Trigger: Chest Pain

Discussion:

1. Definition:
Chest Pain:
a. defined as the presence of abnormal pain or discomfort in the chest, between the
diaphragm and the base of the neck.
b. Pain described as pressure, fullness or tightness on the chest
c. Crushing or searing pain on the chest that radiates to the back, neck, jaw, shoulder and
arms.
d. A general term for any dull, aching pain in the thorax. It can be cardiac or non-cardiac
related.
e. Localized sensation of discomfort or distress at chest.

2. Problem Identification.
a. How strenuous is the physical activity required to elicit symptoms?

b. History of the behavior of pain, what precipitates it and what relieves it?

3. What are the causes of chest pain?

Ischemia:

a. Structures involved:
1. Myocardial cells
2. Afferent cardiac nerves
3. Thoracic ganglia
4. Spinal Cord
5. Spino-thalamic tract
6. Thalamus
7. Cortex

This chest pain originate from several different structures within the chest, including the skin,
ribs, intercostal muscles, pleura, esophagus, heart, aorta, diaphragm, or thoracic vertebrae. The
pain may be transmitted by intercostal, sympathetic, vagus, and phrenic nerves.

b. Pathophysiology:
1. Myocardial ischemia develops when coronary blood flow becomes inadequate
to meet myocardial oxygen demand.
2. This cause ischemic episodes to excite local chemosensitive and
mechanoreceptive receptors that, in turn, stimulate release of adenosine,
bradykinin, and other substances that activate the sensory ends of sympathetic
and vagal afferent fibers.
3. The afferent fibers traverse the nerves that connect to the upper 5 thoracic
sympathetic ganglia and upper 5 distal thoracic roots of the spinal cord.
 4. From there, impulses are transmitted to the thalamus.
5. Within the spinal cord, cardiac sympathetic afferent impulses may converge
with impulses from somatic thoracic structures leading to chest pain.
6. In addition, cardiac vagal afferent fibers synapse in the nucleus tractus solitaries
of the medulla and then descend to the upper cervical spinothalamic tract, and
this route may contribute to angina pain experienced in the neck and jaw.
c. Cause or Etiology:
 Precipitated by an imbalance between myocardial oxygen supply and
myocardial oxygen consumption due to atheromatous plaque that obstructs
one or more of the epicardial coronary arteries.

(1) Stable (2) Unstable angina (3) MI

Condition Definition Quality Location Assoc. Features

Stable Angina characterized by Pressure, Retrosternal; S4 gallop or
ischemic episodes tightness, often radiation mitral
that are typically squeezing, to neck, jaw regurgitation
precipitated by heaviness, shoulders, or murmur (rare)
superimposed burning arms; during pain
increase in sometimes S3 or rales if
oxygen demand epigastric severe ischemia
during physical or complication
activity and of myocardial
relieved upon infarction
resting.

Precipitated by
exertion, cold, or
stress

2-10 minutes

Unstable Manifest by self- Pressure, Retrosternal; S4 gallop or

Angina limited angina tightness, often radiation mitral
chest discomfort squeezing, to neck, jaw regurgitation
that is exertional heaviness, shoulders, or murmur (rare)
but occurs at burning arms; during pain
increased sometimes S3 or rales if
frequency with epigastric severe ischemia
progressively or complication
lower intensity of of myocardial
physical activity infarction
or even at rest.

Marked ischemic
 symptoms at rest,
with minimal
activity, or in an
accelerating
pattern, unstable
ischemic heart
disease is
classified as
unstable angina
when there is no
detectable
myocardial injury
and as non-ST
elevation MI
(NSTEMI) when
there is evidence
of myocardial
necrosis

When there is
rupture or
erosion of one or
more
atherosclerotic
lesion triggers
coronary
thrombosis.
When acute
coronary
atherothrombosis
occurs, the
intracoronary
thrombus may be
partially
obstructive.

Presence or
absence of
detectable
myocardial injury
and presence or
absence of ST-
segment
elevation in ECG.
MI More severe, not Pressure, Retrosternal; S4 gallop or
relieved by rest. tightness, often radiation mitral
squeezing, to neck, jaw regurgitation
When the heaviness, shoulders, or murmur (rare)
 coronary burning arms; during pain
thrombus is sometimes S3 or rales if
acutely and epigastric severe ischemia
completely or complication
occlusive, of myocardial
transmural infarction
myocardial
ischemia usually
ensues, with ST-
segment
elevation on the
ECG and
myocardial
necrosis leading
to a diagnosis of
ST-elevation MI
(STEMI)

Usually longer
than 30 minutes.

Gastroesophageal Reflux
a. Structures involved:
 Lower esophageal sphincter
b. Pathophysiology:
 Normally the lower esophageal sphincter has to close as soon as the food
passes through it. If the sphincter doesn’t close all the way such in decrease
lower esophageal sphincter tone, or if it opens too often such as in increase
 intra-abdominal pressure acid proceeded by the stomach will move up into
the esophagus. It can cause symptom such as burning and chest pain,
c. Causes/Etiologies:
 Prolonged alcohol consumption
 Smoking
 Caffeine
 Obesity
 Pregnancy

Condition Definition Quality Location Assoc. Features

GERD Gastroesophageal Burning Substernal, Worsened by
Reflux Epigastric postprandial
Disease (GERD) is recumbency;
a digestive relived by
disorder that antacids
occurs when
acidic stomach
juices, or food
and fluids back up
from the stomach
into the
esophagus.

10-60 minutes

POTENTIALLY SERIOUS CAUSES OF CHEST PAIN

Myocardial Ischemia: Angina Pectoris- Substernal pressure, squeezing, constriction, with radiation often
to left arm; usually on exertion, especially after meals or with emotional arousal. Characteristically
relieved by rest and nitroglycerin.

Acute Myocardial Infarction - Similar to angina but usually more severe, of longer duration (≥30 min),
and not immediately relieved by rest or nitroglycerin. S3 and/or S4 may be present.

Pulmonary Embolism -May be substernal or lateral, pleuritic in nature, and associated with hemoptysis,
tachycardia, and hypoxemia.

Aortic Dissection - Very severe, in center of chest, a sharp “ripping” quality, radiates to back, not
affected by changes in position. May be associated with weak or absent peripheral pulses.

Mediastinal Emphysema- Sharp, intense, localized to substernal region; often associated with audible
crepitus.

Acute Pericarditis- Usually steady, crushing, substernal; often has pleuritic component aggravated by
cough, deep inspiration, supine position, and relieved by sitting upright; pericardial friction rub often
audible.
Pleurisy- Due to inflammation; less commonly tumor and pneumothorax. Usually unilateral,Nknifelike,
superficial, aggravated by cough and respiration.

LESS SERIOUS CAUSES CAUSES OF CHEST PAIN

Costochondral Pain- In anterior chest, usually sharply localized, may be brief and darting or a persistent
dull ache. Can be reproduced by pressure on costochondral and/or chondrosternal junctions. In Tietze’s
syndrome (costochondritis), joints are swollen, red, and tender.

Chest Wall Pain- Due to strain of muscles or ligaments from excessive exercise or rib fracture from
trauma; accompanied by local tenderness.

Esophageal Pain- Deep thoracic discomfort; may be accompanied by dysphagia and regurgitation.

INITIAL INQUIRY STAGE.

Name:
Age:
Work of patient: why?  would most likely have revealed important diagnostic clues regarding the nature
of this patient's illness
- Assess the patient’s level of activity in their occupation (sedentary jobs are associated with increased
cardiovascular risk).
- If the patient is experiencing chest pain and works with heavy machinery or at heights, it is important
to advise them to take time off work until they have been fully investigated.
Address:
# of Admission:

HPI
Onset
- When did the pain first start? And How long did the pain last for?
Reason : important component in making diagnosis

Location
- Where is the location of pain?
Reason: location is very important for the etiology of pain.

Character
- How did the patient describe the pain?
- Is the pain constant or does it come and go?

Radiation
-Does the pain spread elsewhere?

Associated symptoms
- Are there any other symptoms that seem associated with the pain?

Time course
- Did the pain has changed over time:
Reason: This question can be useful to determine if the chest pain has become progressively worse over
time.
An example might be a patient describing chest pain that was initially only present during exertion which
is now also present at rest (e.g. unstable angina).

Exacerbating or relieving factors

- Does anything make the pain worse?
- Does anything make the pain better?

Severity
- I would like to ask for the pain scale to asses the severity of pain doc..
- Assess the severity of the pain by asking the patient to grade it on a scale of 0-10:
“On a scale of 0-10, how severe is the pain, if 0 is no pain and 10 is the worst pain you’ve ever
experienced?”
This allows you to assess the patient’s response to treatments (e.g. pain was initially 8/10 and improved
to 3/10 with GTN spray).

Family history
-Do any of your parents or siblings have any heart problems?
*at what age the disease developed (disease developing at a younger age is more likely to be associated
with genetic factors)

Social history and economic history

-the type of accommodation they currently reside in (e.g. house, bungalow) and
-if there are any adaptations to assist them (e.g. stair lift)
-who else the patient lives with and their personal support network

Smoking
- Smoking increases the risk of cardiovascular disease (e.g. myocardial infarction, angina), venous
thromboembolism (e.g. pulmonary embolism) and pneumonia.
- Record the patient’s smoking history, including the type and amount of tobacco used.
- Calculate the number of ‘pack-years‘ the patient has smoked for to determine their cardiovascular risk
profile: pack-years = [number of years smoked] x [average number of packs smoked per day] one pack is
equal to 20 cigarettes

Recreational drug use

Ask the patient if they use recreational drugs and if so determine the type of drugs used and their
frequency of use. Recreational drugs may be the underlying cause of a patient’s presentation with chest
pain symptoms:
Diet
Ask if the patient what their diet looks like on an average day. Take note of unhealthy foods which are
known to contribute to cardiovascular disease (e.g. high salt intake, high saturated fat intake).
Exercise
Ask if the patient regularly exercises and if so clarify the frequency and activity type of exercise.