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)