CHEST PAIN

Source :
1. Tintinalli Emergency Medicine Section 7,Chapter 52
Chest Pain : Cardiac or Not
2. Emergency Medicine : Sherley Ooi; Peter Manning
3. Clinical Examination 6th : Talley, NJ & O’Connor, S
INTRODUCTION
 The management of the patient with chest
pain is a diagnostic and therapeutic
challenge of critical importance.

 Approximately 5% of all U.S. ED visits, or

about 5 million visits per year, are for chest
pain.
 TYPICAL
ANGINA

CHEST PAIN ATYPICAL

ANGINA

NON CARDIAC
CHEST PAIN
CLINICAL CLASSIFICATION OF
ANGINA
TYPICAL ANGINA Meets all 3 of following characteristics :
1. Characteristic retrosternal chest discomfort
typical quality & duration
2. Provoked by exertion or emotion
3. Relieved by rest or GTN (Glyceryl Trinitrat) or
both
ATYPICAL ANGINA Meets 2 of the above characteristics
NON CARDIAC CHEST Meets 1 or none of the above characteristics
PAIN
 Pain Causes Typical Features
Vascular Pain Aortic dissection Very sudden onset, radiates
Aortic Aneurysm to the back
Pleuropericardial Pain Pericarditis; Myocarditis; Pleuritic pain
pneumothorax;
Pneumonia;etc
Chest Wall Pain Persisten cough; muscular Worse with movement,
strain; thoracic chest wall tender, pleuritic
zooster;intercostal pain.
myositis;rib fracture;rib
tumour
Gastrointestinal Pain Gastro-oesophageal reflux; Not related to exertion,
Diffuse Oesophageal spasm may be worse when patient
lies down; Associated with
dysphagia
Airway Pain Tracheitis; Central Pain in throat, breathing
bronchial carcinoma; painful
inhaled foreign body
Other causes Panic attack Often preceded by anxiety,
associayed with
breathlessness &
hyperventilation
Mediastinal Pain Mediastinitis; sarcoid
adenopathy, lymphoma
 Pulmonary
AMI
Embolism

Life
threatening Unstable Tension
causes of angina Pneumothorax
chest pain

Aortic Oesophageal
dissection rupture
 Stable Angina;
Prinzmetal
Cardiac Angina;
Pericarditis/
Myocarditis

Simple
Pneumothorax;
Respiratory Pneumonia with
pleurisy
Non Life
Threatening
Causes Of
Chest Pain Reflux
Oesophagitis;
Gastrointestinal Oesophageal
spasm

Gastritis/ peptic
Referred Pain ulcer; biliary
disease
ACUTE CHEST PAIN
 Acutechest pain is pain
(1) of recent onset, typically <24 hours,
which causes the patient to seek prompt
medical attention

(2) with location on the anterior thorax

(3) with a sensation distressing to the

patient.
ACUTE CORONARY SYNDROME
 ACSis signs and symptoms resulting from an
imbalance between myocardial oxygen
supply and demand.

 There are three general classifications:

 unstable angina
 NSTEMI
 STEMI.
PATIENTS AT HIGHER RISK FOR
AMI & ISCHAEMIA
 Time since onset of pain ≤ 4 hr
 Longest episode of pain ≥ 30 min
 Pain described as ‘preassure’
 Radiation of pain to left arm, shoulder, neck
or jaw.
 History of angina or MI
 ED ECG changes of ischaemia or infarction
 The following 3 features together make chest
pain very unlikely to be due to cardiac
ischaemia :
a. Chest pain sharp or stabbing
b. No history of angina or MI
c. Pain reproducible by palpating chest
wall or has a positional or pleuritic
component.
 Chest discomfort associated with nausea 
should be assumed cardiac until proven
otherwise.
 Think of aortic dessection in any patient with
chest pain suggestive AMI but with
neurological as well.
 The following associated symptoms, ie
diaphoresis, dyspnea & syncope are seen in
AMI, PE, Aortic dissection.
 In chest pain  Normal ECG doesn’t rule out
ACS.
 The key is to repeat serial ECG.
 MANAGEMENT
 Ensure the vital signs are stable. If unstable 
bring the patient to resuscitation area
immediately.

 Oxygen supplementation, pulse oximetry,

continuous ECG monitoring, BP monitoring.

 Do an immediate 12 lead ECG.

 Repeat serial ECG if ECG normal or suspicious
but non confirmatory of ACS.

 Set IV plug and take blood test for cardiac

enzymes.

 Give pain relief depanding on provisional

diagnosis.

 Do chest x-ray.
CARDIAC MARKER

Cardiac Marker Detected Peak Level Normalized by

within
Myoglobin 1 – 2 hr 6 – 9 hr 24 – 36 hr
CK – CKMB 4 – 6 hr 18 – 24 hr 48 – 72 hr
Troponin T 4 – 6 hr 12 – 120 hr 10 – 14 days
Troponin I 4 – 6 hr 12 – 36 hr 7 – 9 days
DISPOSITION
 Admit ACS with ECG changes or continuing pain
to ICU.
 Admit Unstable angina with no ECG changes, or
if the oain has subsided to Cardiology general
ward.
 Admit patient with diagnosis of atypical chest
pain with risk factor for CAD to Cardiology
general ward.
 Stable angina can be discharged with medication
(Aspirine 300 mg then cardiprin 100 mg, ISDN 5 –
10 mg, propanolol 20 mg).
 Admit patients with aortic dissection to ICU.
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