CHEST PAIN

A Chest pain always needs to be diagnosed with all seriousness always. There is an urgent need to diagnose the cause of any patient presenting with chest pain to ensure that serious and life-threatening conditions are not missed. Urgent hospital referral is indicated if there is any indication of a severe underlying disorder or of the patient being acutely unwell.

Chest pain is a common symptom,

Cardiac:

Ischemic: stable angina, acute coronary syndrome (ACS), coronary vasospasm, hypertrophic cardiomyopathy, aortic stenosis.
Non-ischemic: arrhythmias, aortic dissection, mitral valve disease, pericarditis. Respiratory: pneumothorax, pulmonary embolism, pneumonia, pleurisy, lung cancer.

Assessment

Our first aim is to exclude a life-threatening cause, which needs immediate attention, from other causes of chest pain. Diagnosis of chest pain is difficult but the history often gives an indication of the underlying cause. As the patient walks into the consultation chamber we usually look for general appearance/status, including any confusion, anxiety, shortness of breath, pain, distress, whether pale or sweaty, and any vomiting. If there is any suspicion of ACS or other serious cause, or any concern regarding the patient's general well being, we arrange urgent hospital assessment and admission.

History

Any Pain of radiation nature (type, frequency, severity), onset, duration, variation with time, modifying factors (eg, exercise, rest, eating, breathing or medication) and any previous episodes is noted.
Associated symptoms may be useful in determining the underlying cause but may be nonspecific (eg, breathlessness may be associated with a cardiac, musculoskeletal, respiratory or psychological cause)
Breathlessness, cough, haemoptysis may indicate a respiratory or a cardiac cause of chest pain. Excessive sweating may be associated with shock.
Palpitations, dizziness, and syncope increase the likelihood of a cardiac cause and imply the need for hospital admission - but palpitations may be associated with anxiety.
Consider the presence of any risk factors for ischaemic heart disease. We refer to any previous ECGs for comparison and any previous cardiac investigations (where available).

Examination

Vital signs are taken including blood pressure measurement in both arms. A detailed cardiovascular and respiratory examination is done, looking particularly for signs of cardiac failure or dysrhythmia.

Investigations

Within primary care, non-acute chest pain:

  • Resting ECG
  • CRP
  • Fasting lipids
  • Glucose

Note:

A resting ECG is normal in over 90% patients with recent symptoms of angina. If an urgent ECG is considered necessary on clinical grounds, admission to hospital is usually required. Additional tests if a non-cardiac cause is suspected - eg, CXR, LFTs and amylase, 2DEcho, abdominal ultrasound.