Chest pain

Question 1

Most common cause of non-cardiac chest pain

Answer 1

GORD

Question 2

Chest pain relation with age and gender

Answer 2

• Incidence of chest pain increases with age and is more common in men

Question 3

Cardiac causes of chest pain

Answer 3

Ischaemic: stable angina, acute coronary syndrome (ACS), coronary vasospasm (Prinzmetal’s angina), hypertrophic cardiomyopathy, aortic stenosis.

Non-ischaemic: arrhythmias, aortic dissection, mitral valve disease, pericarditis.

Question 4

Respiratory causes of chest pain

Answer 4

• Pneumothorax, pulmonary embolism, pneumonia, pleurisy, lung cancer

Question 5

MSK causes of chest pain

Answer 5

• Costochondritis, Tietze’s syndrome, trauma, rib pain (including fracture, bone metastases, osteoporosis), radicular pain, nonspecific musculoskeletal pain (eg, fibromyalgia)

Question 6

GI causes of chest pain

Answer 6

• GORD, oesophageal rupture, oesophageal spasm, peptic ulcer disease, cholecystitis, pancreatitis, gastritis.

Question 7

Skin related causes of chest pain

Answer 7

Herpes zoster infection

Question 8

Psychological causes of chest pain

Answer 8

eg, anxiety, depression, panic disorder

Question 9

Visceral chest pain

Answer 9

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 - eg, referred cardiac pain felt in the jaw or left arm.

Question 10

Somatic chest pain (pleuritic)

Answer 10

Somatic chest pain arises in the chest wall, pericardium and parietal pleura and is characteristically sharp in nature and more easily localised (usually dermatomal).

Question 11

Associated symptoms to investigate with chest pain

Answer 11

Anorexia, nausea, vomiting may suggest a gastrointestinal or cardiac cause of chest pain depending on the individual context.

Breathlessness, cough, haemoptysis may indicate a respiratory or a cardiac cause of chest pain.

Excessive sweating may be associated with shock.
Palpitations, dizziness, and syncope increase the likelihood of a cardiac cause and imply the need for hospital admission - but palpitations may be associated with anxiety.

Question 12

Investigations within primary care, non-acute chest pain

Answer 12

FBC (to exclude anaemia).

Renal function tests and electrolytes.

TFTs.

CRP.

Fasting lipids and glucose.

Resting ECG. Note: a resting ECG is normal in over 90% patients with recent symptoms of angina. If an urgent ECG is considered necessary on clinical grounds, admission to hospital is usually required.

Additional tests if a non-cardiac cause is suspected - eg, CXR, LFTs and amylase, abdominal ultrasound.
Referral to a rapid access chest pain clinic is now usual for further assessment and review.

Question 13

Investigations with acute chest pain, in a hospital setting

Answer 13

Blood tests: FBC, renal function tests, electrolytes, LFTs, amylase, coagulation screen, serial cardiac enzymes (troponin I or T).
Serial ECG.
CXR.

Second-line investigations when indicated include echocardiography, angiography, exercise testing, myocardial perfusion scan, CT/MRI scan, upper gastrointestinal endoscopy, and lung ventilation/perfusion (V/Q) scan.

Question 14

What are symptoms that may indicate cardiac chest pain

Answer 14

Pain in the chest and/or other areas (eg, the arms, back or jaw) lasting longer than 15 minutes.

Chest pain with nausea and vomiting, marked sweating and/or breathlessness, or haemodynamic instability.

New-onset chest pain, or abrupt deterioration in stable angina, with recurrent pain occurring frequently with little or no exertion and often lasting longer than 15 minutes.

Question 15

What does pleuritic pain indicate

Answer 15

Pleuritic pain (pain is aggravated during inspiration and when coughing) may indicate a respiratory or musculoskeletal cause of pain.

Musculoskeletal pain is usually associated with tenderness of the chest wall.

Question 16

Screening for panic disorder

Answer 16

A positive screen (‘yes’ to either question) is highly sensitive for panic disorder but should not preclude cardiac testing in patients with risk factors:

‘In the past six months, did you ever have a spell or an attack when you suddenly felt anxious or frightened or very uneasy?’

‘In the past six 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?’

Question 17

Pain associated with cardiac ischaemia and pericarditis

Answer 17

• Restrosternal pain

- Pericarditis is pleuritic and may be worse on lying flat but relieved by sitting forward

Question 18

What can sometimes mimic cardiac pain

Answer 18

• Oesophageal disease can also cause restrosternal pain and may mimic cardiac pain

Question 19

Referred pain from vertebral collapse or shingles

Answer 19

• Will follow a dermatomal pattern

Question 20

In what other conditions is troponin also raised

Answer 20

• Renal impairment, failure, sepsis, PE, acute pericarditis

Question 21

What changes on ECG are suggestive of ACS

Answer 21

• New-onset left bundle branch block, T-wave changes, ST depression and elevation on ECG

Question 22

Changes suggestive of PE on ECG

Answer 22

• Sinus tachycardia
• Atrial arrythmia
• Right heart strain
• Right axis deviation
• Right bundle branch block

Question 23

What is the grace score

Answer 23

A scoring system to predict outcome for those patients presenting with acute coronary syndrome (ACS). It calculates a score based on (at presentation): age, heart rate, systolic blood pressure, creatinine, class of CCF, troponin rise and ECG changes. The score predicts subsequent chance of death or MI during admission and at 6 months. All patients with ACS should be Grace scored as a matter of routine

Question 24

Test to confirm oesophagitis

Answer 24

Upper gastrointestinal endoscopy will confirm oesophagitis and should be considered when the cause of chest pain is unclear