Chest Pain
Clinical definition
There are many different types of chest pain. These reflect the different associated
underlying organs and their pathologies. More than one cause may be present in the
same patient and one source or its treatment may trigger another.
Clinical Relevance

Chest pain is very common. It is responsible for up to fifteen admissions
per day to Ninewells Hospital. Myocardial infarction is now the most
common causes of death in the UK and other developed countries.
Pneumonia, another cause of chest pain, is an important cause of death in
the over 70 age group.

It may be associated with serious pathology, where medical intervention
is required; for example, pain in the chest is the most common symptom
associated with ischaemic heart disease.

There are a number of causes which may need to be differentiated if the
patient is to be managed appropriately.

Pain in the chest may present as an emergency where immediate action is
required to treat the underlying pathology. The priority is to differentiate
acute myocardial infarction, unstable angina and pulmonary embolism
from other causes of chest pain. These are potentially fatal conditions
whose course may be modified by appropriate early treatment.

Angina often presents in an atypical way as a tightness or heaviness.
Elderly patients can be very vague in the descriptions of their symptoms.
Additionally, patients may present with chest pain in a number of situations such as postoperatively or associated with another illness such as a malignancy. It is important that
you can assess how to manage chest pain in various settings and appreciate the potential
urgency of the management.
Clinical Presentation
There are several types of chest pain and they may present in the following ways:
Description
Tight crushing chest pain
Most Likely Source of
Pain
Heart
Sharp pain worse on a deep Pleura
breath
Burning pain relieved by
food
Lateral localised chest pain
worse on pressing ribs
Oesophagus stomach or
duodenum
Musculoskeletal
Common Conditions
Responsible
Myocardial infarction
Unstable angina
Angina
Pneumonia
Pleurisy
Pulmonary embolism
Reflux oesophagitis
Peptic ulcer
Muscular strain
Fractured ribs
Trauma
Priorities in assessing the patient with chest pain
One of the key priorities in assessing a patient with chest pain is to establish the aetiology of the
pain as the pain may be life threatening. This may not always be initially possible from clinical
history and simple investigations may need to be considered. Usually an electrocardiogram can
assist in the evaluation of chest pain. However, the situation may vary in individual patients and
can be complex when patients have had several episodes of pain. Usually when the implications
of the pain are unclear, the patient is admitted for a short period of observation.
What investigations may be performed?
FBC,U/E, glucose, Thyroid function
Electrocardiogram
Troponin
Chest X Ray
Echocardiogram
Nuclear Medicine Scan (Myocardial Scintigraphy or Lung Ventilation Perfusion Scan)
Exercise Electrocardiography
Coronary Angiography
What are the key differential diagnoses?
Myocardial Ischaemia (with or without infarction)
Reflux Oesophagitis
Musculoskeletal Chest Pain
Pulmonary Thromboembolic Disease
What is the modern management of Chest pain?
The initial management requires immediate identification of those patients with myocardial
infarction with transfer to a coronary care unit where appropriate. Other less severe forms of
chest pain are often managed in a rapid access chest pain clinic where the various differential
diagnoses can be considered and managed in an appropriate way.
Where a patient has a clear myocardial infarction, aspirin should be administered and the patient
transferred to a coronary care unit for immediate thrombolysis if indicated. Additional specialist
investigations may be performed depending on the clinical condition of the patient.
Where the chest pain is not as a result of a myocardial infarction, the patient should be observed
and additional investigations should be considered to diagnose the underlying cause of the
patient’s symptoms. For example, this may include arranging an endoscopy for patients with
symptoms more suggestive of oesophagitis.
What Should I Do and what practical procedures should I be able to do ?
By the end of Phase 3 you should be able to:

Take a full history from a patient with chest pain

Undertake a physical examination

Differentiate between different causes of chest pain in an individual
patient

Interpret the meaning of cardiac enzyme estimations.

Be aware of which investigations are indicated with a view to
differentiating the various causes of chest pain.

Understand the changes of the ECG in ischaemia

Interpret a Chest X-Ray and learn to identify a normal appearance and
common abnormalities such as pulmonary oedema, consolidation or
pneumothorax.

Understand the appropriate management for each cause of chest pain.

Communicate the diagnosis, treatment and future course to the patient
and family.

Communicate appropriate life style advice.

Prioritise the urgency of referral, investigation and treatment of different
causes of chest pain.
To help you achieve this here are some tasks to carry out during Phase 3

In myocardial pain you should see an electrocardiograph (ECG) being
performed and eventually carry out the ECG yourself. You should be
capable of identifying:
 a definite myocardial infarction (MI) on the ECG - (an inferior MI and
an anterior MI)
 common arrhythmias’ e.g. atrial fibrillation - (ventricular tachycardia and
ventricular fibrillation)
 2nd and 3rd degree heart block.

You will find good examples of these in the ECG Made Easy, J R
Hampton, Churchill Livingstone.

In acute coronary syndrome the investigations are for a myocardial
infarction. You should know how to differentiate these conditions and
the appropriate treatment. The key difference in treatment is that an STelevation MI requires treatment with thrombolysis. You should be aware
of the contraindications of thrombolytic therapy.

Angina. The investigations are the same as those for an MI. The key
management differences is that the patient can be sent home when pain
free. Angina patients should have their future risk stratified by an
exercise test or a radionuclide scan. They may also require coronary
angiography.

Pleuritic chest pain. You should clerk in at least 1 patient with pleuritic
chest pain and interpret your findings on examination. A CXR is crucial.
It is often clear in pulmonary embolism and pleurisy and shows
consolidation in pneumonia. You should be able to recognise a localised
abnormality on chest x-ray, make a differential diagnosis and suggest
further investigations. Look at Cuschieri et al P331 and P349 for further
information. If the history is suggestive of PE (post op, history of
malignancy, haemoptysis, DVT present) a ventilation perfusion lung scan
should be performed. You should be able to interpret the significance of
findings on a ventilation/perfusion scan. Out of hours as a house officer
if you are convinced this is a likely diagnosis, you should initiate heparin
therapy and do the scan later. You should understand the advantages and
disadvantages of using low molecular weight heparin.Oesophageal pain.
Oesophageal pain is diagnosed by the characteristic history and
confirmed by endoscopy, manometry, PH monitoring or contrast
radiology. It is important to differentiate cardiac and pleuritic pain from
oesophageal pain as if untreated, the first two may have fatal
consequences.
Additionally heparin/aspirin could have dire
consequences in peptic ulceration.

Musculoskeletal pain. Diagnosed from the history and from springing
the ribs. The treatment is non-steroidal anti-inflammatory drugs
(NSAIDs). A chest x-ray should identify bone causes of chest pain and
these should be further investigated e.g. with a bone scan.
Where Can I Learn About Chest Pain?
You are likely to meet patients with chest pain in the following Phase 3 Blocks:

A & E department, Ward 15 (acute medical ward), Coronary care unit,
Medical wards (wards 1-6), Post op surgical ward and Cardiology outpatient department.

You may also meet patients with chest pain during community
attachment. Severe unrelenting chest pain despite analgesia requires
urgent referral. When MI, PE and unstable angina are suspected, urgent
referral is required as with chest pain after trauma. Musculoskeletal and
oesophageal pain do not require the same urgency. Advanced age should
not be a barrier to this policy.

It will also be one of the topics in your preparation for house officer
block
What is the potential Surgical Managment of Patients with chest pain ?
Patients with chest pain and associated 3 vessel coronary artery disease are often managed
surgically after evaluation of the coronary anatomy. You should understand the various
investigations patients may undergo and how patients are evaluated for coronary artery
bypass surgery. In addition to the surgical management, you should know how to advise
patients to modify their lifestyle by giving up smoking and participating in regular
exercise.
What are the rehabilitation considerations for the patient with Chest Pain ?
The important aspects include regular exercise and cessation of smoking. Various patient
support groups and classes encourage patients to adopt a healthy lifestyle which is an
important aspect of treatment as well as pharmacological therapy.
What drug treatments are available for patients with chest pain ?
The treatments may vary depending on whether the patient has angina or a myocardial
infarction. Aspirin, clopidogrel, oral nitrates, B blockers, ACE inhibitors may be used
depending on individual patient characteristics. Thrombolytic therapy is recommended in
patients with ST elevation myocardial infarction.
Recommended Reading
There are good descriptions of different types of chest pain in your standard texts:

Clinical Medicine by Kumar and Clark (6th edition). Elsevier Saunders,
2005.
Davidson’s Principles and Practice of Medicine (20th edition). Churchill

Livingstone, 2006.
Clinical Surgery (2nd edition).
Rowley. Blackwell, 2003.
Cuschieri, Grace, Darzi, Borley and
Additional information may be obtained via SIGN guidelines 93-7 February 2007.
Look up the references noted below.
Cause of Chest Pain
Angina pectoris
Acute coronary syndrome
Myocardial infarction
Pulmonary embolism
Pneumonia
Pleurisy
Oesophagitis, Gastrooesophageal reflux disease
Musculoskeletal
Further Description
Kumar and Clark P732
Kumar and Clark P808;
European Society for Cardiology Acute Coronary
Syndrome Guidelines 2007 (on Blackboard, particularly
Figs 1 and 14)
Kumar and Clark P812
Kumar and Clark P844
Kumar and Clark P922
Kumar and Clark P952– relevant pages
Kumar and Clark P277
Kumar and Clark P547
Chest Pain
Problem as seen by the Doctor
Problem as experienced by your patient
System links
_____________________
Cardiovascular/Respiratory
Gastroenterology/Musculoskeletal
What a doctor will be able to do:
1
What aspects of the history and examination in a patient with chest pain help
you reach a likely diagnosis to explain the patient’s symptoms?
2
The following are suggested procedures you should be familiar with:

CPR

Venous Access

Electrocardiography
What routine investigations are performed in patients who present with chest
pain ?
3
4
What are the current guidelines on indication and contraindication for the use
of thrombolytic therapy?
5
What issues are important in preventing patients developing myocardial chest
pain ? How might patients and their families be educated to prevent them
developing coronary artery disease ? What treatments are used in the
secondary prevention of myocardial infarction ?
6
How was discussion of the following issues dealt with in talking with the
patient and his/her family?

Driving

Healthy lifestyle changes

Stopping smoking
What evidence is there for lipid lowering, and for control of blood pressure in
the prevention of secondary cardiovascular disease?
7
How a doctor approaches their practice:
8
What are the underlying pathophysiological processes that give rise to the
symptom of chest pain in patients who have ischaemic heart disease ?
9
What, if any, are the legal problems in relation to driving?
10
How would you differentiate serious causes of chest pain from the majority of
non-serious causes presenting in a primary care setting?
Doctor as a professional:
11
12
What were the doctor’s responsibilities in relation to other healthcare
providers?

Early management of your patient in the Community regarding
diagnosis of MI and thrombolysis

Initial management in hospital
How would you organise an audit of patients receiving thrombolytic therapy ?
APPROACHING THE CORE CLINICAL PROBLEM
Chest pain
Clinical Assessment : Onset, site, character, precipitating factors, relieving factors, nature
of the pain. Associated arm pain, vomiting, dizziness.
Investigations : Electrocardiogram, Troponin, FBC, U/E, Chest X Ray. Exercise
Electrocardiography. Specialist investigations.
Differential Diagnoses : Myocardial Ischaemia, Reflux Oesophagitis, Musculoskeletal pain,
pulmonary thromboembolic disease.
Treatment : Thrombolysis for myocardial infarction, H.Pylori eradication for gastrooesophageal disease, anticoagulation for pulmonary thromboembolic disease.
APPROACHING THE CORE CLINICAL PROBLEM
Clinical Definition
Clinical Relevance
Clinical Presentation
Priorities in assessing the patient with the CCP
What investigations would you perform ?
What are the main differential diagnoses ?
What is the modern management of the Core Clinical Problem?
What are the Medical and Surgical Options for the
management of the core clinical problem ?
What issues are relevant for the rehabilitation of the patient
with the core clinical problem ?
What is the recommended drug treatment for the core clinical
problem ?
Linkage of the Core Clinical Problem to the 12 Curriculum
Outcomes.
June 2008
Dear
We are presently in the process of updating the study guides and the approach to the core
clinical problems. In the new curriculum the approach continues to be task based and for
phase 3 students, there is an emphasis on developing diagnostic reasoning skills and
considering aspects of patient management in more detail. Enclosed are 2 of the core clinical
problems which include a task based approach to the assessment, diagnosis and treatment of
the core clinical problems. I would be grateful if you could update your present study guide
for the core clinical problems associated with your system. A template is enclosed with areas
which we would like to include in the upgraded study guides. When reviewing and updating
your study guide, we would be grateful if you would consider this approach to facilitate a
streamlined evaluation of the core clinical problems. As ever, the schedule is fairly tight. As a
result, I would be grateful if you could send back your revised study guide by the ..... This
will enable them to be made available to the students for the next academic year.
Enclosed are 2 study guide examples and the templates/headings which we plan to utilise for
the core clinical problems. Thankyou for your assistance with this. Please do not hesitate to
contact me directly if you need further assistance with this.
Yours sincerely
Neil Gillespie
Senior Lecturer in Medicine (Ageing & Health).