Chest pain
| Chest pain | |
|---|---|
| Classification and external resources | |
| ICD-10 | R07 |
| ICD-9-CM | 786.5 |
| DiseasesDB | 16537 |
| MedlinePlus | 003079 |
| MeSH | D002637 |
Chest pain may be a symptom of a number of serious disorders and is, in general, considered a medical emergency. Even though it may be determined that the pain is noncardiac in origin (does not come from a heart problem), this is often a diagnosis of exclusion made after ruling out more serious causes of the pain. Cardiac (heart-related) chest pain is called angina pectoris. Pain in the chest wall muscles is called by other names, such as pectoralgia,stethalgia, thoracalgia, and thoracodynia.
Chest pain is a common presenting problem, as the following numbers illustrate:
- In the US, an estimated 5 million patients per year present to the Emergency Department with chest pain.
- More than 50% of patients presenting to emergency facilities with unexplained chest pain will have coronary disease ruled out.
- 1.5 million patients are admitted annually for workup of acute coronary syndrome (ACS).
- Approximately 8 billion dollars are used annually to evaluate complaints of chest pain.
- Pediatric patients with chest pain account for 0.3% to 0.6% of pediatric emergency department visits
Contents
Differential diagnosis
Causes of chest pain range from non-serious to serious to life-threatening. DiagnosisPro lists more than 440 causes on its website.
In adults the most common causes of chest pain include: gastrointestinal (42%), coronary artery disease (31%), musculoskeletal (28%), pericarditis (4%) and pulmonary embolism (2%). Other less common causes include: pneumonia, lung cancer, and aortic aneurysms.
Chest pain in children differs from adults in that there can be congenital causes and syndromes. In children the most common causes for chest pain are musculoskeletal and unknown.
Cardiovascular
- Acute coronary syndrome
- Unstable angina
- Myocardial infarction ("heart attack")
- Aortic dissection
- Pericarditis and cardiac tamponade
- Arrhythmia - atrial fibrillation and a number of other arrhythmias can cause chest pain.
- Stable angina pectoris - this can be treated medically, and, although it warrants investigation, it is not an emergency in its strictest sense
- Myocarditis
- Mitral valve prolapse syndrome
- Aortic aneurysm
Respiratory
- Bronchitis
- Pulmonary embolism
- Pneumonia
- Hemothorax
- Pneumothorax and Tension pneumothorax
- Pleurisy - an inflammation that can cause painful respiration
- Tuberculosis
- Tracheitis
- Lung malignancy
Gastrointestinal
- Esophageal rupture
- Gastroesophageal reflux disease (GERD) and other causes of heartburn
- Esophagitis
- Hiatus hernia
- Achalasia, nutcracker esophagus, diffuse esophageal spasm and other motility disorders of the esophagus
- Functional dyspepsia
Chest wall
- Costochondritis or Tietze's syndrome - a benign and harmless form of osteochondritis often mistaken for heart disease
- Spinal nerve problem
- Fibromyalgia
- Chest wall problems
- Radiculopathy
- Precordial catch syndrome - another benign and harmless form of a sharp, localised chest pain often mistaken for heart disease
- Breast conditions
- Herpes zoster commonly known as shingles
- Tuberculosis
- Osteoarthritis
- Bornholm disease
Psychological
Others
- Hyperventilation syndrome often presents with chest pain and a tingling sensation of the fingertips and around the mouth
- Da costa's syndrome
- Carbon monoxide poisoning
- Sarcoidosis
- Lead poisoning
- High abdominal pain may also mimic chest pain
- Prolapsed intervertebral disc
- Thoracic outlet syndrome
Diagnostic approach
History taking
Knowing a patient's risk factors can be extremely useful in ruling in or ruling out serious causes of chest pain. For example,heart attack and thoracic aortic dissection are very rare in healthy individuals under 30 years of age, but significantly more common in individuals with significant risk factors, such as older age, smoking, hypertension, diabetes, history of coronary artery disease or stroke, positive family history (premature atherosclerosis, cholesterol disorders, heart attack at early age), and other risk factors. Chest pain that radiates to one or both shoulders or arms, chest pain that occurs with physical activity, chest pain associated with nausea or vomiting, chest pain accompanied by diaphoresis or sweating, or chest pain described as "pressure," has a higher likelihood of being related to acute coronary syndrome, or inadequate supply of blood to the heart muscle, but even without these symptoms chest pain may be a sign of acute coronary syndrome.[7]
Physical examination
In the emergency department the typical approach to chest pain involves ruling out the most dangerous causes: heart attack, pulmonary embolism, thoracic aortic dissection, esophageal rupture, tension pneumothorax, and cardiac tamponade. By elimination or confirmation of the most serious causes, a diagnosis of the origin of the pain may be made. Often, no definite cause will be found and reassurance is then provided.
If acute coronary syndrome ("heart attack") is suspected, many people are admitted briefly for observation, sequential ECGs, and measurement of cardiac enzymes in the blood over time. On occasion, further tests on follow up may determine the cause. TIMI score performed at time of admission may help stratify risk.
Careful medical history and physical examination is essential in separating dangerous from trivial causes of disease, and the management of chest pain may be done on specialised units (termed medical assessment units) to concentrate the investigations. Occasionally, invisible medical signs will direct the diagnosis towards particular causes, such as Levine's signin cardiac ischemia. A rapid diagnosis can be life-saving and often has to be made without the help of medical tests. However, in general, additional tests are required to establish the diagnosis.
Medical tests
On the basis of the above, a number of tests may be ordered:
- An electrocardiogram (ECG)
- Chest radiograph or chest x rays are frequently performed
- CT scanning is used in the diagnosis of aortic dissection
- V/Q scintigraphy or CT pulmonary angiogram (when a pulmonary embolism is suspected)
- Blood tests:
- Troponin I or T (to indicate myocardial damage)
- Complete blood count
- Electrolytes and renal function (creatinine)
- Liver enzymes
- Creatine kinase (and CK-MB fraction in many hospitals)
- D-dimer (when suspicion for pulmonary embolism is present but low)
- serum lipase or amylase to exclude acute pancreatitis
Management
Aspirin increases survival in people with acute coronary syndrome and it is reasonable for EMS dispatchers to recommend it in people with no recent serious bleeding.
In people with chest pain supplemental oxygen is not needed unless the oxygen saturations are less than 94% or there are signs of respiratory distress. Entonox is frequently used by EMS personnel in the prehospital environment. However, there is little evidence about its effectiveness.
Epidemiology
Chest pain is the presenting symptom in about 12% of emergency department visits in the United States and has a one-year mortality of about 5%. The rate of ED visits in the US for chest pain increased 13% from 2006-2011.
References
- ^ Thull-Freedman, Jennifer (2010). "Evaluation of Chest Pain in the Pediatric Patient". Medical Clinics of North America 94 (2): 327–347.doi:10.1016/j.mcna.2010.01.004. ISSN 0025-7125.
- ^ a b Woo KM, Schneider JI (November 2009). "High-risk chief complaints I: chest pain--the big three". Emerg. Med. Clin. North Am. 27 (4): 685–712, x.doi:10.1016/j.emc.2009.07.007. PMID 19932401.
- ^ "Differential Diagnosis For Chest Pain: Poisoning (Specific Agent)".
- ^ a b Kontos, MC; Diercks, DB; Kirk, JD (Mar 2010). "Emergency department and office-based evaluation of patients with chest pain.". Mayo Clinic proceedings 85 (3): 284–99. doi:10.4065/mcp.2009.0560. PMID 20194155.
- ^ al.], [edited by] Jill M. Baren ... [et (2008). Pediatric emergency medicine. Philadelphia: Saunders/Elsevier. p. 481. ISBN 9781416000877.
- ^ Mallinson, T (2010). "Myocardial Infarction". Focus on First Aid (15): 15. Retrieved 2010-06-08.
- ^ Swap CJ, Nagurney JT (November 2005). "Value and Limitations of Chest Pain History in the Evaluation of Patients With Suspected Acute Coronary Syndromes.".JAMA 294 (20): 2623–2629.doi:10.1001/jama.294.20.2623. PMID 16304077.
- ^ Hess EP, Perry JJ, Ladouceur P, Wells GA, Stiell IG (March 2010). "Derivation of a clinical decision rule for chest radiography in emergency department patients with chest pain and possible acute coronary syndrome". CJEM 12 (2): 128–34. PMID 20219160.
- ^ O'Connor, RE; Brady, W; Brooks, SC; Diercks, D; Egan, J; Ghaemmaghami, C; Menon, V; O'Neil, BJ; Travers, AH; Yannopoulos, D (2 November 2010). "Part 10: acute coronary syndromes: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.". Circulation 122 (18 Suppl 3): S787–817.doi:10.1161/CIRCULATIONAHA.110.971028.PMID 20956226.
- ^ "Highlights of the 2010 AHA Guidelines for CPR and ECC" (PDF). American Heart Association.
- ^ a b O'Connor, RE; Brady, W; Brooks, SC; Diercks, D; Egan, J; Ghaemmaghami, C; Menon, V; O'Neil, BJ; Travers, AH; Yannopoulos, D (2010-11-02). "Part 10: acute coronary syndromes: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care". Circulation 122 (18 Suppl 3): S787–817. doi:10.1161/CIRCULATIONAHA.110.971028.PMID 20956226.
- ^ Castle, N (February 2003). "Effective relief of acute coronary syndrome". Emergency nurse : the journal of the RCN Accident and Emergency Nursing Association 10 (9): 15–9. PMID 12655961.
- ^ "Entonox for the Treatment of Undiagnosed Chest Pain: Clinical Effectiveness and Guidelines" (PDF). Canadian Agency for Drugs and Technologies in Health. Retrieved12 July 2011.
- ^ Stephen J. Dubner; Steven D. Levitt (2009).SuperFreakonomics: Tales of Altruism, Terrorism, and Poorly Paid Prostitutes. New York: William Morrow. p. 77. ISBN 0-06-088957-8.
- ^ Skiner HG, Blanchard J, Elixhauser A (September 2014)."Trends in Emergency Department Visits, 2006-2011".HCUP Statistical Brief #179. Rockville, MD: Agency for Healthcare Research and Q
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