Approach To A Patient Presenting With Chest Pain

Introduction:
Always take chest pain seriously. It may reflect life-threatening illness. Triage patients with chest pain as ‘urgent’ and ensure that they are seen within a few minutes. Ischaemic heart disease is understandably the first diagnosis to spring to mind in the middle-aged or elderly, but chest pain may have a variety of other disease processes, many of which are also potentially life-threatening.

The differential diagnosis of chest pain:

Common causes

• Musculoskeletal (eg costochondritis)
• Acute coronary syndrome
• Pneumothorax
• Oesophagitis
• Pneumonia
• Pulmonary embolism

Less common causes

• Aortic dissection
• Cholecystitis
• Herpes zoster
• Oesophageal rupture
• Pancreatitis
• Vertebral collapse

Reaching the correct conclusion requires accurate interpretation of the history, examination and investigations, bearing in mind recognized patterns of disease presentations.

History

Characterize the pain

• Site (eg central, bilateral or unilateral).

• Severity.

• Time of onset and duration.

• Character (eg ‘stabbing’, ‘tight/gripping’, or ‘dull/aching’).

• Radiation (eg to arms and neck in myocardial ischaemia).

• Precipitating and relieving factors (eg exercise/rest/GTN spray).

• Previous similar pains.

Enquire about associated symptoms Breathlessness, nausea, and vomiting, sweating, cough, haemoptysis, palpitations, dizziness, loss of consciousness.

Document past history, drug history, and allergies. 

Quickly consider contacting cardiologists if acute coronary syndrome (ACS) is likely.

Examination and resuscitation

• Evaluate Airway, Breathing, Circulation (ABC) and resuscitate (O 2 , venous access, IV analgesia) as appropriate. 
• Listen to both lung fields and check for tension pneumothorax and severe left ventricular failure (LVF). 
• Complete full examination.

Investigations

These depend upon the presentation and likely diagnosis, but an ECG and CXR are usually required. Remember that these may initially be normal in MI, PE and aortic dissection. Ensure that all patients receive ECG monitoring in an area where a defibrillator is readily available.