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:




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 1
A 35 year old woman comes to clinic with a 1 hour history of chest pain and diaphoresis that began while
she was sitting at her desk. She describes a pressure radiating to both arms. She is a smoker. No
history of hypertension, diabetes, or family history of cardiac disease. She has a normal blood pressure.
She blames the diaphoresis on the fact that it is hot outside with a high humidity, and she has just walked
in from the parking lot. She looks relatively calm and comfortable. She has no murmurs, gallops or rubs
on exam. Lungs are clear. She has no tenderness. Her EKG shows nonspecific ST-T changes without
other abnormalities.
Question 1: What is the differential diagnosis of chest pain?













chest wall pain, musculoskeletal, costochondritis
aortic dissection - > 60, HTN, severe pain with normal EKG
aortic stenosis: angina/dyspnea/syncope
pericarditis
myocarditis
GERD, esophageal dysmotility, spasm, esophagitis
pulmonary embolus
pulmonary hypertension
pulmonary parenchymal: pneumonia, cancer, sarcoid, pneumothorax
pleuritic (pneumothorax, viral pleuritis, pneumonia)
psychogenic/panic
referred pain – gallbladder
cardiac ischemia
o ischemia
o
o
o
stable angina
acute MI
Prinzmetal (variant) angina
Question 2: What is the differential of cardiac chest pain?
Note: One-third of cardiac patients have no chest pain!



stable angina
unstable angina
acute MI acute coronary syndrome
o unstable angina and acute MI acute coronary syndrome = acute coronary syndrome
Unstable angina is:





rest angina
crescendo angina
change in angina pattern
new angina
perioperative angina
Question 3: What historical features help you better characterize it as cardiac versus noncardiac
chest pain? What is this patient’s risk according to the clinical decision rule in the Ebell article?
Assess risk factors (diabetes, hyperlipidemia, family history of premature CAD, smoking, obesity,
hypertension) is useful in prevention and long term prediction but are not useful in discriminating cardiac
from noncardiac causes in the acute setting.
Cardiac
Non-cardiac
Quality of Pain squeezing, tightness, pressure,
sharp/stabbing: - pleuritic or
constriction, strangling, burning, heartburn, musculoskeletal, reproducible by palpation:
fullness, lump, heavy (elephant)
musculoskeletal tearing: aortic dissection
Region
hard to localize, often left-sided, substernal, localizes pain with one finger
or epigastric
Radiation
radiating to one or both arms
not
Time and
course
gradual onset
seconds or constant pain sudden and severe
- pneumothorax and aortic dissection
Provocation
exertion
swallowing: esophogeal spasm
postprandial: GRO
stress: anxiety
body position: (movement: musculoskeletal,
pleuritic, pericarditis
breathing: pulmonary or pleuritic
Palliation
nitroglycerin
rest
antacids: GI
lean-forward position better:
pericarditis
worse lying down: pleuritic
Severity
NOT useful
NOT useful
Associated
Symptoms
Nausea/vomiting, diaphoresis, dyspnea,
syncope
cough, chest wall tenderness, palpitations,
anxiety/fear
This patient would fall into the low risk classification (her pain is not reproducible).
Question 4: Which has the highest likelihood ratio of being associated with cardiac disease, right
arm radiation, left arm radiation or pain to both arms?
Pain may radiate to neck, throat, lower jaw, teeth and upper extremity, shoulder. Wide extension
increases odds for chest pain of cardiac origin.
Radiation to both arms is a stronger predictor of cardiac chest pain.
Question 5: What physical findings increase the likelihood that chest pain is due to a cardiac
source?
Hypotension - S3 -
Pulmonary crackles – Diaphoresis - (Dyspnea is not a strong indicator!)
Question 6: What lab tests or other studies do you want to order and how will you use the results
in your decision making?





Serial EKG – 20% are normal in unstable angina – look for new LBBB, new ST elevation >0.5
mm or ST depression >1 mm in two or more leads, T wave hyperacuity or inversion in two or
more leads, or Q waves to indicate acute cardiac ischemia
o ST/TW changes – ischemic
o ST elevation in V1 – V3 – anteroseptal (LAD)
o ST elevation in V4 – V6 – apical/lateral
o ST elevation in II, III, AVF – inferior (RCA + LCX)
o reciprocal ST ¯ V1 – V3 – posterior
o diffuse ST - pericarditis – new LBBB
CXR – look for cardiomegaly, pulmonary disease, mediastinal widening, fracture, mass,
pneumothorax
Serial enzymes
o myoglobin
o CK MB – low sensitivity till 4-12 h after onset of pain
o Troponin sensitive, specific, early rise in MI (within 6 hours)
Stress testing
o Stress EKG (exercise or pharmacologic)
o Thallium (Mi perfusion)
o stress echo
o angiogram
Response to therapy – nitroglycerin can improve pain in cardiac ischemia or esophageal spasm,
antacids help in GI causes
Question 7: How might women present differently than men? What are special challenges with
female patients in the evaluation of chest pain?
Women are more likely to have "atypical chest pain" (often pain in the neck, back, or epigastrium).
Women and their physicians often don’t recognize these symptoms as cardiac.
Women have a high false positive rate on exercise stress testing. Experts recommend using immediate
radionuclide imaging or stress echocardiography.
Question 8: How might the presentation change for a diabetic patient? An elderly patient?
Diabetic patients often feel little or no pain. Elderly patients often have shortness of breath instead of
pain. Patients over 65 often have unreliable results on stress ECG testing as well.
Question 9: How would you manage this patient?
According to the clinical decision rule presented in the Ebell article, this patient should be evaluated for
noncardiac causes of chest pain unless there are other reasons for concern. An EKG may have been
avoided in this patient, though many physicians would order one anyway. Because this was ordered, it
may prompt following the moderate risk pathway with a nonconcerning EKG (serial troponins). This does
not add any statistical value to the analysis, but it may help reassure a worried patient or provide
opportunities for education about lifestyle modification.