Chest pain
Sam speaks to Dr Adele Pope, advanced cardiology trainee at Auckland Hospital, about how to attack the most common, and often the most uncertain, ward call.
Differential
- Life threatening
- ACS
- PE
- Dissection
- Cardiac tamponade
- Pneumonia
- Pneumothorax
- Oesophageal bleed
- Heart
- Pericarditis
- Lungs
- Mechanical (foreign body, surgical, chest drain, post-pleurocentesis)
- Oesophagus
- Reflux
- Oesophagitis
- Oesophageal spasm
- MSK
- Musculoskeletal
- Costochondritis
- Rib fracture
- Below the chest
- Upper abdominal pain
- Above the chest
- Anxiety
Approach
- Eyeball the patient
- ABCs
- Calling a code
- 777 (or your local hospital emergency number)
- This is Sam, medical house officer. I need the adult resus team to attend North Shore Hospital, ward 10, room E3.
- Calling a code
- History
- SOCRATES (site, onset, character, radiation, associated symptoms, timing, exacerbating factors, severity)
- Previous similar episodes? History of exertion chest pain?
- Diaphoresis
- Shortness of breath
- Review of systems
- Identify risk factors
- Vitals + Examination
- General inspection + peripheries
- Aiming to identify red flags of hypotension, reproducibility on palpation and respiratory issues
- Abdomen, calves, catheter and drains (for completeness)
- ECG
- Take your time and be systematic
- Look at an old ECG
- Ischaemic ECG defined as STEMI, or any T wave inversion, ST depression, Q waves.
- Look for contiguous and reciprocal abnormalities.
- T wave change normal variants occur in III, aVR, V1.
- A repeat ECG in 15 minutes is useful to identify dynamic changes.
- Consider investigations
- FBC, U&E, troponin
- CXR if failure or respiratory issues are within your differential (not so useful for ACS, but unlikely to harm)
- Management
- Call for help (code or at least registrar support)
- Attach continuous monitoring e.g. defibrillator pads
- Re-assess stability of the patient
- Oxygen only if hypoxic
- GTN spray
- Opiate analgesia (IV morphine boluses ideally)
- Determine bleeding risk
- Identify any anti-platelet and anti-coagulation medicines in use
- Post-operative status
- Consider loading with aspirin 300 mg PO
- Document
- Review past notes
- Basics (date/time/name/reason for review)
- Positives and pertinent negatives
- Impression and differential with justification. Have you eliminated life threatening conditions?
- Consider TIMI or HEART score (acknowledging use outside of ED)
- Clear and specific plan
- Consider discussion with senior and escalation, especially if called back to patient again
Specificity of chest pain symptoms and examination findings [Evidence]
Fanaroff AC, Rymer JA, Goldstein SA, Simel DL, Newby LK. Does This Patient With Chest Pain Have Acute Coronary Syndrome?The Rational Clinical Examination Systematic Review. JAMA. 2015;314(18):1955–1965. doi:10.1001/jama.2015.12735
- No single finding rules in or rules out acute coronary syndrome.
- The most specific (convincing) symptoms of ACS were:
- Pain radiation to both arms (specificity, 96%; LR, 2.6 [95% CI, 1.8-3.7]).
- Pain similar to prior ischaemia (specificity, 79%; LR, 2.2 [95% CI, 2.0-2.6]).
- Change in pain pattern over the prior 24 hours (specificity, 86%; LR, 2.0 [95% CI, 1.6-2.4]).
- Moderately helpful:
- Worse with exertion (specificity, 73-77%; LR, 1.5 – 1.8).
- Diaphoresis (specificity, 79-82%; LR, 1.3 – 1.4).
- Dyspnoea (specificity, 45%; LR, 1.1 – 1.3).
- Unhelpful, but classical symptoms:
- Response to nitroglycerin – improvement or lack of improvement had likelihood ratios approaching 1.0.
- Pleuritic pain had an LR range of 0.35 to 0.61.
- Palpitations LR 0.37 – 1.3.
- Hypotension was the strongest clinical sign (LR, 3.9 [95% CI, 0.98-15]), though the CI was broad and did not exclude 1.0.
- Of all risk factors, symptoms, and signs, pain reproduced by palpation lowered the likelihood of ACS most (LR, 0.28 [95% CI, 0.14-0.54]).
- ECG abnormalities
- ST elevation → STEMI
- ST depression was most specific for ACS (LR, 5.3 [95% CI, 2.1-8.6]).
- TwI was not so reliable (LR, 1.8 [95% CI, 1.3-2.7]).
- Take your time and draw on the ECG, and if it looks concerning, call for help.
Tamponade
- Causes
- Infection
- Trauma
- Tumour
- Aortic dissection
- Cardiac surgery
- Beck’s triad (suggestive of tamponade)
- Hypotension
- Jugular vein distension
- Absent/distent heart sounds
- Treatment is fluids and urgent pericardiocentesis
Troponin
- TnI binds to actin to hold troponin-tropomyosin; lasts 7-10d
- TnT: binds to tropomyosin; lasts 10-14d
- Normally undetectable, ↑ suggests myocardial damage. Very sensitive + specific.
- TnI and TnT can ↑ in renal failure and other ischaemic causes (rule out w/ Exercise Stress Test or angiography)
- Rises 3 hours post-MI, persisting up to 7-14 days >66% increase = reinfarct