Definition

Chest pain can be of multiple etiologies with certain urgent etiologies that must be ruled out quickly. All patients with chest pain should be seen and evaluated.

Differential Diagnosis

• Cardiac:
  • Myocardial infarction: usually “pressure” pain associated with dyspnea, dizziness, nausea and radiation to the neck/arm.  MI can present atypically in women and those with diabetes.
  • Aortic dissection: “tearing” pain, associated with hypertension, unequal pulses and discordant blood pressure between both arms.
  • Pericardial tamponade: associated with hypotension, tachycardia, muffled heart sounds.
  • Pericarditis: pleuritic chest pain that improves when leaning forward, associated with a friction rub and diffuse ST elevations.
• Pulmonary:
  • Pneumothorax: sudden onset, associated with COPD, intubated patients on positive pressure ventilation and after central line placement. Decreased breath sounds.
  • Pulmonary embolism: sudden onset, sharp and pleuritic in nature, associated with tachypnea, tachycardia, hypoxia and potentially hypotension.
  • Pleurisy: due to irritation of the pleura from etiologies such as pneumonia, empyema or chest tubes.
• Other:
  • Gastrointestinal:
    • Gastritis/peptic ulcer disease/GERD: burning sensation, associated with dyspepsia.
    • Esophageal spasm: “squeezing” sensation that follows the path of the esophagus.
  • Musculoskeletal:
    • Costochondritis: often reproducible on exam with palpation.
    • Rib fractures: reproducible on exam, localized, crepitus often present.

Evaluation

• Obtain a full set of vital signs, paying attention to hypoxia, hypotension/hypertension and changes in baseline heart rate in particular. Check BP in both arms.
• Obtain a 12-lead ECG first, and evaluate it for ischemia.
• Examine the patient: cardiac exam (new murmurs, evidence of CHF), pulmonary exam (absent or diminished breath sounds-->PTX), tracheal deviation (tension PTX), asymmetric lower extremity edema (DVT-->PE?) and peripheral pulses (if unequal consider aortic dissection).
• Direct exam and initial tests towards likely etiology. Consider CXR, CT chest, labs including cardiac biomarkers.

Management

• Acute coronary syndrome:
  • Consult cardiology for urgent catheterization for patients with STEMI, refractory pain on maximal nitroglycerin, or an unstable arrhythmia. Otherwise, your goal is to start medical management and get the patient chest pain free.
  • Antiplatelets: Aspirin 325mg to be chewed/swallowed. Ticagrelor 180mg load followed by 90mg BID or Clopidogrel 600 mg followed by 75 mg daily. Avoid starting Ticagrelor/Clopidogrel in patients who may require CABG/urgent surgery. Often this is institution specific.
  • Anticoagulation: Heparin drip for 48-hours or until cardiac catheterization.
  • Statin: Atorvastatin 80mg.
  • β-blocker: Metoprolol tartrate 12.5mg q6H and uptitrate to keep HR <60 and decrease myocardial oxygen demand. Use caution if blood pressure is marginal and in patients with bradycardia or heart failure.
  • Symptomatic treatment: Sublingual nitrates (0.4mg SL NTG q5min X3 doses, hold for SBP<100), oxygen only as needed (supplemental oxygen can be deleterious). Morphine only as needed for severe pain.
    • Use nitrates with caution in those who potentially have moderate-severe aortic stenosis (causes decrease in preload leading to hypotension and decreased cardiac output).
  • See: Cardiology: Management of suspected acute coronary syndrome.
• Aortic Dissection:
  • Diagnosis: CT angiogram, MR angiogram, transesophageal echocardiogram.
  • Transfer to ICU and consult cardiothoracic surgery. Type A dissections are a surgical emergency, but Type B dissections are usually managed medically.
  • Goals of acute management include HR and BP control to decrease vessel wall stress. Start with a β-blocker (i.e. labetalol or esmolol drip). Target HR <60 and SBP 100-120. If HR is controlled but BP still above goal, add a vasodilator such as nicardipine or nitroprusside. 
  • Avoid hydralazine due to reflex tachycardia.
  • ECG may show evidence of ischemia if the dissection is proximal, but is often non-specific.
• Pneumothorax:
  • CXR to evaluate for size, evidence of mediastinal shift.
  • Tension PTX: if suspected (hypotension, tachycardia, tracheal deviation), place 14g angio-catheter below the 2nd intercostal space in the mid-clavicular line on the anterior chest wall of the affected side. A “rush” of air may be heard and vital signs should improve.
  • Cardiothoracic and general surgery should be consulted for placement of chest tube.
• Pulmonary Embolism:
  • In a moderate-risk patient (as calculated by a PE-risk stratification score), you can send a D-dimer. If positive, you should get a CT pulmonary angiogram (CTPE).
  • If PE is very likely, go straight to CT angiogram.
  • For treatment, see: Pulmonary: Pulmonary Embolism

Key Points

• Always rule out myocardial infarction and ischemia in any patient with chest pain.
• Tension PTX, myocardial infarction, aortic dissection are medical emergencies and must be identified and managed quickly.
• Always consider pulmonary embolism.
• Narrowing the differential diagnosis based on exam and history is key to the management of chest pain.
• Chest pain relieved with nitrates is not always of a cardiac origin.

Lee TH, Goldman L. Evaluation of the patient with acute chest pain. N Engl J Med 2000;342:1187-1195.

Henrikson CA, Howell E, Bush DE, et al. Chest pain relief by nitroglycerin does not predict active coronary artery disease. Ann Intern Med 2003;139:979-986. 

Amsterdam EA, Wenger NK, Brindis RG, et al. 2014 AHA/ACC Guideline for the Management of Patients with Non-ST-Elevation Acute Coronary Syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines [published correction appears in J Am Coll Cardiol. 2014 Dec 23;64(24):2713-4. Dosage error in article text]. J Am Coll Cardiol. 2014;64(24):e139-e228. doi:10.1016/j.jacc.2014.09.017