Chest pain

Chest pain is discomfort or pain felt between the diaphragm and the base of the neck, anterior or posterior. It includes pressure, tightness, heaviness, burning and sharp pain, and so covers chest tightness and exertional chest pain. It is among the commonest reasons for emergency attendance.

Clinical relevance. About 5% to 10% of emergency attendances are for chest pain; only 10% to 20% have an acute coronary syndrome, but missed myocardial infarction carries a major risk of death. In sub Saharan Africa, rheumatic heart disease, pericarditis (tuberculous), cardiomyopathy and pneumonia contribute alongside coronary disease, whose incidence is rising.

Classification by mechanism.

• Cardiac ischaemic: stable angina, unstable angina, myocardial infarction, coronary spasm, microvascular angina.
• Cardiac non ischaemic: pericarditis, myocarditis, aortic stenosis, hypertrophic cardiomyopathy, arrhythmia, Takotsubo syndrome.
• Vascular: aortic dissection, pulmonary embolism, pulmonary hypertension.
• Pleuropulmonary: pneumothorax, pneumonia, pleurisy.
• Gastrointestinal: reflux, oesophageal spasm, oesophageal rupture, peptic ulcer, biliary disease, pancreatitis.
• Musculoskeletal and chest wall: costochondritis, rib fracture, muscle strain, herpes zoster.
• Psychogenic: anxiety, panic.

Typical anginal pain. Retrosternal pressure or tightness, radiating to the arm, neck or jaw, provoked by exertion or emotion, relieved within 5 to 10 minutes by rest or glyceryl trinitrate. Three features present: typical angina; two: atypical; one or none: non anginal.

Grading of angina (Canadian Cardiovascular Society). Class I: strenuous exertion only. II: slight limitation (walking over 2 blocks or one flight of stairs). III: marked limitation (walking 1 to 2 blocks). IV: pain at rest or any activity.

History.

• Character (pressure, crushing, tearing, stabbing, burning), site, radiation (arm, jaw, back, between the scapulae), onset (sudden or gradual), duration, severity, provoking factors (exertion, cold, meals, breathing, posture, movement), relieving factors (rest, glyceryl trinitrate, antacids, leaning forward, sitting up).
• Associated: breathlessness, sweating, nausea, vomiting, palpitations, syncope, cough, haemoptysis, fever, dysphagia, regurgitation, leg swelling.
• Risk factors for coronary disease: age, male sex, hypertension, diabetes, smoking, hyperlipidaemia, family history of premature coronary disease, HIV, chronic kidney disease, cocaine or amphetamine use, inflammatory disease.
• Risk for pulmonary embolism: recent surgery, immobility, long travel, cancer, previous thrombosis, oestrogen therapy, pregnancy.
• Dissection risk: hypertension, Marfan syndrome, bicuspid aortic valve, cocaine, pregnancy, recent cardiac procedure.
• Previous coronary disease, stents, bypass, rheumatic fever, tuberculosis, recent viral illness.
• Drugs: antihypertensives, nitrates, anticoagulants, NSAIDs, corticosteroids, bisphosphonates (oesophagitis), sumatriptan, fluorouracil.

Examination.

• Vital signs in both arms (difference over 20 mmHg suggests dissection), pulse, rhythm, temperature, respiratory rate, oxygen saturation, capillary glucose.
• General: pallor, sweating, cyanosis, distress.
• Cardiac: jugular venous pressure, heart sounds (third sound), murmurs (aortic stenosis, aortic regurgitation, mitral regurgitation), friction rub, pulsus paradoxus.
• Chest: asymmetric expansion, hyperresonance, reduced breath sounds, crackles, wheeze, rub.
• Peripheral pulses and bruits, calf swelling.
• Chest wall tenderness (reproducible pain lowers but does not exclude cardiac cause), vesicular rash.
• Abdomen: epigastric tenderness, hepatomegaly, pulsatile mass.

Red flags.

• Ongoing pain over 20 minutes with sweating, nausea or breathlessness; pain at rest.
• Haemodynamic instability, hypoxia, syncope, new heart failure or arrhythmia.
• Tearing pain radiating to the back, unequal pulses or blood pressures, new aortic regurgitation murmur, neurological deficit.
• Pleuritic pain with breathlessness, tachycardia, haemoptysis or leg swelling.
• Tracheal deviation, absent breath sounds, hypotension.
• Pain after vomiting, subcutaneous emphysema, fever (oesophageal rupture).
• Beck triad (hypotension, raised jugular venous pressure, muffled heart sounds).
• ECG with ST elevation, new left bundle branch block, deep ST depression, deep T wave inversion.

Life threatening ("must not miss"). ST elevation myocardial infarction, non ST elevation myocardial infarction, unstable angina, aortic dissection, pulmonary embolism, tension pneumothorax, oesophageal rupture (Boerhaave), cardiac tamponade.

Cardiac. Stable angina, coronary spasm, microvascular angina, pericarditis, myocarditis, Takotsubo syndrome, aortic stenosis, hypertrophic cardiomyopathy, arrhythmia, spontaneous coronary artery dissection (young women, peripartum), anomalous coronary artery, coronary arteritis (Kawasaki disease), cocaine related ischaemia.

Pulmonary and pleural. Pneumonia, pleurisy, pneumothorax, pleural effusion, empyema, pulmonary hypertension, lung cancer, tuberculosis, asthma, pulmonary infarction.

Mediastinal and vascular. Aortic dissection, aortic aneurysm, mediastinitis, mediastinal tumour, thymoma.

Gastrointestinal. Gastro-oesophageal reflux, oesophageal spasm and motility disorders, oesophagitis (infective, pill induced), peptic ulcer, hiatus hernia, biliary colic, cholecystitis, pancreatitis, perforated viscus.

Musculoskeletal and neural. Costochondritis, Tietze syndrome, rib fracture, intercostal muscle strain, cervical or thoracic radiculopathy, herpes zoster, precordial catch, fibromyalgia, sternoclavicular arthritis, slipping rib.

Psychological. Anxiety, panic disorder, hyperventilation, somatic symptom disorder.

Haematological and others. Sickle cell acute chest syndrome, severe anaemia, herpes zoster before the rash, breast disease, diabetic complications.

1. Within 10 minutes of arrival obtain a 12 lead ECG for any acute chest pain, and repeat at 15 to 30 minutes if pain persists or the first ECG is not diagnostic. Add right sided and posterior leads (V7 to V9) if the inferior or posterior wall is suspected.
2. ST elevation of 1 mm or more in two contiguous leads (2 mm in V2 and V3 in men, 1.5 mm in women), or new left bundle branch block with ischaemic symptoms, indicates a ST elevation myocardial infarction and immediate reperfusion.
3. High sensitivity troponin at presentation and at 1 to 3 hours (a rapid rule out strategy) or 0 and 6 hours.
4. A value under the assay specific low threshold with no delta, more than 3 hours after pain onset, excludes infarction. A rise or fall with at least one value over the 99th percentile confirms myocardial injury. Interpret in context (myocarditis, heart failure, pulmonary embolism, sepsis, renal failure).
5. Bedside: oxygen saturation, glucose, blood pressure in both arms. Chest radiograph (pneumothorax, pneumonia, effusion, widened mediastinum, cardiomegaly, free air under the diaphragm).
6. Blood tests: full blood count, urea, creatinine, electrolytes, glucose, lipids, liver function tests, C reactive protein, D-dimer when pulmonary embolism has low or intermediate probability (age adjusted cut off: age x 10 micrograms/L over age 50), lipase if abdominal features, blood cultures if febrile.
7. Echocardiography for new murmur, heart failure, wall motion abnormality, effusion or tamponade, right ventricular strain, aortic root dilatation.
8. CT pulmonary angiography for pulmonary embolism (when D-dimer positive or probability high). CT aortography for suspected dissection (ECG gated). CT coronary angiography in low to intermediate risk patients with negative troponin. Chest CT if mediastinal or lung disease.
9. Stable chest pain: exercise ECG (low sensitivity), stress echocardiography, myocardial perfusion imaging, stress cardiac MRI, or CT coronary angiography with calcium score; invasive angiography for high risk.
10. Risk scores: HEART score (history, ECG, age, risk factors, troponin; 0 to 3 low risk, 4 to 6 intermediate, 7 to 10 high), Wells score and Geneva score for pulmonary embolism, aortic dissection detection risk score.
11. Gastrointestinal tests as indicated: endoscopy, abdominal ultrasound, contrast swallow with water soluble agent for suspected perforation, pH and manometry.
12. Anxiety and depression screening after exclusion of organic causes.

Limits. The first ECG is normal in about 30% to 50% of patients with acute coronary syndrome. Troponin may be raised without coronary occlusion. Atypical presentations are frequent in women, older adults, diabetes and the immunosuppressed. Reproducible chest wall tenderness does not exclude cardiac disease.

Immediate (all patients with acute chest pain). Monitor ECG, pulse oximetry and blood pressure; intravenous access. Oxygen only if saturation under 90% (target 94% to 98%).

Analgesia: glyceryl trinitrate and, if needed, titrated morphine 2.5 to 5 mg intravenously with antiemetic, repeated at 5 minute intervals to a maximum of 10 to 15 mg.

Acute coronary syndrome.

• Aspirin 300 mg chewed at once, then 75 to 100 mg daily.
• Second antiplatelet: ticagrelor 180 mg loading then 90 mg twice daily.
• Alternative: prasugrel 60 mg then 10 mg daily (not with prior stroke, age over 75, weight under 60 kg).
• Alternative: clopidogrel 300 to 600 mg loading then 75 mg daily when anticoagulated or after thrombolysis.
• Glyceryl trinitrate 400 to 800 micrograms sublingually every 5 minutes up to three doses; intravenous infusion 10 to 200 micrograms/minute for ongoing pain, heart failure or hypertension. Avoid with systolic pressure under 90 mmHg, right ventricular infarction, or phosphodiesterase inhibitor use in the past 24 to 48 hours.
• Anticoagulation: enoxaparin 1 mg/kg subcutaneously twice daily (30 mg intravenous bolus in ST elevation; 1 mg/kg once daily if eGFR under 30), or unfractionated heparin 60 units/kg bolus (maximum 4,000 units) then 12 units/kg/hour (maximum 1,000 units/hour), adjusted to activated clotting time or aPTT.
• Beta blocker oral within 24 hours if no heart failure, shock or heart block: metoprolol tartrate 25 to 50 mg every 6 to 8 hours, or bisoprolol 2.5 to 5 mg daily.
• High intensity statin: atorvastatin 80 mg at once and daily.
• ST elevation myocardial infarction: primary percutaneous coronary intervention within 120 minutes of first contact (ideally door to balloon within 90 minutes).
• If not available in time, fibrinolysis within 12 hours of onset: tenecteplase weight based (30 mg under 60 kg, 35 mg 60 to under 70 kg, 40 mg 70 to under 80 kg, 45 mg 80 to under 90 kg, 50 mg 90 kg or more; halve in those aged 75 and over).
• Alternative fibrinolytic: alteplase 15 mg bolus, 0.75 mg/kg over 30 minutes (maximum 50 mg) then 0.5 mg/kg over 60 minutes (maximum 35 mg).
• Transfer for angiography at 2 to 24 hours.
• Contraindications to fibrinolysis: previous intracranial haemorrhage, ischaemic stroke in the past 6 months, intracranial tumour, recent major trauma or surgery, active bleeding, suspected dissection, bleeding disorder.
• Non ST elevation acute coronary syndrome: risk stratify (GRACE); invasive strategy within 24 hours for high risk, within 72 hours for intermediate.
• After revascularisation: dual antiplatelet therapy for 12 months, ACE inhibitor (ramipril 2.5 mg twice daily increased to 5 mg), beta blocker, statin, spironolactone or eplerenone 25 to 50 mg daily if ejection fraction 40% or less, cardiac rehabilitation, smoking cessation.

Stable angina. Aspirin 75 mg daily, atorvastatin 40 to 80 mg, sublingual glyceryl trinitrate 400 micrograms as required, then bisoprolol 2.5 mg daily increased to 10 mg or amlodipine 5 mg increased to 10 mg.

Add isosorbide mononitrate modified release 30 to 60 mg daily (asymmetric dosing to avoid tolerance), ivabradine 5 mg twice daily (heart rate over 70), ranolazine 375 mg twice daily increased to 750 mg twice daily, or nicorandil 10 mg twice daily.

Angiography for refractory or high risk disease. Manage risk factors (blood pressure under 130/80 mmHg, HbA1c about 53 mmol/mol, LDL under 1.4 mmol/L).

Aortic dissection. Heart rate under 60 and systolic pressure 100 to 120 mmHg: labetalol 20 mg intravenously then 20 to 80 mg every 10 minutes, or esmolol infusion; add sodium nitroprusside 0.25 to 0.5 micrograms/kg/minute if needed after beta blockade; opioid analgesia. Type A: emergency surgery; type B: medical management, endovascular repair for complications.

Pulmonary embolism. Anticoagulate at once if probability is high or intermediate: rivaroxaban 15 mg twice daily for 21 days then 20 mg once daily, or apixaban 10 mg twice daily for 7 days then 5 mg twice daily, or enoxaparin 1 mg/kg twice daily. Massive embolism with shock: alteplase 100 mg over 2 hours (or 50 mg bolus in cardiac arrest), or catheter directed therapy or surgical embolectomy.

Pneumothorax. Tension: immediate needle decompression (large bore cannula, 5th intercostal space anterior axillary line) then chest drain. Simple: observation or aspiration if symptomatic, chest drain if large or unstable.

Pericarditis. Ibuprofen 600 mg every 8 hours or aspirin 750 to 1,000 mg every 8 hours for 1 to 2 weeks with taper, plus colchicine 500 micrograms once daily (under 70 kg) or twice daily for 3 months, and a proton pump inhibitor. Restrict exercise until symptoms resolve and markers normalise. Tuberculous pericarditis: four drug anti tuberculous therapy with prednisolone 60 mg daily tapered over 6 to 11 weeks. Tamponade: urgent pericardiocentesis.

Other causes. Pneumonia: amoxicillin 1 g three times daily for 5 days for mild disease. Reflux: omeprazole 20 to 40 mg daily for 4 to 8 weeks, with lifestyle measures. Oesophageal rupture: nil by mouth, broad spectrum antibiotics, urgent surgical review. Musculoskeletal: paracetamol 1 g every 6 hours (maximum 4 g; 3 g if frail or under 50 kg), ibuprofen 400 mg every 8 hours (maximum 2.4 g) with food, heat, and reassurance.

Herpes zoster: valaciclovir 1 g three times daily for 7 days started within 72 hours. Panic and anxiety: explanation, breathing retraining, cognitive behavioural therapy, and sertraline 50 mg daily if indicated.

Disposition. Admit with ECG changes, positive troponin, haemodynamic instability, ongoing pain, high HEART score, suspected dissection, pulmonary embolism with risk features, or pneumothorax needing drainage. Discharge after negative serial troponin with low risk score, a follow up plan and outpatient stress testing or CT coronary angiography.

Monitoring. Continuous ECG for 24 to 48 hours in acute coronary syndrome. Daily troponin trends, echocardiography, renal function and haemoglobin. Review within 1 to 2 weeks for stable chest pain.

Referral and escalation. Cardiology urgently for acute coronary syndrome. Cardiothoracic surgery for dissection, tamponade, perforation. Respiratory medicine for pleural disease. Gastroenterology for refractory reflux or dysphagia.

Safety netting. Return at once for pain lasting over 15 minutes, pain at rest, breathlessness, sweating, fainting, palpitations, or pain not relieved by glyceryl trinitrate (call emergency services; do not drive).

Special groups.

• Women, diabetes, older adults: atypical presentations (breathlessness, fatigue, epigastric pain) and higher risk.
• Pregnancy: aortic dissection, pulmonary embolism, peripartum cardiomyopathy, spontaneous coronary dissection; avoid radiation where possible, but do not withhold imaging when life threatening disease is suspected.
• Young people: musculoskeletal, pleural and anxiety causes are common, but consider cocaine, myocarditis, hypertrophic cardiomyopathy, coronary anomalies.
• Endemic regions: rheumatic heart disease, tuberculous pericarditis, cardiomyopathy, and pneumonia.