CHEST PAIN

CAUSES AND MANAGEMENT

BRIEF OVERVIEW ABOUT CAUSES OF CHEST PAIN

D.Ds: (from outside to inside)

- Lung: PE/pneumonia/pneumothorax- 3Ps

- Heart: stable/unstable angina- MI- Pericarditis/
Dissecting thoracic aortic aneurysm.
- Oesophagus: GORD- oesophageal motility
- Bone: costochondritis- trauma
- Muscle: myositis- trauma/fall/sport/accidents
- Skin: rash (herpes zoster)
- Trauma
Questions for the cause of each causes:

- Pericarditis: look for:

 Recent viral infection
 Recent TB, use of Anti- TB drugs
 Recent heart attack
 Uraemia

- For MI:
 DESA
 Five conditions (DM, HT, Thyroid, high cholesterol
 Family History

- PE:
 Previous or current DVT (leg pain)
 FH of blood clot and bleeding disorders.
 Recent immobilisation: pelvic surgery/ recent long
travel history
 Use of medications like/ OCP/ HRT/ blood thinners.
 Smoking

- Pneumonia: look for

 Travel history (TB)
 Sexual history and IV drug use (HIV and PCP)
 Contact history.
 Weakened immunity: steroids- chronic conditions- old
age (for underlying Lung Cancer).
Complications:

- For pericarditis:
 Heart failure symptoms: (swelling in feet/tummy/ SOB
when lying flat)
 If persisted: think of Constrictive/Pericardial effusion.

- For MI:
 heart failure
 arrythmia
 stroke
MANAGEMENT OF MI VS UNSTABLE ANGINA

- Admission (Admit if MI. If in suspicion, do not send home

until troponin results are out excluding MI, until then
keep the patient in the observation unit)
- Talk to senior.

- Investigations: basic bloods (FBC, Chol, BS, KFT all) +

ABG+ U&E+ ECG+ serial measurement of Heart Attack
Markers+ CXR (HEC in all chest pain).

- Symptomatic and (lifestyle: later)— with appointment

MONA (O2- GTN- Morphine- Aspirin 300 mg) + when
going home ABCD (check prevention below).

- Specialist: heart specialist: Echo/ angiography-

angioplasty (tube with a camera- through thigh-balloon-
inflated to dilate it & stent).
- Safety netting/Prevention:
o ABCD (Aspirin- Atorvastatin- ACEI- Bisoprolol-
Clopidogrel + DESA)
o No Driving after MI until after 4 weeks for
domestic purposes, 6 weeks if works as a driver.
o Safety net for persistent- complications such as
HF/arrythmia (SOB- swelling of feet/ racing heart-
fever).
- Follow up.
N.B:

ECG Cardiac enzymes

MI (STEMI) ST elevation high
Non-STEMI ------- high
Unstable angina Symptoms at rest, ----------
lasting for longer
than 30 minutes.
Stable angina Symptoms with -------------
exertion only
Relieved by rest
Management of stable angina: in a GP clinic

Clues in the history and findings: (Pain on exertion- last for 5-10
minutes- relived on rest- no sweating/no nausea/no vomiting-
normal ECG- normal heart attack markers)- NO SYMPTOMS OR
PAIN NOW.

- Observe
- Talk to senior.

- Investigations: all basic bloods + HEC (heart attack

makers- ECG- CXR)- clotting profile/KFT/TFT/
Chol/FBS/FBC/U&E.

- Symptomatic:
 GTN when needed+ Aspirin+ statins.
 Control any long-term condition (DM- HT-
Hypothyroidism).
 DESA/stress/ avoid caffeine/avoid cold weather/
avoid exertion/ physical work.
 ABCDG (ABCDG= Atorvastatin+/- ACEI +/-
Bisoprolol+ /-Clopidogrel/Aspirin+ DESA+GTN). (must
have statin + aspirin + GTN).

- Specialist: heart specialist- stress test/exercise test-

Heart scan- Echo for complications and vascular—
angioplasty considered.
 - Safety netting: for chest pain at rest/ not
relived/Sweating/N/V+ medications. (MI).
- Follow up.

Note: comparison of return to physical activities, driving, work

and sex after MI and angina

MI (after intervention) angina

work 2-3 months Nothing
Drive 4 weeks- when you Nothing
are able to do
emergency stop.
-If a driver--- 6wks.
Exercise and 4-6 weeks GTN when
sex needed
MANAGEMENT OF PE
- Admit
- Talk to senior.
- Investigations:
All basic blood + clotting profile/D-Dimer/CTPA- ABG-
U&E) + HEC (heart attack makers- ECG- CXR) +
Doppler US on the leg for the cause (DVT)
- Symptomatic:
O2- IV fluids if in shock- pain killer (morphine) – heparin
(if immediate high risk: start by bolus IV unfractionated
heparin followed by daily LMW heparin SC, if low risk:
LMW SC Heparin only).
- Specialist: chest specialist- haematologist if unprovoked
PE.

- Safety net:
 Persistence of symptoms
 Complications of the condition/prescribed
medication+ (medications: oral blood thinner
(apixaban or Warfarin) + bleeding anywhere/falls.
 Stop the cause: DESA+ HT+ DM+ smoking+
immobilisation (must be well controlled)
 Cause: OCPs/ /HRT/Oestrogen (must be reviewed
by senior and possibly stopped if risks outweigh
the benefit.
 Note: If transgender taking oestrogen, can be
reviewed by Gender Identity Clinic, and possibly
 substituted for patches rather than oral form as
they have less risk for PE.

- Follow up (at anti-coagulation clinic/warfarin clinic).

MANAGEMENT OF PERICARDITIS

 Admission depends on the cause (admit if the cause is

uraemia or post-MI).
 Observe then send home if post-viral- post-TB or due
to Anti-TB.

- Talk to senior.
- Investigations: HEC+ all bloods:
 ECG: saddle shape ST elevation or alternating R waves
(tall and short)).
 CXR: globular shaped heart

- Symptomatic
 Pain killer and anti-inflammatory (NSAID; Ibuprofen).
 If not improving after 14 days---give colchicine
 Still not improving---give steroids.

- Specialist: heart specialist (ECHO) to exclude

complications: heart failure/pericardial effusion/
constrictive peri-carditis. (refer later only if symptoms
persists or complicated).
- Safety net for heart failure/ persistence after few days-
week—send to specialist.

- Follow up with GP/heart specialist (according to severity

and underlying cause).
MUSCLOSKELETAL CAUSE: MYOSITIS/ COSTOCHONDRITIS
Usually, a young patient who has been physically
active/exercising/minor chest wall trauma. Sometimes the patient
has family history of heart attack. Make sure to exclude MI. The
patient can point to specific areas of pain in case of costochondritis
with one finger. Chest wall is tender to touch, and the pain
increases with chest wall movement and respiration. In
costochondritis: tenderness at the costochondral junction.

MANAGEMENT
- Observe then send home after HEC (Heart attack
Markers- ECG- CXR) to exclude MI and other causes
such as pneumonia, pericarditis, fractured rib, etc.
- Talk to senior.
- Investigations: HEC (Heart attack Markers, ECG, CXR)+
basic bloods. All should be normal.

- Symptomatic
 Pain killer (Paracetamol or NSAID; Ibuprofen).
 Ice pack wrapped in a cloth reduces the symptoms.
 Avoid strenuous physical activities until improved, as
it increases the pain.
 If not improving ---specialist referral for steroid
injections or TENS therapy.
- Specialist: refer later only if symptoms persists or new
type of pain.
- Safety net for MI and persistence of symptoms.
- Follow up.
POST- HERPETIC NEURALGIA

Unilateral chest wall pain post- shingles. Pain is either burning

in character or electric shock like. It is irritated by overlying
clothes or touch. It follows dermatomal distribution from the
front and back of chest, but never crosses the midline. More
common in older age groups. If old patient; rule out MI and Lung
Cancer.

MANAGEMENT
- Symptomatic treatment: Pain control is the mainstay
here.
 Local preparation: Lidocaine patches, Local lidocaine
cream/ capsaicin cream (chilli-like natural product).
 Paracetamol if not so severe +/- Codeine. (Co-
Codamol).
 Neuropathic pain management:
o Amitriptyline (TCA antidepressant).
o Anticonvulsants: Gabapentin, Pregabalin.
o Tramadol tablets: if not responding to the above
and codeine.
 Advice:
o Wear loose fitting clothes.
o Cooling by using wrapped ice pack or frozen peas
wrapped in a towel.
- Specialist: if not improving referral to pain clinic
- Safety net for MI, Lung Cancer, mood disturbance and
daily functioning.
- Follow up: it is a long standing and debilitating condition.
It can last for months/years or even lifelong. affect the
patient’s quality of life. Screen for mood changes and
offer support accordingly (CBT- support groups- carers if
cannot carryout daily activities like showering, toileting,
dressing, feeding, groceries, appointments, etc).