Chest Pain

NB If the patient is acutely unwell with chest pain, treat with ABCDE and/or as an acute coronary syndrome i.e. MONA(C) (morphine; oxygen; nitrates; aspirin +/- clopidogrel).  In a hospital situation, where the history is not so clear cut, you might be able to hold off empiric treatment until investigation results have come back.

History

  • SOCRATES

    • Site (central, diffuse, localised: can the patient point to it)
      • anterior or back
    • onset (sudden/acute; subacute; gradual; with exertion/at rest)
    • character (crushing, heavy, sharp, dull, stabbing, pleuritic)
      • pressure (angina, MI, oesophageal spasm)
      • tearing (aortic dissection)
      • sharp/stabbing (pericarditis, PE, musculoskeletal, pneumothorax)
      • pleuritic (PE, pneumothorax, pneumonia, musculoskeletal, pericarditis, drug causes)
    • radiation (left shoulder/arm, jaw, back)
    • associated symptoms
      • breathlessness
      • cough, sputum, haemoptysis
      • sweating
      • palpitations
      • dizziness, syncope
      • anxiety
      • nausea/vomiting
      • systemic symptoms: fever, chills, sweats, weight loss, fatigue
    • Timing (Has it got better/worse?  Intermittent/constant?)
      • Any previous episodes?
    • Exacerbating/Alleviating factors (e.g. GTN spray, inhalers, position, painkillers, gaviscon etc)
    • Severity
  • You also want to ask about
    • Past medical history
      • Cardiovascular disease- angina, hypertension, peripheral vascular disease
        • Ask about leg pain and differentiate between claudication and DVT (pain on exertion, which is deep, burning, stabbing vs hot, red, swollen, tender, more superficial)
        • how well controlled; any previous admissions/treatments
      • Any lung disease- COPD, asthma
        • again, how well controlled is this
      • Any diabetes
      • Any hypercholesterolaemia
      • Any heartburn
      • Any rheumatoid arthritis or connective tissue disease
      • Ask what drugs the patient is taking/has taken recently
        • Any drug allergies (particularly aspirin)
      • Any allergies
    • Family History
      • In particular, that of heart disease
    • Social history
      • Smoking- quantify
      • Alcohol- quantify
      • Illicit drugs
      • Occupation
      • Home situation
      • If relevant, ask about travel history.
  • Remember ICE

Examination

  • Does the patient look unwell? (Do they require immediate attention and life support?)

General

  • Any end of the bed signs?
    • Is the patient hunched over clutching their chest?  Are there multiple inhalers around the patient?  Does the patient look well/unwell?  Is there anything that stands out?
  • Examine the patients hands
    • Any nail bed/splinter haemorrhages?  Any nicotine stains? Any peripheral cyanosis?  Any Reynaud’s?
    • Check capillary refill by compressing the distal phalanx for 5 secs, releasing and observing a return to normal colour (normal <2 secs)
    • Any pallor of the palmar creases (anaemia)
    • Any Osler’s nodes (painful swellings on the fingertips- infective endocarditis)
    • Any arthritic changes
  • Feel the radial pulse- comment on rate, rhythm, character, strength/volume
    • You might also, at this point, want to check for a radial-radial delay (coarctation of the aorta) and/or a collapsing pulse (aortic regurgitation)
      • Check if the patient has any joint pain; With your dominant hand, feel the radial pulse; with your non-dominant hand on the patient’s elbow, raise the patient’s arm up above the level of the heart; feel for a change of character in the pulse
        • Normally will remain similar
        • A collapsing pulse is one which ‘collapses’ under your fingers (might not completely disappear)
  • Take blood pressure
    • Ideally both sitting and standing and on both arms (difference can be suggestive of aortic dissection/coarctation)
  • Look at the face
    • Any xanthomata (yellowish deposits of lipid around the eyes- hyperlipidaemia) or corneal arcus (ring of lipid around the cornea)
    • Any conjunctival pallor
    • Any malar rash
    • Ask the patient to stick out their tongue and point it upwards
      • Any tongue changes e.g. beefy tongue
      • Any central cyanosis
  • Look at the neck
    • Look at the JVP
      • Ask the patient to relax their head/neck and turn it slightly to the left/right by about 30-45°
      • Observe the pulsation of the JVP.
        • If the JVP is not seen or is very faint, deeply push the upper right quadrant up under the ribcage- this may help to see the JVP (hepatojugular reflex)
      • The JVP is measured, in cm, as the vertical height (NOT direct distance) from the sternal angle
    • You may want to feel the carotid pulse and note characteristics
    • You could auscultate in the neck for bruits now or after auscultation of the chest
  • For full examination of the chest- see here
    • NB In an OSCE, you may only be asked to examine the cardiovascular features i.e. Inspection, palpation of the apex beat/heaves/thrills, auscultation of the heart.
      • You might say that you would also like to auscultate the lungs (particularly the bases)
  • You may also want to examine the peripheral vascular system:
    • Completely expose and look at both legs, comparing left and right for:
      • swelling
      • colour
      • scars
      • dressings
      • pallor
      • loss of hair/nails/toes (or indeed limb)
      • ulcers
      • varicosities
      • venous eczema
      • oedema
      • haemosiderin deposits
      • lipodermatosclerosis – brown/red thickened skin caused by fibrosis of subcutaneous fat
      • “inverted champagne bottle” of the legs – chronic venous insufficiency leading to fibrosis
    • Make sure to inspect the soles of the feet, in between the toes and the toenails for any signs
    • Feel and compare the temperature of both legs
    • Test capillary refill of the big toe
    • Palpate for arterial pulses
      • Dorsalis pedis- dorsum of the foot lateral to the extensor tendon of the great toe
      • Posterior tibial- posterior to the medial malleolus of the tibia
      • Popliteal- taking the weight of the patient’s knee joint at about 45 degrees, feel deep in the popliteal fossa
      • Femoral- midinguinal point, below the inguinal ligament
    • You may also want to palpate any varicosities.  If they are tender, this may be a sign of phlebitis
    • Berger’s test
      • Lift the leg up 45° for 30-60 secs and see if they go pale.  If they do, then drop the leg over the side of the bed
        • If the leg goes a deep red/purple- this is positive test.
          • Reflex hyperaemia- dilation of the peripheral vessels in response to a drop in BP
    • You may also want to test sensation of the lower limb
      • 2 methods- microfilament testing (usually used for diabetic screening) or neurological examination techniques e.g. pin tip/cotton wool (+/- test of vibration and joint position)
        • microfilament testing is probably more appropriate for the glove/stocking loss of sensation seen in diabetes and vascular disease
    • Mention that you would also want to measure the Ankle-Brachial pressure Index (ABPI)
      • Using the sphygmomanometer and a doppler probe (to check for a pulse), you can measure the BP of the lower limb
      • BPleg/BParm = ABPI
        • If <0.9 (+ symptoms of claudication/PAD) or <0.8 (without) suggest arterial disease/obstruction
        • If >1.3, suggests calcification of the arteries/hardening of the arteries
  • Finally, you may also want to examine the abdomen for any pulsatile masses

Investigations

  • ECG
    • +/- Excercise tolerance testing (if intermittent chest pain on exertion)
  • CXR
  • You may want to send the patient to the cath lab for percutaneous coronary intervention (PCI)
    • This may reveal and treat coronary artery blockages
  • Blood tests
    • Troponin (muscle enzymes that are released after muscle infarction)
      • Troponin T (I think) is what is used in Tayside (Troponin I may also be used elsewhere)- normally <40ng/l
      • Troponin levels tend to peak at around 12 hours.  Therefore a level is usually taken ASAP and at 6 hours.  If there is a rise (usually more than double), then this is usually considered a positive test,
    • FBC/U&E (particularly K+)
  • Echocardiogram (particularly if a murmur is heard)
  • CTPA may be used if PE is suspected, as might D-dimers

Differential Diagnosis

  • Cardiac:
    • Ischaemic: stable angina, acute coronary syndrome (ACS), coronary vasospasm (Prinzmetal’s angina), hypertrophic cardiomyopathy, aortic stenosis.
    • Non-ischaemic: arrhythmias, aortic dissection, mitral valve disease,pericarditis.
  • Respiratory: pneumothorax, pulmonary embolism, pneumonia, pleurisy, lung cancer.
  • Musculoskeletal: costochondritis, Tietze’s syndrome, trauma, rib pain (including fracture,bone metastases, osteoporosis), radicular pain, nonspecific musculoskeletal pain (egfibromyalgia).
  • Breast disease.
  • Gastrointestinal: gastro-oesophageal reflux disease (GORD), oesophageal rupture,oesophageal spasm, peptic ulcer disease, cholecystitis, pancreatitis, gastritis.
  • Skin: herpes zoster infection.
  • Psychological, eg anxiety, depression, panic disorder.
  • Others: sickle cell crisis, diabetic mononeuritis, tabes dorsalis

EMERGENCY MANAGEMENT OF CHEST PAIN

  • Manage the patient initially with ABCDE approach
  • Manage appropriately depending on the suspected cause
    • For a tension pneumothorax- decompress ASAP by sticking a needle/venflon into the 2nd intercostal space midclavicular line on the affected side
      • Consider insertion of a chest drain once in hospital/stable
    • For suspected ACS- administer MONA
      • Morphine 2-4mg IV or 5mg IM
      • Oxygen (15l high flow)
      • Nitrates (0.4mg sublingual (crush or spray); 5 microgram/minute IV (increase up to usually ~200 micrograms/min)
      • Aspirin 300mg
    • For acute PE
      • Oxygen and calculate Well’s score
        • CTPA or V/Q scan
          • Massive PE- alteplase 10mg stat and 90mg infusion over 120mins (unless contraindicated)
          • Non-massive- start rivaroxiban 15mg BD for 3 weeks then 20mg BD (OR, if contraindicated, start warfarin/LMWH)
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