Pathophysiology Of Chest Pain
Tillie
Chest pain appears in many forms, ranging from a sharp stab to a dull ache. Sometimes chest pain feels crushing or burning. In certain cases, the pain travels up the neck and into the jaw and then spreads to the back or down one or both arms.
Many different problems can cause chest pain. The most life-threatening causes involve the heart or lungs. Because chest pain can be due to a serious problem, it's important to seek immediate medical help.
Chest pain is often associated with heart disease. But many people with heart disease say they have a mild discomfort that they wouldn't really call pain. Chest discomfort due to a heart attack or another heart problem may feel like:
If you have new or unexplained chest pain or think you're having a heart attack, call 911 or emergency medical help immediately. Don't ignore the symptoms of a heart attack. If you can't get an ambulance or emergency vehicle to come to you, have a neighbor or a friend drive you to the nearest hospital. Drive yourself only if you have no other option.
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Chest pain is a common complaint and encompasses a broad differential diagnosis that includes several life-threatening causes. A workup must focus on ruling out serious pathology before a clinician considers more benign causes. Common descriptors of visceral pain are dull, deep, pressure, and squeezing. Visceral pain also refers to other locations as a result of the nerves coursing through somatic nerve fibers as they reach the spinal cord. Ischemic heart pain, for example, may refer to the left or right shoulder, jaw, or left arm. This activity highlights the role of the interprofessional team in caring for patients with chest pain.
Objectives:
- Identify the causes of chest pain.Describe the history and physical exam of a patient with chest pain.Outline the evaluation of a patient with chest pain.Explain the role of the interprofessional team in caring for patients with chest pain.
Chest pain is a common complaint and encompasses a broad differential diagnosis that includes several life-threatening causes. A workup must focus on ruling out serious pathology before a physician considers more benign causes.
It sometimes is helpful to consider the different etiologies of pain. Visceral pain usually presents with a vague distribution pattern meaning that the patient is unlikely to localize the pain to a specific spot. When asking patients to point with one finger where they feel the pain, they will often move their hand around a larger area. Common descriptors of visceral pain are dull, deep, pressure, and squeezing. Visceral pain also refers to other locations as a result of the nerves coursing through somatic nerve fibers as they reach the spinal cord. Ischemic heart pain, for example, may refer to the left or right shoulder, jaw, or left arm. Symptoms like nausea and vomiting may also be a sign of visceral pain. Diaphragmatic irritation may refer to the shoulders as well.[1] Somatic pain is more specific than visceral pain, and patients will usually be able to point to a specific spot. Somatic pain is also less likely to refer to other parts of the body. Common descriptors of somatic pain are sharp, stabbing, and poking.
In the emergency department, chest pain is the second most common complaint comprising approximately 5% of all emergency department visits. In evaluating for chest pain, the provider should always consider life-threatening causes of chest pain. These are listed below with approximate percent occurrence in patients presenting to the emergency department with chest pain based on a study by Fruerfaard et al. [2]
Once you have thoroughly ruled out life-threatening causes, move on to other possibilities. Pneumonia should be considered in patients with a productive cough and/or recent upper respiratory infection (URI). Gastroesophageal reflux disease (GERD) is a common cause of chest pain so ask about any reflux symptoms. New exercise routines or recent trauma may help support a musculoskeletal cause. [2]
A complete discussion of the management of ACS is beyond the scope of this paper; however, initial steps should be performed in patients with a diagnosis of ACS. Place patient on a cardiac monitor, establish intravascular access (IV) access, give 162 mg to 325 mg chewable aspirin, clopidogrel, or ticagrelor (unless bypass surgery is imminent), control pain and consider oxygen (O2) therapy. Nitroglycerin has shown a mortality benefit, aiming for a 10% mean arterial pressure (MAP) reduction in normotensive patients and a 30% MAP reduction in hypertensive patients; avoid in hypotensive patients and those with inferior ST elevation. Patients with ST elevation on ECG patients should receive immediate reperfusion therapy, either pharmacologic (thrombolytics) or transfer to the catheterization laboratory for percutaneous coronary intervention (PCI). PCI is preferred and should be initiated within 90 minutes onsite or 120 minutes if transferred to an outside facility. If PCI is not possible, thrombolytics should be initiated within 30 min. Patients with non-ST elevation myocardial infarction (NSTEMI) and unstable angina should be admitted for a cardiology consult and workup. Patients with stable angina may be appropriate for outpatient workup. In elderly patients and those with comorbidities, patients should be admitted for observation and further cardiac workup. [3][4]
CT pulmonary angiogram (CTPA) is the best confirmatory test, a VQ scan can also be used, but this test is not as accurate in patients with chronic lung disease. Patients who are hemodynamically unstable should be started on thrombolytics; stable patients should be started on anticoagulants. [5][6]
Bedside ultrasound is useful for establishing a diagnosis. A fluid bolus may be used as a temporizing measure. Needle pericardiotomy or pericardial window to relieve pressure inside the pericardial sack.[9]
A left pleural effusion on a chest x-ray may suggest esophageal rupture. A contrast esophagram is the best confirmatory test. This is a medical emergency, and an immediate surgical consult is warranted. [11]
The patient can be given viscous lidocaine mixed with Maalox (known as a GI cocktail). While this is therapeutic, it is not diagnostic. ACS can present with dyspepsia and may respond to a GI cocktail; it is, therefore, important to rule out ACS before assigning GERD as a final diagnosis. Long-term treatment of GERD is best accomplished with proton pump inhibitor (PPI) or H2 blocker therapy.[13]
Aortic dissection can cause a stroke. Do not forget to consider this in your workup. Younger patients and those without risk factors can still have an MI. People with diabetes and the elderly may have nerve damage which may make it difficult for them to interpret pain. They may have more atypical presentations of diseases like acute coronary syndrome (ACS).
Chest pain is a common symptom encountered in clinical practice by the nurse practitioner, primary provider, internist, emergency department physician, and surgeon. In most cases, a thorough medical history will provide a clue to the diagnosis. The key is to not miss a life-threatening disorder like an acute MI or an aortic dissection. When the cause of chest pain remains unknown, it is recommended that the patient be referred to a specialist for care. The outcomes for patients with chest pain depending on the cause.
Pleuritic chest pain is characterized by sudden and intense sharp, stabbing, or burning pain in the chest when inhaling and exhaling. Pulmonary embolism is the most common serious cause, found in 5% to 21% of patients who present to an emergency department with pleuritic chest pain. A validated clinical decision rule for pulmonary embolism should be employed to guide the use of additional tests such as d-dimer assays, ventilation-perfusion scans, or computed tomography angiography. Myocardial infarction, pericarditis, aortic dissection, pneumonia, and pneumothorax are other serious causes that should be ruled out using history and physical examination, electrocardiography, troponin assays, and chest radiography before another diagnosis is made. Validated clinical decision rules are available to help exclude coronary artery disease. Viruses are common causative agents of pleuritic chest pain. Coxsackieviruses, respiratory syncytial virus, influenza, parainfluenza, mumps, adenovirus, cytomegalovirus, and Epstein-Barr virus are likely pathogens. Treatment is guided by the underlying diagnosis. Nonsteroidal anti-inflammatory drugs are appropriate for pain management in those with virally triggered or nonspecific pleuritic chest pain. In patients with persistent symptoms, persons who smoke, and those older than 50 years with pneumonia, it is important to document radiographic resolution with repeat chest radiography six weeks after initial treatment.
Pleuritic chest pain is characterized by sudden and intense sharp, stabbing, or burning pain in the chest when inhaling and exhaling. It is exacerbated by deep breathing, coughing, sneezing, or laughing. When pleuritic inflammation occurs near the diaphragm, pain can be referred to the neck or shoulder. Pleuritic chest pain is caused by inflammation of the parietal pleura and can be triggered by a variety of causes.
The visceral pleura does not contain pain receptors, whereas the parietal pleura is innervated by somatic nerves that sense pain due to trauma or inflammation. Inflammatory mediators released into the pleural space trigger local pain receptors. Parietal pleurae at the periphery of the rib cage and lateral hemidiaphragm are innervated by intercostal nerves. Trauma or inflammation in these regions results in pain localized in the cutaneous distribution of those nerves. In contrast, the phrenic nerve innervates the central diaphragm and can refer pain to the ipsilateral neck or shoulder.
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