Chest Pain

Question 1

List cardiac causes included in the differential diagnosis for chest pain.

Answer 1

• Stable angina
• Acute coronary syndromes (ACS; UA, NSTEMI, STEMI)
• Pericarditis
• Aortic dissection

Question 2

What are the most important life threatening causes of chest pain?

Answer 2

MI, Cardiac tamponade, PE, Pneumothorax, Esophageal perforation.

Question 3

What is the most common non-cardiac etiologies of chest pain?

Answer 3

GI disorder.

Question 4

Chest pain that radiates to the back and the patient has unequal SBP in both arms is likely … ?

Answer 4

Aortic dissection.
- A CXR would show a widened mediastinum
- Chest CTA is used for hemodynamically stable patients (false lumen).
- TEE if the patient is unstable.

Question 5

Which gastrointestinal conditions can cause chest pain?

Answer 5

• Gastroesophageal reflux disease (GERD)
• Diffuse esophageal spasm
• Peptic ulcer disease
• Esophageal rupture

Question 6

What are pulmonary causes of chest pain?

Answer 6

• Pulmonary embolism
• Pneumothorax
• Pleuritis
• Pneumonia
• Status asthmaticus

Question 7

A 75-year-old man presents to the emergency room for evaluation of chest pain and shortness of breath for the past two days. The patient has also experienced a productive cough yielding purulent sputum. Past medical history is notable for hypertension, type Il diabetes mellitus, and hyperlipidemia. The patient has a 30-pack-year smoking history.
Temperature is 38.7°C (101.7°F), blood pressure is 145/82 mmHg, and pulse is 102/min. Physical examination is notable for decreased breath sounds over the right lower lung field. Which of the following would be most helpful in confirming the underlying cause of this patient’s symptoms?

Answer 7

This patient presents with chest pain, shortness of breath, productive cough, and fever. Physical examination reveals decreased breath sounds over the right lower lung field. In combination, these findings are most concerning for pneumonia, which can be best confirmed via a chest radiograph (or chest x-ray). Chest radiographs serve as the first-line imaging modality when a pulmonary or mediastinal etiology is suspected. Chest x-rays are generally safe and carry a low radiation dose; however, they should be avoided in pregnant patients unless diagnostically necessary. Common indications for chest x-ray include chest pain, shortness of breath, and cough. It is also used as a part of the trauma and preoperative evaluation, as well as after placement of monitoring and support devices (e.g., endotracheal tube, chest tube). While there are no absolute contraindications for chest x-rays, they should be avoided in patients who are pregnant unless diagnostically necessary.

Question 8

What are some chest wall-related causes of chest pain?

Answer 8

Costochondritis
- muscle strain
- rib fracture
- herpes zoster

Question 9

What would effectively rule in chest wall-related causes of chest pain?

Answer 9

Physical exam with tenderness to palpation.

Question 10

Which psychiatric disorders can present with chest pain?

Answer 10

Panic attacks, anxiety disorders, and somatization disorder.

Question 11

How can substance use lead to chest pain?

Answer 11

Cocaine and methamphetamine use can cause angina or myocardial infarction (MI).

Question 12

A patient presents during the summer/early fall, with sharp, stabbing, lateral chest wall pain after a viral infection, involving spasms of the intercostals and elevated CK?

Answer 12

Pleurodynia, also known as Bornholm disease or “devil’s grip,” is a viral illness characterized by sudden, severe, stabbing chest or upper abdominal pain due to inflammation of the intercostal muscles and pleura. It is most commonly caused by Coxsackievirus B, a type of enterovirus.

Question 13

What are the general steps in treating a patient with chest pain?

Answer 13

1. Rule out life-threatening causes (e.g., ACS, PE, aortic dissection).
2. Assess vital signs.
3. Perform a focused history and physical examination.
4. Order appropriate ancillary tests.
5. Develop a diagnosis based on findings.

Question 14

How should life-threatening causes of chest pain be prioritized?

Answer 14

Prioritize identifying and treating conditions like ACS, aortic dissection, tamponade, PE, and esophageal rupture. These are medical emergencies and require immediate intervention. Where as other sources of chest pain from GI, chest wall, psych, are less likely medical emergencies.

Question 15

How should the focused medical exam for chest pain be organized?

Answer 15

Gather information about:
- Character of the pain (pressure, squeezing, tearing, sharp, stabbing)
- Location of the pain
- Duration of the pain
- Setting of onset (exercise or after a meal) of the pain
- Radiation
- Aggravating or alleviating factors
- Prior cardiac history

Question 16

What details about the character of chest pain are important to elicit?

Answer 16

Pain can be described as pressure, squeezing, tearing, sharp, stabbing, or pain that radiates to the jaw or left arm. Pain radiating to the back could indicate aortic dissection.

Question 17

Sharp, stabbing chest pain tends to go for against cardiogenic chest pain?

Answer 17

Against.

Question 18

Chest pain that intensifies with respiration goes for against cardiogenic chest pain?

Answer 18

Against.

Question 19

Chest pain that intensifies with changes in body position goes for against cardiogenic chest pain?

Answer 19

Against.

Question 20

Chest pain with what qualities indicate ischemia of the heart?

Answer 20

• Dullness
• Soreness
• Pressure-like

Question 21

What are the associated symptoms of ischemic chest pain?

Answer 21

Dyspnea (shortness of breath), diaphoresis, lightheadedness, fatigue.

Question 22

How can duration of the chest pain help to lead to a diagnosis of ischemic chest pain?

Answer 22

Stable angina usually lasts for 2 to 10 min
Acute coronary syndrome usually lasts for 10 to 30 min

Question 23

What should be evaluated about the location and severity of chest pain?

Answer 23

The location (e.g., retrosternal, left-sided) and severity (mild to severe) are key diagnostic clues for more emergent issues.

Question 24

Ischemia of the heart tends to signal a sense of pain in what region?

Answer 24

substernal.

Question 25

How can the setting in which chest pain occurs provide diagnostic clues?

Answer 25

Pain occurring during exertion, at rest, or postprandial may indicate different conditions (e.g., ACS, GERD).

Question 26

Why is previous cardiac history essential when assessing chest pain?

Answer 26

Previous history of angina, stress tests, PCI, or CABG helps differentiate new from old pain patterns.

Question 27

What does relief of chest pain with nitroglycerin suggest?

Answer 27

Nitroglycerin relief suggests a cardiac origin, though it can also relieve diffuse esophageal spasm.

Question 28

How does pleuritic or positional chest pain guide diagnosis?

Answer 28

Pleuritic, positional, or reproducible pain with palpation is less likely cardiac in origin.

Question 29

What are the initial steps for managing unstable angina symptoms?

Answer 29

1. Obtain ECG and cardiac enzymes. 2. Administer aspirin. 3. Begin IV heparin if no contraindications. 4. Admit the patient for further evaluation.

Question 30

What are the essential ancillary tests in the workup of chest pain?

Answer 30

ECG, cardiac enzymes (troponin), chest X-ray, and specific PE workup if clinically suspected.

Question 31

How is a pulmonary embolism (PE) worked up in the context of chest pain?

Answer 31

Order D-dimer, CT angiography, or V/Q scan depending on clinical suspicion and contraindications.

Question 32

Why is it challenging to distinguish GI causes from cardiac chest pain?

Answer 32

The overlap of symptoms, such as epigastric pain and reflux, with cardiac ischemia symptoms makes distinguishing GI from cardiac causes challenging. Risk factors for CAD and clinical presentation help guide management.

Question 33

A 62-year-old man is brought to the emergency department with substernal pain and mild shortness of breath over the last 2 hours. En route, he was given sublingual nitroglycerin with significant relief of pain. He also received chewable aspirin. The patient currently rates the pain as 1–2 out of 10. His past medical history is significant for hypertension and active smoking. He has no history of bleeding. The patient's father died of a heart attack at age 56. Blood pressure is 154/90 mm Hg, and pulse is 110/min. He is not in respiratory distress. No murmurs are heard. Lungs are clear to auscultation. The initial electrocardiogram (ECG) is shown. Which of the following is the best next step in the management of this patient? A. Anticoagulation, second antiplatelet agent, and close monitoring B. Cardiac catheterization within 90 minutes from first medical contact C. CT scan of the chest with contrast D. Intravenous adenosine E. Transthoracic echocardiogram

Answer 33

A. Anticoagulation, second antiplatelet agent, and close monitoring vvvvvvvvvvvvv This patient's clinical presentation, substernal chest discomfort, relief with nitroglycerine, and electrocardiogram (ECG) findings of ST-segment depression in leads II, aVF, and V3-V6, is consistent with unstable angina/NSTEMI. vvvvvvvvvvvvv All patients with ACS should be managed with **dual antiplatelet therapy** with **aspirin** and **platelet P2Y12 receptor blockers** (clopidogrel, prasugrel, or ticagrelor), as well as nitrates, beta blockers, statins, and anticoagulant therapy (unfractionated heparin, low-molecular-weight heparin, bivalirudin, or fondaparinux).

Question 34

A 62-year-old man comes to the office due to shortness of breath for the past 6 months. He describes his symptoms as progressive difficulty walking a block without becoming out of breath. He experiences midline chest tightness and describes his pain as a "squeezing" sensation that is relieved after 5 minutes of rest. He also has fatigue and poor sleep but no palpitations, orthopnea, cough, or syncope. He has hypertension and gastrosophageal reflux disease. His medications are hydrochlorothiazide and famotidine. The patient has 35 pack year history of smoking and drinks 1 or 2 beers daily. On physical examination, the patient appears comfortable at rest. Blood pressure is 136/78 mm Hg and pulse is 84/min and regular. BMI is high. No cardiac murmurs are heard. The lungs are clear on auscultation. There is trace edema of the lower extremities bilaterally. Resting ECG shows normal sinus rhythm with no ST-segment or T-wave abnormalities. What should be the next step in managing this patient?

Answer 34

Along with an ECG, this patient's cardiac biomarkers should be evaluated and if they are normal, he should be further evaluated with an exercise stress test. If the stress test is positive, the patient should be started on aspirin, atorvastatin, and metoprolol, along with counseling for smoking cessation.

Question 35

What are the modalities available for evaluation of coronary artery disease (CAD)?

Answer 35

-Stress EKG -Stress ECHO -Pharm stress test

Question 36

What would justify further workup and possible revasculariztion in a patient with a concerning exercise stress test?

Answer 36

An ECG that shows 1-mm ST depressions at minimal exertion.

Question 37

What is the next step following a positive stress stress test?

Answer 37

Schedule an urgent percutaneous coronary angiography.

Question 38

When are patients who have a concerning stress EKG managed conservatively?

Answer 38

Medical management of CAD and stable anginal symptoms is appropriate in patients with positive stress testing results without high-risk features.

Question 39

If a patient continues to experience chest pain after being managed conservatively following a stress test, and their prior ECG did not reveal high-risk features, what should now be prioritized in their management?

Answer 39

Patients who initially lacked high-risk stress testing features but with anginal symptoms refractory to several months of optimal medical management should undergo coronary angiography to assess for revascularization.

Question 40

A 33-year-old woman presents to the emergency department for evaluation of chest pain. The patient states the pain feels sharp, but she does not note any exacerbating or relieving factors. The patient says she has eaten several spicy meals recently and wonders if the pain is related to indigestion. The patient reports she recently began a new exercise regimen involving arm and chest strengthening exercises. The patient is otherwise healthy and takes an oral contraceptive pill daily. Temperature is 37.0°C (98.6°F), pulse is 103/min, respirations are 16/min, blood pressure is 120/65 mmHg, and oxygen saturation is 96% on room air. Physical examination shows a young, healthy woman in no acute distress. The cardiopulmonary examination is normal. There is some reproducible pain with palpation over the costal cartilage. ECG demonstrates sinus tachycardia, and chest radiography is unremarkable. Initial troponin is <.05 ng/L. What is the next best step in management?

Answer 40

"Must not miss" causes of chest pain include acute coronary syndrome, pulmonary embolism, aortic dissection, esophageal rupture, pneumothorax, and cardiac tamponade. Low risk patients can be risk-stratified for pulmonary embolism using the PERC criteria. This patient with non-specific chest pain represents a multitude of diagnostic possibilities. Given her tachycardia and current use of oral contraceptive pills, she cannot be safely discharged before evaluation for pulmonary embolism per the PERC (pulmonary embolism rule-out criteria) rule. She should therefore undergo d-dimer testing before discharge to rule out a pulmonary embolism as the cause of her symptoms. A patient with chest pain poses a complicated diagnostic challenge given the broad differential diagnoses it encompasses, including cardiac, biliary, musculoskeletal, gastrointestinal, pulmonary and psychiatric etiologies. Life-threatening etiologies that must always be considered for any adult patient presenting with chest pain include acute coronary syndrome, pulmonary embolism, aortic dissection, esophageal rupture, pneumothorax, and cardiac tamponade. It is often helpful to employ clinical decision rules such as the PERC criteria to rule out a life-threatening diagnosis. In the case of pulmonary embolism (PE), this tool has been validated to rule out PE if no criteria are present and the pre-test probability is ≤15%. Listed criteria include the presence of tachycardia (heart rate ≥100 bpm), 02 sat >95%, age >50, hormone use, evidence of deep vein thrombosis, hemoptysis, history of thrombophilia, and recent surgery/trauma. Only once emergent causes of adult chest pain have been considered should more common diagnoses be considered, including cardiac etiologies like pericarditis and myocarditis, pleural causes like pneumonia, or gastrointestinal causes like an esophageal spasm, gastrosophageal reflux disorder, and peptic ulcer disease. Other common causes of chest pain include rib fracture, herpes zoster, and anxiety.

Question 41

A 65-year-old woman presents to the emergency department for evaluation of chest pain. The patient reports left-sided chest discomfort while she was on her daily two-mile walk this morning. It resolved when the patient stopped walking. The patient describes the pain as a pressure-like sensation that lasted approximately 15 seconds. She currently has no chest pain. Past medical history includes hypertension for which the patient takes amlodipine. Temperature is 37°C (98.6°F), blood pressure is 120/71 mmHg, pulse is 89/min, respiratory rate is 14/min, and oxygen saturation is 99% on room air. BMI is 28. Physical examination is unremarkable. Initial laboratory results and electrocardiogram are shown below. Which of the following is the best next step in management?

Answer 41

The HEART score can be used to risk stratify patients presenting to the emergency department with This patient presents to the emergency department with chest pain. Using the HEART score to determine her risk of ACS she falls into the intermediate risk category. The next best step in management for this patient is exercise stress testing to determine if ischemia is present. The HEART score is a well-validated tool to determine the risk for ACS in patients who report to the emergency department with chest pain. Using this scoring system, patients are divided into low, intermediate, and high-risk categories based on the type of chest pain they have, their risk factors, ECG findings, and troponin results. Low-risk patients have a score 0-3 and have less than 2.5% risk of major adverse cardiac events at 6 weeks, while a moderate score (4-6 points) predicts a risk of major cardiac events at 6 weeks of 12-16.6%, and a high score >6 indicates a 50-65 % risk of major adverse cardiac events at 6 weeks. Intermediate-risk patients like this patient should have stress testing to further determine the management strategy. The type of stress test is determined by the patient's ability to exercise. If they can exercise and have a normal ECG, like this patient, then an exercise stress test is appropriate.