Chest Pain

1. Given a patient with undefined chest pain, take an adequate history to make a specific diagnosis (e.g., determine risk factors, whether the pain is pleuritic or sharp, pressure, etc.).
2. Given a clinical scenario suggestive of life-threatening conditions (e.g., pulmonary embolism, tamponade, dissection, pneumothorax), begin timely treatment (before the diagnosis is confirmed, while doing an appropriate work-up).
3. In a patient with unexplained chest pain, rule out ischemic heart disease.* (*See also the key features on ischemic heart disease)
4. Given an appropriate history of chest pain suggestive of herpes zoster infection, hiatal hernia, reflux, esophageal spasm, infections, or peptic ulcer disease:
   1. Propose the diagnosis.
   2. Do an appropriate work-up/follow-up to confirm the suspected diagnosis.
5. Given a suspected diagnosis of pulmonary embolism:
   1. Do not rule out the diagnosis solely on the basis of a test with low sensitivity and specificity
   2. Begin appropriate treatment immediately

Chest Pain DDx

• Cardiac
  • Acute Coronary Syndrome (ACS)
  • Myocarditis
  • Pericarditis
    • Pleuritic chest pain, decreased on leaning forward
    • Diffuse ST elevation, PR depression, pericardial friction rub
    • Treatment
      • Supportive, NSAIDs, steroids
• Pulmonary
  • Pulmonary Embolism
  • Tension pneumothorax (see trauma)
  • Pneumonia
  • COPDE
  • Acute chest syndrome (sickle cell)
• Thoracic aortic dissection
  • Sudden, severe pain radiating to back
  • Widened mediastinum on CXR, >20mmHg difference in BP on left vs. right
  • Treatment
    • Decrease contractility and BP (target sBP <120)
    • ABC, surgery/ICU
• GI
  • Boerhaave's sydrome (esophageal rupture)
    • Treatment
      • NPO
      • IV Abx, IV PPI, Endoscopy/surgical repair
  • GERD/PUD
• Chest wall
  • Costochondritis
  • MSK
  • Herpes Zoster
• Psychogenic (Anxiety)

Outpatient Management

• Refer to emergency if <24h for monitoring of worsening symptoms and potential complications
  • 1.5% of primary care office visits for chest pain will have an Acute Coronary Syndrome
• Consider using Marburg Heart Score (MHS) prediction rule to aid in out-patient primary care decision-making
  • Assign one point for each of the following
    • Age/sex: men 55 years or older, women 65 years or older
    • Known clinical vascular disease (CAD, occlusive vascular disease, cerebrovascular disease)
    • Pain worse with exercise
    • Pain not elicited with palpation
    • Patient assumes pain is of cardiac origin
  • 0-1 points predicts a 1% CAD risk
  • 0-2 points predicts a 3% CAD risk
• May consider investigations (EKG +/- STAT Troponin) in office-setting in only certain cases
  • Resolved symptoms with ACS symptoms >24h prior to presentation
  • Atypical chest pain with very low likelihood of ACS (and want to "rule out" ACS), consider repeat 3h after presentation if symptoms <6h