Table of Contents
Overview #
- Chest pain is potentially serious and should be addressed urgently and escalated early
- Red flag differentials to exclude include acute coronary syndromes (ACS), pulmonary embolism (PE), pneumothorax and aortic dissection
Differentials #
- Cardiac(1)
- Acute coronary syndrome (unstable angina, NSTEMI, STEMI)
- Stable angina
- Myocarditis
- Pericardium
- Pericardial effusion
- Pericarditis
- Vascular
- Aortic dissection
- Pulmonary embolism
- Pulmonary
- Pneumothorax
- Pleural effusion
- Pneumonia
- Pleurisy
- Gastrointestinal
- Gastroesophageal reflux disease
- Oesophagitis
- Gastritis/peptic ulcer disease
- Pancreatitis
- Oesophageal spasm
- Musculoskeletal
- Rib fractures
- Costochondritis
- Muscular tics
- Muscular strains
- Skin
- Shingles
- Spinal
- Radiculopathy
Assessment #
- Obtain an ECG as soon as possible
- Conduct a focused history and primary survey in parallel
Key Clinical Features of Important Causes of Chest Pain
- ACS (2)
- Diaphoretic (sp 70%)
- Central crushing chest pain radiating to left shoulder, jaw, neck (sn 62-72%)
- Palpitations (sp 66-77%)
- Cardiovascular risk factors
- Pulmonary Embolism (3)
- Shortness of breath with visible distress (73%)
- Pleuritic, sharp chest pain (44%)
- Unilateral pain and swelling of lower limb (44% of patients with PE have calf or thigh pain)
- DVT risk factors
- Pneumothorax (4)
- Asymmetrical lung expansion
- Hyperresonance of affected lung field
- Diminished breath sounds of affected side on auscultation
- Pericarditis (5)
- Pleuritic chest pain that is worse when lying down, and relieved when leaning forward
- Pericardial friction rub on auscultation
- Aortic dissection (6)
- Systolic blood pressure ≥20mmHg between left and right arms
- Radial-radial delay
- Neurological deficits
- Sharp central chest pain that may radiate through to the back
- Diastolic decrescendo murmur
Investigations #
Initial investigations
Investigation | Significance |
Serial ECG every 20 min while pain ongoing | STEMI – ST elevation >1 mm in contiguous limb leads or >2 mm in continuous chest leads or new LBBBNSTEMI – ST depression or T wave inversionSinus tachycardia – pulmonary embolismCardiac tamponade – electrical alternansPericarditis – widespread saddle shaped ST elevation, PR depression |
FBE, UEC, CMP, LFT | |
VBG | High lactate – low perfusion status |
Serial high sensitivity troponin | Every 6 h until peak observedA single normal troponin may be sufficient if chest pain present for >6 h |
Chest Xray (CXR) | Pneumonia – consolidationPneumothorax – visceral pleural edge, tracheal deviationAortic dissection – widened mediastinum, double or irregular aortic contour, deviation of mediastinal structuresPericardial effusion – water bottle sign (heart)Rib fracture |
HEART pathway for acute chest pain [link to MD Calc]
Consider if ACS is suspected. Discuss with a senior clinician.
Not suitable in patients with new ST-segment elevation ≥1 mm or hypotension.
- If HEART Score ≤3:
- If initial troponin 0 point and serial troponin at 3 hours negative, consider early discharge
- If initial troponin 1-2 points and serial troponin at 3 hours positive, consider admission with cardiology consult
- If HEART Score >3:
- If initial troponin 0 point and serial troponin at 3 hours negative, consider Short Stay Unit admission for further workup
- If initial troponin 1-2 points and serial troponin at 3 hours positive, consider admission with cardiology consult
Pulmonary embolism workup (7)
Note: Only serves as a guide. Should not replace clinical judgement. Discuss with senior clinician if concerned or uncertain
- Wells score for pulmonary embolism [link to MD Calc]
- If Wells’ score <2, proceed to PERC score
- If Wells’ score 2-4, proceed to D-dimer
- If Wells’ score >4, proceed to CTPA (or V/Q scan)
- Revised Geneva score (an alternative to Wells score without incorporating gestalt) [link to MD Calc]
- If Geneva score ≤3, proceed to PERC score
- If Geneva score 4-10, proceed to D-dimer
- If Geneva score >10, proceed to CTPA (or V/Q scan)
- PERC score (to rule out PE if pre-test probability is low) [link to MD Calc]
- If PERC = 0, PE is unlikely
- If PERC >0, proceed to D-dimer
- D-dimer (97% sn for VTE) (8)
- If D-dimer is normal, PE is unlikely
- If D-dimer is elevated, proceed to CTPA (or V/Q scan)
- CTPA or V/Q scan
- If no evidence of PE, PE is unlikely
- If evidence of PE, diagnosis is confirmed
Further investigations
- CRP if suspecting infection
- Lipase if suspecting pancreatitis
- CTA of the aorta if suspecting aortic dissection
Management – unstable vitals #
- Call a MET call
- Obtain ECG
- IV access
- If hypoxic give oxygen aiming for SpO2 >92% (or 88-92% if a chronic CO2 retainer)
- If hypotensive give IV fluid resuscitation
- Investigate as above
- Initiate initial management based on clinical suspicion
Management – if ACS suspected #
- Escalate to a senior doctor immediately
Aim to completely relieve ischaemic pain
1. Oxygen – only if SpO2 <93% (aim 88-92% if a chronic CO2 retainer) (9) AND 2. Glyceryl trinitrate 300-600 microg sublingual every 5 min up to 3 doses OR 400-800 microg spray every 5 min up to 3 doses (9)CONTRAINDICATIONS – phosphodiesterase-5-inhibtior (sildenafil, vardenafil, tadalafil) used within 24h, or 48h with tadalafil; hypotensionCAUTION – inferior STEMI (associated with RV infarction) If pain unrelieved 3. Glyceryl trinitrate* 10microg/min IV infusion, increasing by 10microg/min every 3 min until pain relieved (10)CONTRAINDICATIONS – as for sublingual GTN If pain unacceptably severe 4. Morphine 2-4 mg IV every 5-15 minCAUTION – may worsen AMI outcomes |
Antiplatelet therapy
Aspirin 300 mg PO dissolved or chewed, then 100mg PO daily thereafter (9)CONTRAINDICATIONS – active bleeding, renal impairment, allergy to NSAIDs |
Further management will be required if acute coronary syndrome is confirmed.
Management – GORD #
1. Magnesium hydroxide and aluminium hydroxide 10-20 mL PO QID PRN Consider adding 2. Esomeprazole 20 mg PO daily OR pantoprazole 40 mg PO daily |
References #
- Hollander JE, Chase M. Evaluation of the adult with chest pain in the emergency department [Internet]. UpToDate. 2022 [cited 2022Oct29]. Available from: https://www.uptodate.com/contents/evaluation-of-the-adult-with-chest-pain-in-the-emergency-department
- DeVon HA, Rosenfeld A, Steffen AD, Daya M. Sensitivity, specificity, and sex differences in symptoms reported on the 13‐item Acute Coronary Syndrome Checklist. Journal of the American Heart Association. 2014;3(2).
- Stein PD, Beemath A, Matta F, Weg JG, Yusen RD, Hales CA, et al. Clinical characteristics of patients with acute pulmonary embolism: Data from PIOPED II. The American Journal of Medicine. 2007;120(10):871–9.
- MacDuff A, Arnold A, Harvey J. Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. Thorax. 2010;65(Suppl 2):ii18–ii31.
- Pericarditis [Internet]. Therapeutic Guidelines. 2018 [cited 2022Oct29]. Available from: https://www.tg.org.au/
- Black JH, Manning WJ. Clinical features and diagnosis of acute aortic dissection [Internet]. UpToDate. 2022 [cited 2022Oct29]. Available from: https://www.uptodate.com/contents/clinical-features-and-diagnosis-of-acute-aortic-dissection
- Skinner S. Pulmonary embolism: Assessment and imaging [Internet]. Australian Family Physician. The Royal Australian College of general Practitioners; 2013 [cited 2022Oct29]. Available from: https://www.racgp.org.au/afp/2013/september/pulmonary-embolism
- Chunilal SD, Brill-Edwards PA, Stevens PB, Joval JP, McGinnis JA, Rupwate M, et al. The sensitivity and specificity of a red blood cell agglutination D-dimer assay for venous thromboembolism when performed on Venous Blood. Archives of Internal Medicine. 2002;162(2):217.
- Chew DP, Scott IA, Cullen L, French JK, Briffa TG, Tideman PA, et al. National Heart Foundation of Australia & Cardiac Society of Australia and New Zealand: Australian clinical guidelines for the management of acute coronary syndromes 2016. Heart, Lung and Circulation. 2016;25(9):895–951.
- Acute coronary syndromes [Internet]. Therapeutic Guidelines. 2018 [cited 2022Oct29]. Available from: https://www.tg.org.au/
Contributors
Reviewing Consultant/Senior Registrar
Dr Jahin Ahmed, Dr Cheng Xie
Dr Tsung Chung