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Chest pain

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

InvestigationSignificance
Serial ECG every 20 min while pain ongoingSTEMI – 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
VBGHigh lactate – low perfusion status
Serial high sensitivity troponinEvery 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 #

  1. Call a MET call 
  2. Obtain ECG
  3. IV access
  4. If hypoxic give oxygen aiming for SpO2 >92% (or 88-92% if a chronic CO2 retainer)
  5. If hypotensive give IV fluid resuscitation
  6. Investigate as above
  7. 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 #

  1. 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 
  2. 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).  
  3. 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.  
  4. MacDuff A, Arnold A, Harvey J. Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. Thorax. 2010;65(Suppl 2):ii18–ii31.  
  5. Pericarditis [Internet]. Therapeutic Guidelines. 2018 [cited 2022Oct29]. Available from: https://www.tg.org.au/ 
  6. 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 
  7. 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 
  8. 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.  
  9. Chew DP, Scott IA, Cullen L, French JK, Briffa TG, Tideman PA, et al. National Heart Foundation of Australia &amp; 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.  
  10. 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

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