Chest Pain
Note: This information is for preceptors only. Students are asked to not access this information and to
respect this restriction as an honor code issue.
Learning Objectives:
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Define the accuracy of the initial EKG, labs, etc., in the diagnosis of cardiac disease in the ED or
office
Define the role and significance (or lack thereof) of risk factors such as diabetes, family history,
smoking and hypertension in the decision of whether or not to admit a patient for cardiac disease
Define the roles of various diagnostic tests in the diagnosis of possible pulmonary embolism
Discuss the differential diagnosis of chest pain
Suggested Readings:
Green LA, Rodgers PE, Chest Pain (Chapter 9). In: Sloan PD, Slatt LM, Ebell MH, Smith MA, eds.
Essentials of Family Medicine, 6th ed. Philadelphia, PA: Wolters Kluwer/Lippincott, Williams and Wilkins,
2012, 99-112. Note: This is the required text for the FM Preceptorship.
Panju AA, et al. Is This Patient Having a Myocardial Infarction? JAMA 1998;280:1256-63.
http://jama.jamanetwork.com/data/Journals/JAMA/4579/JRC80000.pdf (verified
06/20/12)
Ebell, MH, Evaluation of Chest Pain in Primary Care Patients. Am Fam Physician. 2011 Mar 1; 83
(5):603-605. http://www.aafp.org/afp/2011/0301/p603.html (verified 06/20/12)
CASE 2
55 year old man with no prior history of cardiac disease presents stating he feels as though he is going to
die. He notes chest pain that reached a maximum intensity about 10 minutes after it started. It is
described as a pressure that radiates to his left arm. He complains of dyspnea, is diaphoretic and
appears in distress. He has a long history of smoking and hypertension but a negative family history.
When questioned, the patient notes that he also has a past history of depression but has been fine for the
past 10 years or so. His job is stressful but no more than usual, and he usually handles things pretty
well. His blood pressure is 142/94. 02 saturation is 97% on room air and his pulse is about 130. His pain
is not reproducible.
Question 1: What signs and symptoms does this patient display that are consistent with cardiac
disease?
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chest pressure
radiation
diaphoresis
feeling of impending doom
dyspnea
crescendo pattern of pain
tachycardia
Question 2: What signs and symptoms does this patient have that are associated with panic
disorder?
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"going to die"
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dyspnea
tachycardia
Question 3: What would you do for this patient?
Subjective discussion about whether he should be admitted to rule out MI or not. According to the
referenced clinical decision rule, he would be a moderate risk patient, necessitating an EKG evaluation
and either stress testing or serial troponin levels.
If he does have ischemia/infarction, Aspirin has proven strong benefit in reducing mortality. IV beta
blockers are contraindicated in unstable patients due to increased risk for cardiogenic shock, but they
may have a net benefit for stable patients. Oral beta blockers can reduce death and reinfarction rates
and should be initiated within 24 hours if there is no sign of CHF. Metoprolol is preferred over atenolol.
ACE inhibitors are indicated within 24 hours and may reduce mortality in patients who have an MI.
Heparin adds little benefit. Nitroglycerin reduces preload and afterload and provides good pain relief.
Morphine reduces pain and anxiety. Oxygen and bed rest are often used but are not proven to be
beneficial. Reperfusion therapy (thrombolytic or emergent PCI) is essential in patients with ST elevation,
new LBBB, or ST depression in anterior precordial leads. Thrombolytic therapy must be initiated within 6
hours of symptom onset (perhaps 12 hours) if there are no contraindications. PCI should occur within 90
minutes of patient presentation.
Treatment for chronic CAD would include continued aspirin and beta blocker therapy, smoking cessation,
lipid management, long-acting CCBs, avoidance of NSAIDs. Revascularization may be indicated based
on angiogram results.