Chest Pain

See also Cardiac Type Chest Pain Presenting in Primary Care

Chest pain is a common symptom, accounting for about 1% GP visits, 5% A&E department visits and 40% emergency hospital admissions.¹ Undifferentiated chest pain is a diagnostic challenge, raising the anxiety levels of both doctor and patient. There is an urgent need to ensure that serious and life-threatening conditions are not missed but the majority of chest pain seen in primary care is due to more benign conditions (e.g. gastro-oesophageal reflux (GORD), muscle sprains, panic disorder or shingles) - cardiac disease accounts for only 8-18% of all cases.¹ Frequently once a cardiac cause for chest pain is excluded, further investigative effort is curtailed and many patients continue to suffer undiagnosed chest pain, a condition that carries significant psychological morbidity.²

The cause of chest pain is rarely certain, but clues can be taken from the history - cardiac pain is often heavy, pressing and tight, pleuritic pain is likely to be worse with breathing whilst musculoskeletal pain is usually a diagnosis of exclusion. Risk factors should be used to help prioritize and guide investigations.

Epidemiological studies of chest pain, in particular the risk of pain being cardiac in nature, vary according to setting. Community based studies with their undifferentiated populations see high rates of non-cardiac chest pain, whilst studies based in A&E departments have much higher proportions of cardiac chest pain, as patients are already self-selected based on the severity of symptoms, or triaged via contact with their GP, paramedics, NHS Direct etc.

Incidence

In the UK, new presentations of chest pain accounted for 1.5% GP consultations. Incidence of chest pain consultations increases with age and particularly in association with maleness.¹ 8% of these were diagnosed clinically within primary care as IHD, 83% were excluded as cardiac-based and in 9% there was diagnostic uncertainty, leading to referral for further assessment of about 17%.³
Combined hospital and primary care data produced an incidence of cardiac chest pain of 6.5 per 1000 general population per annum.

Prevalence

Population-based, questionnaire studies show about 20% adults reporting chest pain over the course of a year. This reflects the chronicity of IHD but also low consultation rates, particularly in those without a diagnosis of cardiac disease.

Risk factors

Initial assessment

As the patient walks into the consultation room or listening actively over the telephone, discern:

• General appearance/status:
  • Confused
  • Highly anxious
  • Short of breath
  • In severe pain and distress
  • Pale or sweaty
  • Vomiting
• ABC & vital signs - if any of the following are present in conjunction with chest pain, treat as an emergency and arrange urgent transfer to hospital:⁴
  • Respiratory rate is <10 or >29/min
  • O2 sats<93%
  • Pulse<50 or >120/min
  • Systolic BP<90 mmHg
  • Glasgow coma score<12

The aim is to exclude a life-threatening cause which needs immediate treatment from other causes of chest pain.

History

• Pain:
  • Site
  • Radiation
  • Nature (type, freq, severity)
  • Onset
  • Duration
  • Variation with time
  • Modifying factors e.g. exercise, rest, eating, breathing or medication
  • Previous episodes
  Visceral chest pain originates from deep thoracic structures (heart, blood vessels, oesophagus) and is often (but not always) described as dull, heavy or aching in nature. It is transmitted via the autonomic system but may be referred via an adjacent somatic nerve e.g. referred cardiac pain felt in the jaw or left arm. Somatic chest pain arises in the chest wall, pericardium and parietal pleura and is characteristically sharp in nature and more easily localised (usually dermatomal).
• Associated symptoms:
  • Anorexia
  • Nausea
  • Vomiting
  • Breathlessness
  • Excessive sweating (diaphoresis)
  • Cough
  • Haemoptysis
  • Palpitations
  • Dizziness
  • Syncope
• Risk factors for IHD and other causes of chest pain
• Recent trauma
• Past medical history
• Current medications
• Previous ECGs for comparison and any prior cardiac investigations (where available)
• Exclude thrombolysis contraindications if AMI suspected
• Screen for panic disorder:
  • "In the past 6 months, did you ever have a spell or an attack when you suddenly felt anxious or frightened or very uneasy?"
  • "In the past 6 months, did you ever have a spell or an attack when for no apparent reason your heart suddenly began to race, you felt faint or couldn't catch your breath?"
  A positive screen ('yes' to either question) is highly sensitive for panic disorder but should not preclude cardiac testing in patients with risk factors.⁵

Examination

• Vital signs including BP both arms
• Detailed cardiovascular & respiratory examinations looking particularly for signs of cardiac failure or dysrhythmia
• Chest wall looking for localised tenderness and evidence of trauma
• Also examine the abdomen (possible GI cause), legs (oedema or possible DVT) and skin (rash)

• Cardiac:
  • IHD - AMI, angina (stable/unstable)
  • Arrhythmias
  • Aortic dissection
  • Aortic stenosis / Mitral valve disease
  • Pericarditis
  • Vasospasm secondary to illicit drug use
  • HOCM
• Respiratory:
  • Pneumothorax (tension or otherwise)
  • PE
  • Pneumonia
  • Pleurisy
• Chest wall / Musculoskeletal:
  • Costochondritis
  • Rib pain
  • Non-specific musculoskeletal pain
  • Bone metastases
  • Radicular pain
  • Breast disease
• Gastrointestinal:
  • Oesophageal rupture
  • Oesophageal spasm
  • Peptic ulcer disease
  • Cholecystitis
  • Pancreatitis
  • Gastrooesophageal reflux / Gastritis
• Neurogenic:
  • Herpes zoster
  • Psychological e.g. panic disorder
• Others:
  • Sickle cell crisis
  • Diabetic mononeuritis
  • Tabes dorsalis

Within primary care, non-acute chest pain:

• FBC (to exclude anaemia)
• U&Es and creatinine
• TFTs
• Creatine kinase
• CRP
• Fasting lipids and glucose
• Resting ECG (note, a resting ECG is normal in over 90% patients with recent symptoms of angina.⁶ If an urgent ECG is considered necessary on clinical grounds, admission to hospital is usually required.)
• Additional tests if non-cardiac cause suspected e.g. CXR, LFT and amylase, abdominal ultrasound
• Referral to a rapid access chest pain clinic is now usual for exercise ECG and review

With acute chest pain, in a hospital setting:

• Bloods:
  • FBC
  • U&E and creatinine
  • LFT and amylase
  • Coagulation screen
  • Serial myocardial markers⁷ - Troponin I or T (Creatine kinase is much less commonly used now)
• Serial ECG
• CXR

Second line investigations, as indicated, include:

• Echocardiography
• CT
• V/Q scan
• Coronary or pulmonary angiography
• Exercise testing
• Myocardial perfusion scan

Management will be dependent on diagnosis:

1. Is this an emergency? Resuscitate and admit as an emergency:
   • Summon help, arrange 999 ambulance
   • High flow O₂via face mask
   • IV access
   • Analgesia
   • Cardiac monitoring (when available)
   • Specific therapy according to diagnosis
2. Is this cardiac chest pain?
   • Is it suggestive of an acute MI or ACS? If so, arrange urgent admission to hospital or prehospital treatment where provision exists.
   • If the chest pain is suggestive of stable angina, arrange referral for exercise tolerance testing and investigate/treat risk factors.
3. Is this non-cardiac chest pain?
   • If the patient is acutely unwell or a life-threatening cause (e.g. PE, pneumothorax) is suspected, arrange emergency transfer to hospital.
   • Has a cardiac cause been satisfactorily excluded? Frequently, patients are seen in Rapid Access Chest Pain clinics and discharged with a 'low probability' of cardiac disease and both the patient and primary care doctor have the challenge of managing future episodes with the need to reduce health anxiety and avoidance behaviour, balanced against the risk of misdiagnosis or de novo development of IHD.
   • What is the diagnosis? Uncertainty is high in patients where they are told they do not have cardiac chest pain but feel no satisfactory diagnosis is given in its place. Often investigation beyond this point is limited and treatment of non-cardiac chest pain patchy. GORD has the highest prevalence as cause of non-cardiac chest pain, and some advocate the empirical trial of a PPI or endoscopy as a legitimate next step.² Psychological treatment may also be helpful with some patients.⁸

Diagnosis of chest pain is difficult:

• Clinical features may not be as reliable as we hope in the diagnosis of acute, undifferentiated chest pain. For example, the site and nature of pain, the presence of nausea and vomiting and diaphoresis were not found to be predictive of ACS in one study.⁹
• ACS is often atypical (without chest pain). There is some evidence to suggest that this occurs more frequently in women,¹⁰ particularly premenopausal women.¹¹
• More than one cause may exist.
• A perennial problem for frontline doctors is the exclusion of IHD. Remember that a normal resting ECG does not exclude ACS or IHD.
  Response to nitrates or antacids does not prove diagnosis, as angina and GORD may appear to be relieved by both. ACS pain can be intermittent and appear to 'settle', providing false reassurance. If in doubt as to whether a patient's chest pain could represent AMI or unstable angina, admit as further monitoring and investigation (serial ECGs and cardiac enzymes) is required.
• Within A&E departments, assessment of chest pain is becoming more protocol-driven but it is important to realise that no definitive decision-making tool yet exists.¹²
• Rapid access chest pain clinics have improved diagnosis of incident angina in those with high CVD risk, but misdiagnosis rates are high and a recent study showed that a third of all cardiac events in subsequent follow up occurred in those diagnosed with non-cardiac chest pain.¹³
• 'Experience' may play some role but evidence suggests that increasing physician experience decreases threshold for admission without an increase in diagnostic accuracy.¹⁴ GPs use their previous experience of patient's behaviour in comparison to the current consultation, plus textbook criteria, to diagnose chest pain.¹⁵

There is a 3% increased mortality rate in the year following consulting a GP regarding the onset of chest pain compared with a control group with no chest pain, the excess being primarily due to CVD.¹