Chest pains and angina

1

Are most emergency room visits for chest pain caused by acute coronary syndromes?

• No. Acute coronary syndromes (e.g., unstable angina, myocardial infarction) account for only a small percentage of emergency room (ER) visits for chest pain. Depending on the study, only a small percentage of patients (1%–11%) are diagnosed as having chest pains caused by coronary artery disease (CAD) or acute coronary syndrome (ACS). ACS is the term used to describe the continuum of syndromes that include unstable angina and myocardial infarction (MI).

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What are the other important causes of chest pains besides chronic stable angina and acute coronary syndrome?

• It is important to quickly recognize and exclude the life-threatening causes of chest pain, which include ACS, aortic dissection, pneumothorax, pulmonary embolism (PE), and esophageal rupture.

• The differential diagnosis for chest pains includes cardiovascular, pulmonary, gastrointestinal, musculoskeletal, psychiatric, and dermatologic causes. Cardiovascular causes include ACSs (unstable angina, non–ST-segment elevation ACS and ST-segment elevation myocardial infarction [STEMI]), aortic dissection, hypertensive crisis, severe aortic stenosis, coronary artery spasm (Prinzmetal angina, cocaine abuse), and cardiac syndrome X (microvascular disease). Pulmonary causes include pneumonia, pneumothorax, PE, and pleuritis. Gastrointestinal causes include esophageal spasms, esophageal reflux and esophagitis, esophageal rupture (Boerhaave syndrome), peptic ulcer disease, gallbladder disease, and pancreatitis. Musculoskeletal causes include costrochondritis and rib fractures. Other causes include cervical radiculopathies, shingles, and somatiform disorders. Table 14.1 summarizes the clinical descriptions and presenting features of the different causes of chest pain.

  Table 14.1

  Common Causes of Acute Chest Pain

  From Lee, T. H., & Cannon, C. P. (2008). Approach to the patient with chest pain. In R. O. Bonow, P. Libby, D. L. Mann, & D. P. Zipes (Eds.), Braunwald’s heart disease: a textbook of cardiovascular medicine (8th ed., Chapter 49). Philadelphia, PA: Saunders.

  SYNDROME	CLINICAL DESCRIPTION	PRESENTING FEATURES
  Cardiovascular
  Stable angina	Retrosternal pressure, heaviness, burning and may radiate to arms, neck, jaw	Provoked by physical or emotional stress
  Unstable angina	Same as stable angina but usually more severe and prolonged	Occurs at rest or with minimal exertion
  Acute MI	Same as angina but usually more severe	Usually >30-min duration; associated symptoms include dyspnea, weakness, diaphoresis
  Aortic dissection	Sudden severe pain and may radiate to back	Commonly associated with hypertension or connective tissue disease
  Pericarditis	Pleuritic pain, worse in supine position	Fever, pericardial friction rub
  Pulmonary
  PE	Sudden onset of pain and dyspnea; pain may be pleuritic with pulmonary infarction	Dyspnea, tachypnea, tachycardia
  Pneumonia	May be associated with localized pleuritic pain	Cough, fever, crackles
  Spontaneous pneumothorax	Unilateral pleuritic pain associated with dyspnea	Sudden onset of symptoms
  Gastrointestinal
  Esophageal reflux	Burning retrosternal and epigastric discomfort	Aggravated by large meals and postprandial recumbency
  Peptic ulcer	Prolonged epigastric or retrosternal burning	Relieved by antacid or food
  Billary disease	Right upper quadrant pain	Unprovoked or following meal
  Pancreatitis	Intense epigastric and retrosternal pain	Associated with alcoholism, elevated triglycerides
  Musculoskeletal
  Costochondritis	Fleeting localized pain and may be intense	May be reproducible by pressure to affected site
  Cervical disk disease	Sudden fleeting pain	May be reproduced by movement of neck
  Psychological
  Somatoform disorders, sudden fleeting pain and may be produced by movement of neck	Symptoms are atypical for any organ system	Symptoms may persist despite negative evaluations of multiple organ systems

  MI, Myocardial infarction; PE , pulmonary embolism.

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Why is prompt diagnosis of acute aortic dissection so important?

• In aortic dissection, the mortality rate increases by approximately 1% every hour from presentation to diagnosis and treatment. Additionally, the treatment of aortic dissection is dramatically different from the treatment of ACS, because anticoagulation is contraindicated with aortic dissection.

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What is angina?

• Angina is the term used to denote the discomfort associated with myocardial ischemia or MI. Angina occurs when myocardial oxygen demand exceeds myocardial oxygen supply, usually as a result of a severely stenotic or occluded coronary artery. Patients with angina most commonly describe a sensation of chest pain , chest pressure , or chest tightness . They may also use words such as heaviness , discomfort , squeezing , or suffocating . The discomfort is more commonly over a region the size of a fist or a larger sized region—that is, larger than just a pinpoint area (although this distinction is not enough in itself to confidently distinguish angina from nonanginal pain). The discomfort classically occurs over the left precordium but may manifest as right-sided chest discomfort, retrosternal discomfort, or discomfort in other areas of the chest. Some people may experience the discomfort only in the upper back, in the arm or arms, or in the neck or jaw. Angina can also manifest as epigastric pain or discomfort and thus is often misdiagnosed as indigestion.

• Typical angina is described as having three characteristics: (1) substernal chest discomfort (with the typical sensations noted above), (2) discomfort provoked by exertion or emotional stress, and (3) discomfort relieved by rest or nitroglycerin (NTG) within minutes.

• Table 14.2 summarizes specific details of the chest pain history that are likely to be helpful in distinguishing anginal chest pain from pain of noncardiac causes.

  Table 14.2

  Specific Details of the Chest Pain History Helpful in Distinguishing Anginal Chest Pain Due to Myocardial Infarction from Pain of Noncardiac Causation

  Modified from Swap, C. J., & Nagurney, J. T. (2005). Value and limitations of chest pain history in the evaluation of patients with suspected acute coronary syndromes. Journal of American Medical Association, 294, 2623–2629.

  ELEMENT	QUESTION	COMMENTS
  Chest Pain Characteristics
  Quality	In your own words, how would you describe the pain? What adjectives would you use?	Pay attention to language and cultural considerations; use interpreter if necessary.
  Location	Point with your finger to where you are feeling the pain.	Can elicit size of chest pain area with the same question.
  Radiation	If the pain moves out of your chest, trace where it travels with your finger.	Patient may need to point to examiner’s scapula or back.
  Size of area or distribution	With your finger, trace the area on your chest where the pain occurs.	Focus on distinguishing between a small coin-sized area and a larger distribution.
  Severity	If 10 is the most severe pain you have ever had, on this 10-point scale, how severe was this pain?	Patient may need to be coached in this: pain of fetal delivery, kidney stone, bony fracture are good references for 10.
  Time of onset and is it continuing	Is the pain still present? Has it gotten better or worse since it began? When did it begin?	Ongoing pain a concern: it is worthwhile to obtain an initial ECG while pain is present.
  Duration	Does the pain typically last seconds, minutes, or hours? Roughly, how long is a typical episode?	Focus on the most recent (especially if ongoing) and the most severe episode; be precise: if the patient says “seconds,” tap out 4 seconds.
  First occurrence	When is the first time you ever had this pain?	Interest should focus on this recent episode—that is, the past few days or weeks.
  Frequency	How many times per hour or per day has it been occurring?	Relevant only for recurring pain: a single index episode is not uncommon.
  Similar to previous cardiac ischemic episodes	If you have had a heart attack or angina in the past, is this pain similar to the pain you had then? Is it more or less severe?	Follow-up questions elicit how the diagnosis of CAD was confirmed and whether any intervention occurred.
  Precipitating or Aggravating Factors
  Pleuritic	Is the pain worse if you take a deep breath or cough?	Distinguish between whether these maneuvers only partially or completely reproduce the pain and if it reproduces the pain only some or all of the time.
  Positional	Is the pain made better or worse by your changing body position? If so, what position makes the pain better or worse?	Distinguish between whether these maneuvers only partially or completely reproduce the pain: on physical examination, turn the chest wall, shoulder, and back.
  Palpable	If I press on your chest wall, does that reproduce the pain?	Distinguish between whether these maneuvers only partially or completely reproduce the pain: ask the patient to lead you to the area of pain; then palpate.
  Exercise	Does the pain come back or get worse if you walk quickly, climb stairs, or exert yourself?	Helpful to quantify a change in pattern (e.g., the number of stairs or distance walked before the pain began).
  Emotional stress	Does becoming upset affect the pain?	Are there other stress-related symptoms (e.g., acroparesthesias)?
  Relieving factors	Are there any things that you can do to relieve the pain once it has begun?	In particular, ask about response to nitrates, antacids, ceasing strenuous activity.
  Associated symptoms	Do you typically get other symptoms when you get this chest pain?	After asking question in open-ended way, ask specifically about nausea or vomiting and about sweating.

  CAD , Coronary artery disease; ECG , electrocardiogram.

5

Who first described angina and when?

• The association between chest pain (angina pectoris) and heart disease was first noted by William Heberden in 1772. He described this as a strangling sensation in the chest in his manuscript entitled “ Some account of a disorder of the breast .”

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