Section 5

Chest Pain

by Asaad S Shujaa
Introduction
Chest pain is one of the most common symptoms presented in the emergency
department (ED), and it is worrisome because the differential diagnosis widely
range between non-emergent conditions and life-threatening conditions such as
acute coronary syndromes (ACS), pulmonary embolism (PE), aortic dissection,
pericarditis with tamponade, pneumothorax, and esophageal rupture. Chest pain
caused by non–emergent conditions include esophageal reflux, peptic ulcer, biliary
colic, muscle strain, costochondritis, pleurisy, pneumonia and non-specific chest
wall pain.

It is important as emergency physicians to have an approach to chest pain that

enables one to recognize life-threatening conditions from non-emergent
conditions. This chapter aims to discuss how to approach a patient with chest
pain.

Currently, we do not have data regarding how many patients visit the ED with
chest pain in the Middle East; however, in the USA, approximately 6 million
patients visit ED with chest pain, which accounts for almost 9% of all ED cases.
This makes it the second most common complaint in ED visits.

Audio is available here

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General Approach to Patient with Chest Pain shock. Also, unequal BP in both arm or pulse deficient indicates

in Emergency Department aortic dissection.

The general appearance of the patient

“As a general rule, any chest pain is ischemic in • Looks sick or not sick or

origin until proven otherwise.” • Patient in pain or not in pain

Initial Approach Electrocardiogram (ECG): To interpret myocardial ischemia,

Airway, Breathing and Circulation (ABC) assessment
• Assessment of the airway by being able to talk without distress,
no obvious upper airway obstruction such as tongue swelling,
lip swelling, hoarseness, etc.
arrhythmias,  pericarditis, and right ventricular strain findings for
PE.
Any abnormality found in the initial approach may need
immediate actions.

• Assessment of breathing by listening to the pulmonary sounds. History

Is it equal or wet (basal crackles indicate CHF)? What types of questions would you like to ask?

• Assessment of circulation by listening to heart sounds. Are • Are you having discomfort, chest pain?
there any S3,4 gallop rhythm (CHF) or new murmurs such as
mitral regurgitation (papillary muscle dysfunction). • How would you describe it?

• Checking the pulses, capillary refill to understand the shock • Where is it?
situation.
• Does it radiate anywhere?
Vital signs should be assessed and repeated at regular intervals.
• Frequency?
For example, respiratory distress with low O2 saturation may
indicate pulmonary edema, plus low BP indicates cardiogenic • Time of onset or acute worsening?

• Has there been any progression?

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• Any aggravating/alleviating factors? Table 3.9 History taking for chest pain

• Any associated symptom?

• Diaphoresis, nausea, vomiting, cough, fever

• History of cardiopulmonary disease?

• Risk factors  for coronary disease such as hypertension,

diabetes, high cholesterol, obesity, male, family history,
smoker, sedentary, post-menopausal, previous history of
ACS and family history of CAD.

• Risk factors for pulmonary embolism  such as travel history,

oral contraceptive use etc.  And risk factors for other critical
diagnoses.

Physical Examination
• Repeat assessment of the airway, breathing, and circulation
with full examination steps.

• Assess abdomen for tenderness and pulsating mass

• Look for swelling in legs (lower limb edema), calf tenderness

(deep vein thrombosis).

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Bedside test
ECG
ECG is the main bedside test for any chest pain patient.
What is your opinion about below ECGs in patients with different
type of chest pain?
Image 3.12 Case – 54 yo female presented with 3 days
history of right side chest pain (pleuritic).
• ECG is more useful as ‘rule in’ than ‘rule out.’
• 1 2 l e a d E C G f o r myocardial infarction and 15 lead
ECG for posterior myocardial infarction
• Any ST elevation in 2 contiguous leads should be evaluated
as S.T. Elevation M.I. However, please do remember, there
are many other problems can elevate S.T. segment.
• Any other changes such as ST depression, T inversion and Q
wave should be evaluated

• In Acute Myocardial Infarction ECG has 50% sensitivity, 90%

specificity.

• 12 lead ECG for PE may show S1 Q3 T3 sign (prominent S

Image 3.13 Case – 46 yo male presented with
central chest pain. He has nausea and diaphoresis.
wave in the lead I, Q wave and inverted T wave in the lead III). It
is a sign of acute right ventricular strain (acute pressure and
volume overload of the right ventricle because of pulmonary
hypertension). Other ECG findings noted during the acute
phase of a PE include new right bundle branch block (complete
or incomplete), rightward shift of the QRS axis, ST-segment
elevation in V1 and aVR, generalized low amplitude QRS
complexes, atrial premature contractions, sinus tachycardia,
atrial fibrillation/flutter, and T wave inversions in leads V1-V4.

• The ECG is often abnormal in PE, but findings are neither

sensitive nor specific for the diagnosis of PE. The greatest utility

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 of the ECG in a patient with suspected PE is ruling out other
life-threatening diagnoses such as acute myocardial infarction.
• Some aortic dissection cases may also show ST-segment
elevation as in acute myocardial infarction.
• ECG may also help  to diagnose pericarditis, especially chest
pain patients with fever.
Laboratory tests
Cardiac markers
• Troponin I or T rise within 3-6  hours and then remain elevated
for about one week
• Serial testing improves sensitivity
• In acute coronary syndrome suspicion, an increased Troponin is
a marker for increased risk of AMI and death
• However, cardiac enzymes do not diagnose cardiac ischemia
D-dimer
• Only use is in a low-risk patient
• A negative test makes PE very unlikely
• A slightly positive test is a positive test
Others
Complete blood count, ESR, C reactive protein, blood
culture, and lactate may help to rule out some infections such as
pericarditis or mediastinitis because of esophageal rupture.  But,
their value in the acute setting is questionable.
Imaging modalities
Chest X-Ray
• To look for heart failure and evaluate for other cause of chest
pain such as Aortic Dissection, pneumothorax, pneumonia etc.
• Widened mediastinum, abnormal aortic knob, pleural effusions
for aortic dissection. These findings are not sensitive for the
aortic dissection. Only 25% of the patients have wide
mediastinum.
• Esophageal rupture signs in chest X-ray; Hydropneumothorax,
Pneumothorax, Pneumomediastinum, Subcutaneous
Emphysema, Mediastinal widening without emphysema,
Subdiaphragmatic air and Pleural Effusion.
What is your opinion about below chest x-ray in a patient with
chest pain?
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Image 3.14 Case – 58 yo male presented with 1 day history CT scan
of sudden onset lef side chest pain radiating to left shoulder. • CT with contrast shows large, central emboli, it is also very
sensitive for aortic dissection.

• In the suspicion of esophageal rupture, contrast-enhanced CT

scan of the chest should be obtained if it is not possible to
obtain a contrast esophagogram, if the esophagogram was
negative, despite a high clinical suspicion, or if seeking to
evaluate for a more likely alternative diagnosis. Perforation may
be suggested by mediastinal air, extravasated luminal contrast,
peri-esophageal fluid collections, pleural effusions, or actual
communication of an air-filled esophagus with an adjacent
mediastinal air-fluid collection. Definitive esophageal
communication with outside structures is often difficult to
visualize.

• The pulmonary angiogram is the gold standard for PE and aortic

dissection but carries a risk of contrast-induced nephrotoxicity
and anaphylactic contrast reaction.

V/Q scan
It is very sensitive but not specific for patients with suspected PE.
Bedside ultrasound 
• RUSH protocol evaluates aorta and pericardial space to rule out Depending on your history, physical exam and bedside
tamponade (video) investigations as well as laboratory and imaging results, the focus
should be given to rule out myocardial ischemia or infarction,
• Consider Doppler ultrasound to see deep vein thrombosis in
pulmonary embolus, pneumothorax, pericarditis with tamponade,
legs (video)
aortic dissection, and esophageal rupture. Each of this specific

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disease entities has various risk stratification methods, treatment
options, and dispositions. Now, it is time to look to some cases
and discuss more specific management in the ED. Case 1 – Critical Bedside Actions and General
Approach
Case 1 Place the patient in a monitored bed, make sure security
A 46-year-old male with a history of diabetes mellitus, chamber established (monitor, IVs, oxygen, etc.)
hypertension, and coronary artery disease presents to the ED. He
ABC intact
is a smoker. He complains of chest tightness and heaviness. The
symptom started gradually 3 hours ago and lasts 20 minutes Vitally stable except he has tachycardia (HR: 110)
when he was watching TV. The pain scale was 5/10, radiated to
Quick History and Physical Examination as described in the
his jaw. The pain is associated with nausea and sweating. He
text. Chest exam: Equal air entry, no wheeze or crackles
took Nitroglycerin spray, and the pain was relieved. The pain
started again before he reached the ED. The pain scale is 10/10. CVS exam: S1+S2 no additional sound, no murmur, JVP was
The initial assessment at triage: ABC intact, BP: 140/80, HR: 110 normal
RR: 24, O2Sat: 98% on room air, Temperature: 37.3, Random
Blood Sugar: normal. No lower limb edema, pulses for four limb present and equal

12 lead ECG shows inferior ST-elevation myocardial infarction

Image 3.15 ECG case 1
Consult cardiologist as soon as possible

Patient in pain needs analgesia

Aspirin 300 mg was given by EMS

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Case 1 – Differential Diagnoses
There are six life-threatening differential
diagnoses for any chest pain patients.
These consist of:
1. Myocardial ischemia or infarction (MI)
2. Pulmonary embolus (PE)
3. Pneumothorax
4. Pericarditis with tamponade
5. Aortic dissection
6. Esophageal rupture
Case 1 – History and Physical
Examination Hints
• The chest pain is typical angina pain
(heaviness radiating to jaw associated
with nausea and sweating), the pain is
not sharp such as in PE or tearing like
in aortic dissection
• The patient has cardiac risk factors
(DM, HTN, CAD, Smoker, and MI 1 year
ago)
• No PE risk factors
• The history does not suggest any past Case 1 – Emergency
esophageal rupture Treatment
• Aspirin should be given immediately
• Physical exam not lead to cardiogenic
shock or pulmonary edema • Great benefit, little risk
• No sign of pneumothorax in the exam • Give the minimum of 182 mg
• Pulses all equal for four limbs and no • Rapid decisions on reperfusion
inequality in BP in both arms, which
• Based on ECG only (PCI vs.
does not go with aortic dissection
Fibrinolysis)
• ECG suggested Inferior MI, no sign of
• Antiplatelet options:
pericarditis in ECG
• Heparin (LMWH versus
Case 1 – Emergency Diagnostic
unfractionated)
Tests and Interpretation
• ECG suggested Inferior MI, no sign of • Clopidogrel
pericarditis in ECG
• Symptomatic / pain control
• Portable CXR: normal which rules out
• GTN    Vasodilator also reduces
pneumothorax and aortic dissection (no
preload
wide mediastinum)
• Troponin I is high, which suggests • Can give SL or IV
Myocardia Ischemia
• Morphine for pain control and reduce
• In bedside echocardiography, there is anxiety and stress
hypokinetic in the inferior wall and no
• Secondary prevention
sign of cardiac tamponade
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 • B-Blocker, statins and ACE inhibitor
Case 1 – Disposition Decision
Assess the risk stratification by using
TIMI score
Case 1 – Admission criteria
• Establish risk level using the TIMI
scoring system
• Moderate risk: Admit for further
evaluation; add beta blockers, ACE
inhibitors. Follow cardiac enzyme
levels. If MI ruled out, exercise stress
test before discharge
• High Risk: Admit for cardiac
catheterization
Case 1 – Discharge criteria
• Low-risk TIMI score: May be
discharged after symptom control and
follow up with cardiologist outpatient
for the stress test and lipid profile test
Case 1 – Referral
• Cardiology
Case 2
A 30-year-old male had an open
reduction and internal fixation (ORIF) of
right ankle fracture 2 weeks ago. C/O
sudden onset of chest pain today. He has
pleuritic sharp chest pain associated with
short breath, increased during inspiration.
Initial assessment at triage
• ABC intact
• Vital signs
• BP 120/80
• Pulse 120
• RR 40
• O2 sat 88% on room air
• T 36.5
• 12 ECG shows sinus tachycardia, T
inversion V2,3 and 4, deep S lead I and
Q and T inversion in the lead III, St
elevation V1 and V4R suggested
pulmonary embolism
Case 2 – Critical Bedside
Actions and General Approach
• O2 Supply and monitor bed
• ABC intact
• Vitally stable except he is tachycardia
(HR 120)
• The quick history that suggested the
patient had a major surgery 2 weeks
ago and was immobilized 2 weeks.
• Physical examination shows
• Chest exam: Equal air entry, no
wheeze or crackles
• CVS exam: S1+S2 no additional
sound, no murmur, JVP was normal
• There is calf swelling in right site of
surgery, pulses for 4 limbs present
and equal
• To do 12 lead ECG shows sinus
tachycardia, T inversion V2,3 and 4,
deep S lead I and Q and T inversion in
the lead III, St elevation V1 and V4R
suggested pulmonary embolism
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• Patient in pain need analgesia
Case 2 – Differential Diagnoses
1. Pulmonary embolus (PE)
2. Myocardial ischemia or infarction (MI)
3. Pneumothorax
4. Pericarditis with Tamponade
5. Aortic dissection
6. Esophageal rupture
Case 2 – History and Physical
Examination Hints
• The chest Pain is atypical angina pain
(sharp, pleuritic chest pain increased by
inspiration and associated with
shortness of breath, no radiation), the
pain is not angina pain OR no tearing
pain as in aortic dissection
• There are PE risk factors (major surgery,
immobilization 2 weeks)
• The history does not suggest any
previous Esophageal rupture
• Physical exam not lead to pneumonia
no crackles in chest exam
• No sign of pneumothorax in the exam
• Pulses all equal for four limbs and no
inequality in BP in both arms, which
does not go with aortic dissection
• ECG suggested PE, no sign of
pericarditis in ECG
Case 2 – Emergency Diagnostic
Tests and Interpretation
• ECG suggested Pulmonary embolism,
no sign of pericarditis in ECG
• Portable CXR: normal which rules out
pneumothorax and aortic dissection (no
wide mediastinum)
• D- Dimer is high
• Cardiac enzymes are negative
• Bedside echocardiography there is
signs of right ventricle enlargement and
strain and no sign of cardiac
tamponade
Case 2 – Emergency
Treatment
• Heparin (Will limit propagation but does
not dissolve clot)
• Unfractionated: 80 u/kg bolus, 18 h/
kg/hr.
• Fractionated (Lovenox): 1 mg/kg SC
BID
• Fibrinolysis
• Consider with large if the patient is
unstable
• No study has shown a survival
benefit, but it is very difficult to study.
• Alteplase 50–100 mg infused over 2–
6 hrs (bolus in severe shock)
Case 2 – Disposition
If there is suspicious of PE, we need to
do pre-test probability; there are multiple
systems for doing this. Most widespread
and validated is Well’s score
There is a difference in Well’s score for PE
& DVT
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PE – Well’s criteria Case 2 – Referral 200/100 on the left arm, tachycardia
• ICU (HR 110)
• 3 points for:
• Unstable Patient, massive PE, • Quick history which suggested sudden
• PE ‘most likely diagnosis onset central chest pain, described as
Bilateral PE
• Signs and symptoms suggesting ripping his chest and radiating to the
• Medical Ward
DVT back, no associated symptoms.

• Stable patient with Small PE

• 1.5 points for: • Physical examination shows:

• PR>100,
• history (PE/DVT),
• immobilization in 2 weeks
• 1 point for:
• Hemoptysis or malignancy
Risk Stratification
• <2 low risk (10%), D-Dimer is good to
rule out PE
• 2-6 medium risk (25%), Spiral CT chest
with contrast to rule out PE
• >6 high (50%), start
anticoagulation(LWMH) and Spiral CT
chest with contrast
Case 3 • Chest exam: Equal air entry, no
A 60-year-old male patient presented to wheeze or crackles
the ED with sudden onset central chest
pain, described as ripping his chest and • CVS exam: S1+S2, a grade 2/6
s y s t o l i c m u r m u r, a n d a s o f t
radiating to the back, no associated
symptoms and patient, previous history decrescendo diastolic murmur are
with HTN, CAD, and smoker. Initial heard at the second right intercostal
assessment by EMS was ABC intact. space. JVP was normal
Vitals were BP 190/95 Right arm, Pulse
• There is radial to radial pulsation
110, RR 20 , T 37 , O2sat 98%.
delay
Case 3 – Critical Bedside • There are abdominal and bilateral
Actions and General Approach femoral bruits, with absent distal
• O2 Supply and monitor bed
pulses.
• ABC intact
• 12 lead ECG shows no ST, T wave
changes, no sign of MI
• Vitally stable except he is high BP
185/85 mmHg on the right arm and
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• Portable CXR shows wide mediastinum,
no sign of CHF, pneumothorax or
pneumonia
• Patient in pain need analgesia
Case 3 – Differential Diagnoses
1. Aortic dissection
2. Myocardial ischemia or infarction (MI)
3. Pulmonary embolus (PE)
4. Pneumothorax
5. Pericarditis with Tamponade
6. Esophageal rupture
Case 3 – History and Physical
Examination Hints
• The chest Pain is sudden onset central
ripping chest pain radiating to back as
in aortic dissection; the pain is not
angina pain.
• There are risk factors: HTN, CAD,
smoker, and age
• The history does not suggest any
previous esophageal rupture
• Physical exam not lead to pneumonia,
no crackles in chest exam
• No sign of pneumothorax in the exam
• Pulses delay in radio –radio pulsation
and different BP in both arm and
abdominal and bilateral femoral bruits,
with absent distal pulses with going
with aortic dissection
• ECG no sign of ischemic changes, no
sign of pericarditis in ECG
• Patient in Pain need analgesia
Case 3 – Emergency Diagnostic
Tests and Interpretation
• 12 lead ECG shows no ST, T wave
changes, no sign of MI
• Portable CXR shows wide mediastinum,
no sign of CHF, pneumothorax or
pneumonia
• The cardiac enzyme was negative rule
out MI
• D-Dimer was negative
•Bedside Echo has no sign of
tamponade
• CT scan is the most accurate and
fastest option
Case 3 – Emergency Treatment
• Involve Cardio-Thoracic surgery as
soon as possible.
• Control the blood pressure
• SBP goal is 120-130 mmHg
• Beta blockers are first-line agents
(Labetalol and Esmolol), they control
blood pressure and heart rate
• Depending on the patient’s vitals you
can add vasodilators such as
nitroprusside
Case 3 – Disposition
• Patients should be admitted to ICU,
• Emergency surgery is needed for
ascending dissections
• If dissection is only descending,
management is only supportive.
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Case 4
A 55-year-old alcoholic with persistent
vomiting presents with sudden onset of
Chest Pain followed by hematemesis.
The chest pain is sudden onset, sharp in
nature, radiating to the back. It is
associated with shortness of breath for 3
hours. Past medical history: DM, HTN,
alcoholic, and smoker. Vitals: BP 120/80
equal bilateral arm, pulse 90 regular and
equal on four limbs, no pulse deficit, RR
40, T 38, O2sat 96% on room air.
Case 4 – Critical Bedside
Actions and General Approach
• O2 Supply and monitor bed
• ABC intact
• Vitally stable except he is febrile (T 38)
• The quick history which suggested the
sudden onset of Chest Pain followed by
hematemesis. The chest pain is sudden
onset, sharp in nature radiating to the
back; it is associated with shortness of
breath for 3 hours.
• Physical examination shows
• Chest exam: decrease air entry in the
left side, and there is subcutaneous
emphysema in the left side of the
chest
• CVS exam: S1+S2. No additional
sound, JVP was normal, pulses equal
in four limbs
• 12 lead ECG shows no ST, T wave
changes, or ischemic changes
• Portable CXR shows left pleural
effusion and pneumomediastinum and
normal width of the mediastinum.
Case 4  – Differential Diagnoses
1. Esophageal rupture
2. Aortic dissection
3. Myocardial ischemia or infarction (MI)
4. Pulmonary embolus (PE)
5. Pneumothorax
6. Pericarditis with Tamponade
Case 4 – History and Physical
Examination Hints
• The chest pain is sudden onset
followed by hematemesis. The chest
pain is sharp in nature radiating to the
back; it is associated with shortness of
breath for 3 hours. A history of repeated
vomiting and associated with short of
breath and vomiting blood
(hematemesis).
• There is Risk factors, HTN, CAD,
smoking, and alcohol use
• There is strong history suggested of
Esophageal rupture
• Physical exam shows decreased air
entry in the left side, and there is
subcutaneous emphysema in the left
side of the chest
• No sign of pneumothorax in the exam
• ECG no sign of ischemic changes, no
sign of pericarditis in ECG
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Case 4 – Emergency Diagnostic initiated when the initial diagnosis is
Tests and Interpretation suspected.
• 12 lead ECG shows no ST, T wave
• Parenteral nutritional support
changes, no sign of MI
• Nasogastric suction – This should be
• Portable CXR shows left pleural
maintained until there is evidence to
effusion and right pneumomediastinum
indicate that the esophageal perforation
and normal width of the mediastinum.
has healed, is smaller or is unchanged
No sign of pneumothorax, no sign of
CHF, no sign of pneumonia • Narcotic analgesics

• Cardiac enzymes were negative, which • Admission to a medical or surgical

rule out MI intensive care unit (ICU)

• D-Dimer was negative • Outcome: survival 65-90%, poor

survival with delayed diagnosis >48hrs
• Bedside Echo: no sign of tamponade
References and Further Reading, click
Case 4 – Emergency Treatment
here.
and Disposition
• Nothing by mouth, NPO

• Broad-spectrum antibiotics – No
randomized clinical trials exist for
antibiotics and esophageal perforation;
h o w e v e r, e m p i r i c c o v e r a g e f o r
anaerobic and both gram-negative and
gram-positive aerobes should be

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