Chest Pain

INTRODUCTION

Checkpoints and golden rules

• Chest pain represents an acute coronary syndrome until proved otherwise

• Immediate life-threatening causes of spontaneous chest pain are (1) myocardial infarction, (2) pulmonary embolism, (3) aortic dissection, (4) tension pneumothorax

• The main differential diagnoses of myocardial infarction include angina, aortic dissection, pericarditis, oesophageal reflux and spasm, hyperventilation with anxiety and Tako-tsubo stress-related cardiomyopathy

• History remains the most important clinical factor in diagnosis of ischaemic heart disease. With angina, a vital clue is reproducibility of the symptom.

SITE, RADIATION AND FEATURES OF CHEST PAIN SYNDROMES

Acute coronary syndromes (ACS)

The typical retrosternal distribution is shown in Figure C3. Retrosternal pain or pain situated across the chest anteriorly should be regarded as cardiac until proven otherwise.

The wide variation of sites of pain (e.g. jaw, neck, inside of arms, epigastrium and interscapular) should always be kept in mind. Pain is referred into the left arm 20 times more commonly than into the right arm.

The quality of the pain is usually typical. The patient often uses the clenched fist sign to illustrate a sense of constriction.

The main types of ACS are:

• ST elevated myocardial infarction (STEMI)

• non-ST elevated acute coronary syndromes:

  • – unstable angina

  • – myocardial infarction (myonecrosis)

Angina is described on 30, myocardial infarction on 356.

Key features

Key history This needs to be meticulous because of the life-threatening causes. Analyse the pain into its usual characteristics with the SOCRATES or the SROT-SARA system.

Note family history, drug history, psychosocial history and past history, especially if ...