Chest pain: Difference between revisions
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==Diagnosis== | ==Diagnosis== | ||
===Workup of emergent chest pain=== | ===Workup of emergent chest pain=== | ||
{{seealso|Acute coronary syndrome}} | |||
{{ | Patients with all of the following findings have sufficiently low risk that even an [[electrocardiogram]] is not needed:<ref name="pmid3970650">{{cite journal| author=Lee TH, Cook EF, Weisberg M, Sargent RK, Wilson C, Goldman L| title=Acute chest pain in the emergency room. Identification and examination of low-risk patients. | journal=Arch Intern Med | year= 1985 | volume= 145 | issue= 1 | pages= 65-9 | pmid=3970650 | doi= | pmc= | url= }} </ref> | ||
* "sharp or stabbing pain" | |||
* "no history of angina or myocardial infarction" | |||
* "pain with pleuritic or positional components or pain that was reproduced by palpation of the chest wall" | |||
In ED patients with chest pain, a structured diagnostic approach with time-focused ED decision points, brief observation, and selective application of early outpatient provocative testing appears both safe and diagnostically efficient, even though some patients with acute coronary syndrome may be discharged for outpatient stress testing on the index ED visit.". <ref name="pmid22221842">{{cite journal| author=Scheuermeyer FX, Innes G, Grafstein E, Kiess M, Boychuk B, Yu E et al.| title=Safety and efficiency of a chest pain diagnostic algorithm with selective outpatient stress testing for emergency department patients with potential ischemic chest pain. | journal=Ann Emerg Med | year= 2012 | volume= 59 | issue= 4 | pages= 256-264.e3 | pmid=22221842 | doi=10.1016/j.annemergmed.2011.10.016 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22221842 }} </ref> | |||
A normal [[electrocardiogram]] has been reported ''not'' to exclude acute coronary syndrome, even when the [[electrocardiogram]] is taken during pain.<ref>{{Cite journal | doi = 10.1111/j.1553-2712.2009.00420.x | volume = 16 | |||
| issue = 6 | pages = 495-499 | last = Turnipseed | first = Samuel D. | coauthors = William S. Trythall, Deborah B. Diercks, Erik G. Laurin, J. Douglas Kirk, David S. Smith, David N. Main, Ezra A. Amsterdam | |||
}}, | | title = Frequency of Acute Coronary Syndrome in Patients with Normal Electrocardiogram Performed during Presence or Absence of Chest Pain | journal = Academic Emergency Medicine | accessdate = 2009-06-13 | date = 2009 | url = http://dx.doi.org/10.1111/j.1553-2712.2009.00420.x }}</ref> Although this study defined unstable angina as either a coronary stenosis or positive stress test and so likely includes patients without true acute coronary syndrome as defined by the American Heart Association<ref name="pmid17692738">{{cite journal |author=Anderson JL, Adams CD, Antman EM, ''et al.'' |title=ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-Elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction) developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine |journal=J. Am. Coll. Cardiol. |volume=50 |issue=7 |pages=e1–e157 |year=2007 |month=August |pmid=17692738 |doi=10.1016/j.jacc.2007.02.013 |url=http://linkinghub.elsevier.com/retrieve/pii/S0735-1097(07)00511-6 |issn=}}</ref>, the study was still not able to show that a normal electrocardiogram helped exclude a NSTEMI. | ||
[[Computed tomographic cardiac angiography]] may reduce the rate of [[hospital admission]]s according to a [[randomized controlled trial]]:<ref name="pmid22449295">{{cite journal| author=Litt HI, Gatsonis C, Snyder B, Singh H, Miller CD, Entrikin DW et al.| title=CT angiography for safe discharge of patients with possible acute coronary syndromes. | journal=N Engl J Med | year= 2012 | volume= 366 | issue= 15 | pages= 1393-403 | pmid=22449295 | doi=10.1056/NEJMoa1201163 | pmc= | url= }} </ref> | |||
* Patients: [[Thrombolysis in Myocardial Infarction (TIMI) risk score]] 0 - 2, with normal [[electrocardiogram]], but the emergency room physician thought that "admission or objective testing to rule out an acute coronary syndrome." 4% of patients had a coronary stenosis ≥ 70% | |||
* Intervention: [[Computed tomographic cardiac angiography]] | |||
* Comparison: usual care | |||
* Outcome: resource use and diagnosis of [[coronary artery disease]] ( ≥ 50%) | |||
* Result: | |||
** Increased diagnosis of [[coronary artery disease]] (9% vs 3.5%) | |||
** Increased rate of discharge from the emergency room (50% vs. 23%) | |||
===First categorization=== | ===First categorization=== | ||
Latest revision as of 11:25, 5 June 2014
In medicine, chest pain is "pressure, burning, or numbness in the chest."[1] Chest pain can be caused by an extremely wide range of conditions, including some, such as myocardial infarction, which, if untreated, could lead to death within minutes or hours. Other causes may be less urgent, while others can indicate self-limiting disease. There are idiopathic chest pain syndromes that have no apparent cause.
Diagnosis
Workup of emergent chest pain
- See also: Acute coronary syndrome
Patients with all of the following findings have sufficiently low risk that even an electrocardiogram is not needed:[2]
- "sharp or stabbing pain"
- "no history of angina or myocardial infarction"
- "pain with pleuritic or positional components or pain that was reproduced by palpation of the chest wall"
In ED patients with chest pain, a structured diagnostic approach with time-focused ED decision points, brief observation, and selective application of early outpatient provocative testing appears both safe and diagnostically efficient, even though some patients with acute coronary syndrome may be discharged for outpatient stress testing on the index ED visit.". [3]
A normal electrocardiogram has been reported not to exclude acute coronary syndrome, even when the electrocardiogram is taken during pain.[4] Although this study defined unstable angina as either a coronary stenosis or positive stress test and so likely includes patients without true acute coronary syndrome as defined by the American Heart Association[5], the study was still not able to show that a normal electrocardiogram helped exclude a NSTEMI.
Computed tomographic cardiac angiography may reduce the rate of hospital admissions according to a randomized controlled trial:[6]
- Patients: Thrombolysis in Myocardial Infarction (TIMI) risk score 0 - 2, with normal electrocardiogram, but the emergency room physician thought that "admission or objective testing to rule out an acute coronary syndrome." 4% of patients had a coronary stenosis ≥ 70%
- Intervention: Computed tomographic cardiac angiography
- Comparison: usual care
- Outcome: resource use and diagnosis of coronary artery disease ( ≥ 50%)
- Result:
- Increased diagnosis of coronary artery disease (9% vs 3.5%)
- Increased rate of discharge from the emergency room (50% vs. 23%)
First categorization
- If there is a history of chest trauma, go to chest trauma. Note that chest trauma can still have major physiologic effects on the heart and lungs
- If the patient is hypotensive orin shock begin emergency hypotension protocol, unless the patient is also in acute distress from pain or dyspnea; if so, begin immediate acute cardiac syndrome care
- Consider:
- Aortic dissection
- Leaking aortic aneurysm
- Myocardial infarction with vagotonia
- If the patient also exhibits central venous hypervolemia (e.g., jugular venous distention), consider:
- If central venous hypervolemia is not present, consider:
- Consider:
Non-emergent chest pain
- chostochondritis
- anxiety
- gout and pseudogout
- Abdominal injury or disease with referred pain
- Herpes zoster
- Acromioclavicular injury
- Anxiety
- Lung cancer
- Sternoclavicular joint injury
Treatment
Strong analgesics such as morphine are usually indicated in sudden, severe chest pain, with care to avoid depressing respiration. If the etiology is cardiac, morphine may improve survival as well as relieve pain.
Since chest pain is a symptom rather than a disease, diagnosis and treatment need to focus on the underlying disease(s).
Idiopathic chest pain
Among patients who have chest pain without any identifiable cause, antidepressants, either tricyclic antidepressants[7] or second-generation antidepressants[8] may reduce pain.
References
- ↑ Anonymous (2024), Chest pain (English). Medical Subject Headings. U.S. National Library of Medicine.
- ↑ Lee TH, Cook EF, Weisberg M, Sargent RK, Wilson C, Goldman L (1985). "Acute chest pain in the emergency room. Identification and examination of low-risk patients.". Arch Intern Med 145 (1): 65-9. PMID 3970650. [e]
- ↑ Scheuermeyer FX, Innes G, Grafstein E, Kiess M, Boychuk B, Yu E et al. (2012). "Safety and efficiency of a chest pain diagnostic algorithm with selective outpatient stress testing for emergency department patients with potential ischemic chest pain.". Ann Emerg Med 59 (4): 256-264.e3. DOI:10.1016/j.annemergmed.2011.10.016. PMID 22221842. Research Blogging.
- ↑ Turnipseed, Samuel D.; William S. Trythall, Deborah B. Diercks, Erik G. Laurin, J. Douglas Kirk, David S. Smith, David N. Main, Ezra A. Amsterdam (2009). "Frequency of Acute Coronary Syndrome in Patients with Normal Electrocardiogram Performed during Presence or Absence of Chest Pain". Academic Emergency Medicine 16 (6): 495-499. DOI:10.1111/j.1553-2712.2009.00420.x. Retrieved on 2009-06-13. Research Blogging.
- ↑ Anderson JL, Adams CD, Antman EM, et al. (August 2007). "ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-Elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction) developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine". J. Am. Coll. Cardiol. 50 (7): e1–e157. DOI:10.1016/j.jacc.2007.02.013. PMID 17692738. Research Blogging.
- ↑ Litt HI, Gatsonis C, Snyder B, Singh H, Miller CD, Entrikin DW et al. (2012). "CT angiography for safe discharge of patients with possible acute coronary syndromes.". N Engl J Med 366 (15): 1393-403. DOI:10.1056/NEJMoa1201163. PMID 22449295. Research Blogging.
- ↑ Cannon RO, Quyyumi AA, Mincemoyer R, Stine AM, Gracely RH, Smith WB et al. (1994). "Imipramine in patients with chest pain despite normal coronary angiograms.". N Engl J Med 330 (20): 1411-7. PMID 8159194.
- ↑ Lee H, Kim JH, Min BH, Lee JH, Son HJ, Kim JJ et al. (2010). "Efficacy of venlafaxine for symptomatic relief in young adult patients with functional chest pain: a randomized, double-blind, placebo-controlled, crossover trial.". Am J Gastroenterol 105 (7): 1504-12. DOI:10.1038/ajg.2010.82. PMID 20332772. Research Blogging.