presents with shortness of breath, reduced oxygen levels, coughing, hemoptysis and shallow breathing-as it hurts to take a deep breath.

Gastric pain can present with bloating, belching, trapped wind, nausea, vomiting, weight loss, diarrhoea, acid reflux, burning sensation in the back of the throat. They often develop a morning cough or horseness due to the back flow of acid up the esophagus.

Musculoskeletal pain often restricts physical activity due to pain on movement. They often describe being unable to sleep on the effected side.

Aortic aneurysm/dissection: Loss of consciousness, low blood pressure, postural hypotension/syncope, signs of ischemic lower limbs.

Timing:

Stable Cardiac chest pain tends to come on with exertion and ease with rest. However, if this becomes an unstable ischemia then the pain can come on at any time.

Pleuritic chest pain is usually constant and does not come and go at a particular time of day.

Aortic dissection is sudden pain that can come on at any time. One of my patients woke in the night with a sudden onset of back pain and went to see his GP the next day. The GP prescribed him analgesia for musculoskeletal pain. Why would you suddenly develop musculoskeletal back pain in your sleep? Needless to say the same happened the following night so he came to A&E where I diagnosed a massive aortic dissection and he was transferred to the Vascular team for life saving aortic surgery.

Gastric pain: pain that is worse at night when lying flat or first thing in the morning then gradually improves during the day.

Exacerbative factors:

Cardiac pain- usually made worse by exertion and improves with rest. If pain is constant or coming even at rest now they may have have a recent build up of angina symptoms.

Respiratory: Worse on deep inspiration, coughing or sneezing.

Aortic Aneurysm: Nothing will make it better or worse initially but the pain may ease eventually then return as it continues to grow

Gastric: Pain can be relieved by belching or passing flatus. Acid reflux remedies may also relieve symptoms. Research has shown GTN is also known to relieve gastric symptoms by improving accomodation in the proximal stomach. Therefore, the relief of pain by GTN is not a good indicator of cardiac chest pain.

Musculoskeletal pain: Always made worse on movement, lifting heavy objects and palpation of the effected bone or soft tissue. It is worth knowing that a small percentage (<10%) of those with myocardial infarction may have chest wall tenderness.

Severity:

The severity of the pain and how long the pain lasted is an important aspect of the history take. For instance if the pain only lasted a few seconds then went away this is less likely to be cardiac or pleuritic in nature.

What to look for in the chest pain Clinical Examination:

Cardiac: Look for Oedema, raised jugular venous pressure, xanthelasma, corneal arcus, heart murmur, arrhythmias, finger nail clubbing, sweating/clammy, restless and agitated. Evidence of pulmonary oedema-crackles or reduced air entry. Coughing up frothy clear phlegm.

Respiratory: RIPPA (Remember Inspection, Palpation, Percussion and Auscultation). Look for wheeze or crackles or more importantly absence of sounds! Absence usually means no air flow due to trapped air-pneumothorax or fluid- haemothorax or pleural effusion. Percussion can help establish if it is air or fluid-if it is hypo-resonant it will be fluid and hyper-resonant it will be air. Any signs of fever? Coughing? Phlegm and its colour will be important. Respiratory rate and oxygen saturations.

Gastric: Examine the abdomen for tenderness. Check Murphy’s sign to rule out cholecystitis. Look for jaundice, anaemia, clubbing, lymphadenopathy or masses.

Aortic aneurysm: Feel for an abdominal pulsating mass (this can be misleading with slim patients). Blood pressure differences of more than 30mm Hg. This is due to the occurrence of pseudohypotension occurring in the limb with the dissected artery. However, poor diagnostic accuracy and potential variability in measurements limits its clinical usefulness. Check for postural hypotension. Look for any signs of limb ischemia.

What else can I do to help me risk assess the patient?

There are some fantastic tools you can use to help you decide if the patient is at risk and requires further investigations:

The HEART score, TIMI Score and helps emergency medicine providers risk-stratify chest pain patients into low, moderate and high risk groups.

My favorite is the PERC criteria to help rule out a PE. If you answer ‘No’ for everything then there is a less than 2% chance of the patient having a PE and therefore warrants no further investigations.

ADD-RS score can be used to help decide if patient is at risk of an Aortic Dissection.

Safety netting advice

Despite all of our best efforts we sometimes get it wrong. Unfortunately, I have witnessed patient’s discharged from A&E collapse and have a cardiac arrests in the car park on several occasions despite all of their investigations being normal.

It is therefore essential to provide the safety netting advice that ‘if their symptoms worsen despite treatments or negative test results they are to return to be reviewed by a senior member of the clinical team asap’.

Returning patients are a big red flag and should always be reviewed by the most senior clinician on duty.