Chest pain

Internal Medicine Rapid Refreshers is a series of concise information-packed videos refreshing your knowledge on key medical issues that general practitioners may encounter in their daily practice. This episode looks closely at critical points in the management of chest pain.

Useful links

Chapter on chest pain from the McMaster Textbook of Internal Medicine

Transcript

Roman Jaeschke, MD: Good afternoon. Welcome to another edition of Internal Medicine Rapid Refreshers. This is a sequence of recordings we are preparing for those who due to the coronavirus disease 2019 (COVID-19) emergency are suddenly finding themselves in unfamiliar territories.

I would like to introduce to you Doctor Akbar Panju, a former division director for General Internal Medicine and former acting chair of the Department of Medicine at McMaster University. Doctor Panju’s interest for the last 30 or 40 years has been chest pain, and that’s what he’ll talk to us today about. Doctor Panju, the floor is yours.

Akbar Panju, MB ChB: Chest pain is one of the common reasons for general internal medicine consultations. This brief Rapid Refresher will hopefully help our colleagues in the Department of Medicine when they approach a patient presenting with this problem.

Introduction

Chest pain may be caused by multiple causes. It’s very important that the physician recognizes and acts quickly on life-threatening causes of chest pain and initiates appropriate management, including asking for help from other colleagues.

I will first discuss the emergent and life-threatening situations.

Evaluation

The evaluation of a patient with chest pain always begins by getting the vital signs—heart rate, blood pressure, respiratory rate, oxygen saturation—taking a history, performing a physical examination, most of the time performing an electrocardiogram (ECG) and chest x-ray, as well as routine bloodwork (blood testing) and obtaining cardiac biomarkers, which in this case is troponin.

Based on the gathered information, the physician will be in a position to formulate a differential diagnosis for the cause of chest pain and will be able to rule in or rule out emergent and life-threatening causes for chest pain.

I will now review emergent and life-threatening causes of chest pain.

Emergent and life-threatening causes

1. Acute coronary syndrome (ACS): ACS includes unstable angina, ST-segment elevation myocardial infarction (MI), and non–ST-segment elevation MI. A patient presenting with ACS usually has a chest pain described as tightness or crushing in nature. They may have pain radiating to the neck or arm. Pain may be associated with shortness of breath. It may be worsened by exertion and resolve with rest. Patients with ACS may have ST-segment changes on their ECG. The troponin level may be elevated.

Based on the history, physical examination, ECG findings, and troponin levels, the physician may be in a position to risk stratify patients into low-risk ACS, moderate-risk ACS, and high-risk ACS. High-risk ACS is very important to identify early, as these patients need to be referred to cardiology service early on an emergency basis for possible reperfusion strategies.

High-risk patients with ACS are patients with ongoing chest pain of the above characteristics, ECG changes including ST-segment elevation MI, ECG changes with dynamic ST-segment changes, ST-segment depression, and elevated troponins. Patients may also be hypotensive.

Initial medical treatment of ACS patients should be instituted as quickly as possible. This usually includes aspirin 160 mg chewable, clopidogrel 150 mg by mouth, and fondaparinux 2.5 mg subcutaneously. Again, remember: early referral to cardiology, particularly for these high-risk patients, should be considered.

2. Pulmonary embolism (PE): This should be considered in patients with pleuritic chest pain associated with shortness of breath, usually of rapid development, especially in the setting of prior history of venous thromboembolism (VTE), recent surgery, or confinement to bedrest; active malignancy; or unilateral leg swelling. Hemoptysis may be occasionally present.

Based on the history and physical examination, the physician should stratify patients into groups with a high probability, moderate probability, and low probability of PE. If the probability is high or moderate, computed tomography pulmonary angiography (CTPA) is the usual investigation and should be done as soon as possible. In patients with low probability, measurement of D-dimer levels may decrease the probability further and allow to avoid CT scanning. In Hamilton, thrombosis service is available 24/7, and a call to thrombosis service is a clear option.

3. Pneumothorax: This will be ruled in or ruled out with a chest x-ray, usually P-A and lateral views. Patients with pneumothorax present with a sudden-onset chest pain. When pneumothorax is confirmed, referral to thoracic surgery or respirology is indicated and should be done quickly.

4. Pericarditis: The pain in pericarditis may be sharp, stabbing, exacerbated by inspiration and coughing, and occasionally reduced with sitting and leaning forward. An echocardiogram should also be considered in this setting and treatment with nonsteroidal anti-inflammatory agents (NSAIDs) or colchicine be started.

5. Aortic dissection: This is a rare, infrequent cause, which nevertheless needs to be considered in patients with a suggestive clinical presentation. The pain in aortic dissection is extremely severe, tearing, and of sudden onset. It may radiate to the interscapular area. Unequal pulses may be present.

If aortic dissection is suspected, an urgent aortic angiogram and urgent referral to a vascular surgeon are needed.

Other causes of chest pain

In addition to the above-listed emergent and life-threatening conditions, there are many other causes of chest pain, which should be grouped into different categories and kept in mind.

Gastrointestinal disorders may include disorders like gastroesophageal reflux disease, peptic ulcer disease, cholelithiasis, and pancreatitis. The characteristics of each of these conditions will be evident on history and physical examination.

There are also other pulmonary disorders, like pneumonia and pleuritis, that can cause chest pain.

Musculoskeletal disorders, like costochondritis, can also present with chest pain.

The goal in patients presenting with chest pain is to rule in and rule out threatening causes, institute treatments, and ask for appropriate consultations from our colleagues from other subspecialties.

References

You may find the McMaster Textbook of Internal Medicine a very good resource to look at for the evaluation of chest pain, both considering a general approach and detailed information about the conditions mentioned above.

I hope you’ll find this Rapid Refresher useful in your approach to patients with chest pain. Thank you very much.