Chest pain – A Clinical Approach

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Introduction

  • A common complaint
  • This article refers to chest pain which is non-pleuritic (dull and poorly localised versus sharp, catching and clearly exacerbated by deep inspiration).  If the patient is not visibly more uncomfortable with deep inspiration consider the pain as non-pleuritic.
  • The range of conditions can range from benign to life-threatening
  • The most important condition to identify quickly is a ST elevation myocardial infarction.   An early ECG is essential (but be aware that the changes may evolve during the early phase of chest  pain)
  • A number of other serious causes for acute chest pain also need to be considered
  • It is important to repeat the ECG several times if pain is unrelieved and a cardiac cause cannot be excluded
  • Benign pathology is more likely if the episodes of pain are brief or fleeting, very focal or has localised tenderness
  • Red flags are severe, persistent or frequently recurring pain, abrupt onset, multiple vascular risk factors, high Wells score, abnormal vital signs or autonomic signs e.g. vomiting, sweating
  • If there is no obvious cause then the patient should be risk stratified for the possibility of a Pulmonary Embolus or Acute Coronary Syndrome

Clinical approach

  • Obtain vital signs.  There are a few important situations where a patient presenting with chest pain is critically unwell with signs of shock, respiratory distress or hypoxia.
  • Obtain ECG within 10 minutes.  If there is ST elevation, perform a targeted assessment for ST elevation myocardial infarction with a view to potential revascularisation.
  • Follow the principles of a careful history and exam to determine the likely cause.  Establish if there is a previous pattern to the pain.   Investigate as appropriate if this is likely e.g. lipase, LFTs, d-dimer, CT Pulmonary Angiography, CT angiogram of chest and abdomen
  • Provide early analgesia but repeat ECG as necessary if pain is slow to settle or is recurrent.
  • Review evidence and risk factors for Pulmonary embolus (Wells score and PERC criteria is useful but also consider the significance of a strong family history of venous thrombolic embolic disease)
  • If the cause of pain remains uncertain then risk stratify for an Acute Coronary Syndrome

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