Chest pain

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Chest pain
ICD-10R07
ICD-9786.5
MedlinePlus003079
 
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Chest pain
ICD-10R07
ICD-9786.5
MedlinePlus003079

Chest pain may be a symptom of a number of serious conditions and is, in general, considered a medical emergency. Even though it may be determined that the pain is non-cardiac in origin, this is often a diagnosis of exclusion made after ruling out more serious causes of the pain.

Differential diagnosis[edit]

Causes of chest pain range from non-serious to serious to life-threatening.[1] DiagnosisPro lists more than 440 causes on its website.[2]

Cardiovascular[edit]

Respiratory[edit]

Gastrointestinal[edit]

Chest wall[edit]

Psychological[edit]

Others[edit]

Diagnostic approach[edit]

History taking:

Knowing a patient's risk factors can be extremely useful in ruling in or ruling out serious causes of chest pain. For example, heart attack and thoracic aortic dissection are very rare in healthy individuals under 30 years of age, but significantly more common in individuals with significant risk factors, such as older age, smoking, hypertension, diabetes, history of coronary artery disease or stroke, positive family history (premature atherosclerosis, cholesterol disorders, heart attack at early age), and other risk factors.

Physical examination:

In the emergency department the typical approach to chest pain involves ruling out the most dangerous causes: heart attack, pulmonary embolism, thoracic aortic dissection, esophageal rupture, tension pneumothorax, and cardiac tamponade. By elimination or confirmation of the most serious causes, a diagnosis of the origin of the pain may be made. Often, no definite cause will be found and reassurance is then provided.[1]

If acute coronary syndrome ("unstable angina") is suspected, many people are admitted briefly for observation, sequential ECGs, and determination of cardiac enzymes over time. On occasion, further tests on follow up may determine the cause. TIMI score performed at time of admission may help stratify risk. Features of the pain suggestive of cardiac ischaemia are describing the pain as heaviness; radiation of the pain to the neck, jaw or left arm; sweating; nausea; palpitations; pain felt upon exertion; dizziness; shortness of breath; and a "sense of impending doom."

Careful medical history and physical examination is essential in separating dangerous from trivial causes of disease, and the management of chest pain may be done on specialised units (termed medical assessment units) to concentrate the investigations. Occasionally, invisible medical signs will direct the diagnosis towards particular causes, such as Levine's sign in cardiac ischemia. A rapid diagnosis can be life-saving and often has to be made without the help of medical tests. However, in general, additional tests are required to establish the diagnosis.

Medical tests:

On the basis of the above, a number of tests may be ordered:[4]

Management[edit]

Administration of an aspirin tablet to be chewed and swallowed at admission was found to correlate with a 30% increase in 30-day survival. "Because aspirin should be administered as soon as possible after symptom onset to patients with suspected ACS, it is reasonable for EMS dispatchers to instruct patients with no history of aspirin allergy and without signs of active or recent gastrointestinal bleeding to chew an aspirin (160 to 325 mg) while awaiting the arrival of EMS providers ...".[5]

In people with chest pain supplemental oxygen is not needed unless the oxygen saturations are less than 94% or there are signs of respiratory distress.[6][7] Entonox is frequently used by EMS personnel in the prehospital environment.[8] However, there is little evidence about its effectiveness.[7][9]

Epidemiology[edit]

Chest pain is the presenting symptom in about 12% of emergency department visits in the United States and has a one-year mortality of about 5%.[10]

References[edit]

  1. ^ a b Woo KM, Schneider JI (November 2009). "High-risk chief complaints I: chest pain--the big three". Emerg. Med. Clin. North Am. 27 (4): 685–712, x. doi:10.1016/j.emc.2009.07.007. PMID 19932401. 
  2. ^ "Differential Diagnosis For Chest Pain: Poisoning (Specific Agent)". 
  3. ^ Mallinson, T (2010). "Myocardial Infarction". Focus on First Aid (15): 15. Retrieved 2010-06-08. 
  4. ^ Hess EP, Perry JJ, Ladouceur P, Wells GA, Stiell IG (March 2010). "Derivation of a clinical decision rule for chest radiography in emergency department patients with chest pain and possible acute coronary syndrome". CJEM 12 (2): 128–34. PMID 20219160. 
  5. ^ [https://circ.ahajournals.org/content/122/18_suppl_3/S787.full 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science Part 10: Acute Coronary Syndromes
  6. ^ "Highlights of the 2010 AHA Guidelines for CPR and ECC". American Heart Association. 
  7. ^ a b O'Connor, RE; Brady, W; Brooks, SC; Diercks, D; Egan, J; Ghaemmaghami, C; Menon, V; O'Neil, BJ; Travers, AH; Yannopoulos, D (2010-11-02). "Part 10: acute coronary syndromes: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care". Circulation 122 (18 Suppl 3): S787–817. doi:10.1161/CIRCULATIONAHA.110.971028. PMID 20956226. 
  8. ^ Castle, N (February 2003). "Effective relief of acute coronary syndrome". Emergency nurse : the journal of the RCN Accident and Emergency Nursing Association 10 (9): 15–9. PMID 12655961. 
  9. ^ "Entonox for the Treatment of Undiagnosed Chest Pain: Clinical Effectiveness and Guidelines". Canadian Agency for Drugs and Technologies in Health. Retrieved 12 July 2011. 
  10. ^ Stephen J. Dubner; Steven D. Levitt (2009). SuperFreakonomics: Tales of Altruism, Terrorism, and Poorly Paid Prostitutes. New York: William Morrow. p. 77. ISBN 0-06-088957-8.