Chest Pain
last authored: March 2012, David LaPierre
last reviewed:
Introduction
Chest pain is a very common and worrying complaint. Many of it's causes can be imminently life-threatening, requiring prompt and thorough investigation. However, many of the more common causes are benign and self-limited. It is important to never be complacent with complaints of chest pain.
The Case of...
Differential Diagnosis
Coronary artery disease is responsible for ~12% of chest pain in primary care patients (Ruigómez et al, 2006).
Life-threatening causes are marked with an *.
Cardiac
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Pulmonary
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Gastrointestinal
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MSK/neuro
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Psychological
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History and Physical Exam
As labs and imaging are often of little value in primary care, clinical assessment is a key diagnostic tool.
- history
- physical exam
History
Red Flags include:
- severe pain
- pain for >20 min
- new onset pain at rest
- severe SOB
- loss of consciousness
- hypotension
- tachycardia
- bradycardia
- cyanosis
Pleuritic pain is sharp and stabbing, increasing with breathing or movement and relieved with breath holding.
Non-pleuritic pain is deep, aching, crushing.
In primary care, a prediction rule has been developed to assess for potential CAD (Bosner et al, 2010):
- female >65, male >55
- known clinical vascular disease
- pain worse with exercise
- pain not reproducible by palpation
- patient assumes pain is cardiac
Using a score of 3 or higher has a sensitivity of 87% and a specificity of 80% if applied to primary care populations.
Past medical history
- diabetes
- hypertension
- atherosclerosis
- smoking
Family history
- 1st degree relative with MI
Physical Exam
Investigations
- lab investigations
- diagnostic imaging
Lab Investigations
Prompt lab work should include:
- complete blood count
- electrolytes
- creatinine
- liver function tests
- serial cardiac enzymes
If concerned, order
- D-dimers
- arterial blood gases
Diagnostic Imaging
ECG should be carried out for everyone in whom MI is possible.
CXR should be a standard test.
Consider V/Q scan, helical CT, and venous doppler if PE is of significant concern
Management
Angina/IHD: nitroglycerin, 5 min between sprays; if no effect after three sprays, call 911 or go to ED
GERD: antacids, H2 blockers, PPIs
costochondritis: NSAIDs
Pathophysiology
Resources and References
Bosner S et al. 2010. Ruling out coronary artery disease in primary care: development and validation of a simple prediction rule. CMAJ. 182(12):1295-300.
Ruigómez A, et al. 2006. Chest pain in general practice: incidence, comorbidity and mortality. Family Practice 23(2): 167-174.
Topic Development
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