Acute chest pain: Difference between revisions
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''See [[Acute coronary syndrome (main)]] for ACS specific workup and risk stratification; see [[Chest pain (peds)]] for pediatric patients.'' | |||
==Background== | |||
== | ==Clinical Features== | ||
{{Clinical features ACS}} | |||
== | ==Differential Diagnosis== | ||
{{Chest Pain DDX}} | |||
==Evaluation== | |||
===Workup=== | |||
====Younger patients/less concerning story==== | |||
*[[ECG]] | |||
*[[CXR]] | |||
====Older patients/more concerning story==== | |||
*[[ECG]] | |||
*CBC | |||
*Chemistry | |||
*PT/PTT | |||
*[[Troponin]] | |||
*[[CXR]] | |||
*Consider: | |||
# | **[[BNP]] | ||
**[[D-dimer]] vs. CTA chest | |||
===Diagnosis=== | |||
''Consider differential diagnosis (see above) and rule out emergent causes'' | |||
*[[ACS]]: Consider using [https://www.mdcalc.com/heart-pathway-early-discharge-acute-chest-pain HEART Pathway] | |||
*[[PE]]: See [[Pulmonary_embolism#Workup_by_Pretest_Probability|Pulmonary embolism by pretest probability]] | |||
==Management== | |||
*Based on underlying cause | |||
==Disposition== | |||
*Based on underlying cause | |||
*HEART score may assist in determining low risk discharge vs admission for further ACS evaluation | |||
==See Also== | ==See Also== | ||
*[[Acute Coronary Syndrome (Main)]] | *[[Acute Coronary Syndrome (Main)]] | ||
*[[Chest pain]] | |||
*[[Chest Pain (Peds)]] | *[[Chest Pain (Peds)]] | ||
*[[Cocaine chest pain]] | |||
*[[HEART Score]] | |||
== | ==References== | ||
<references/> | |||
[[Category: | [[Category:Cardiology]] | ||
[[Category:Symptoms]] | |||
Latest revision as of 06:39, 11 May 2024
See Acute coronary syndrome (main) for ACS specific workup and risk stratification; see Chest pain (peds) for pediatric patients.
Background
Clinical Features
Risk of ACS
Clinical factors that increase likelihood of ACS/AMI:[1][2]
- Chest pain radiating to both arms > R arm > L arm
- Chest pain associated with diaphoresis
- Chest pain associated with nausea/vomiting
- Chest pain with exertion
Clinical factors that decrease likelihood of ACS/AMI:[3]
- Pleuritic chest pain
- Positional chest pain
- Sharp, stabbing chest pain
- Chest pain reproducible with palpation
Gender differences in ACS
- Women with ACS:
- Less likely to be treated with guideline-directed medical therapies[4]
- Less likely to undergo cardiac catheterization[4]
- Less likely to receive timely reperfusion therapy[4]
- More likely to report fatigue, dyspnea, indigestion, nausea or vomiting, palpitations, or weakness,[4] although some studies have found fewer differences in presentation[5]
- More likely to delay presentation[4]
- Men with ACS:
- More likely to report central chest pain
Factors associated with delayed presentation[4]
- Female sex
- Older age
- Black or Hispanic race
- Low educational achievement
- Low socioeconomic status
Differential Diagnosis
Chest pain
Critical
- Acute coronary syndromes (ACS)
- Aortic dissection
- Cardiac tamponade
- Coronary artery dissection
- Esophageal perforation (Boerhhaave's syndrome)
- Pulmonary embolism
- Tension pneumothorax
Emergent
- Cholecystitis
- Cocaine-associated chest pain
- Mediastinitis
- Myocardial rupture
- Myocarditis
- Pancreatitis
- Pericarditis
- Pneumothorax
Nonemergent
- Aortic stenosis
- Arthritis
- Asthma exacerbation
- Biliary colic
- Costochondritis
- Esophageal spasm
- Gastroesophageal reflux disease
- Herpes zoster / Postherpetic Neuralgia
- Hypertrophic cardiomyopathy
- Hyperventilation
- Mitral valve prolapse
- Panic attack
- Peptic ulcer disease
- Pleuritis
- Pneumomediastinum
- Pneumonia
- Rib fracture
- Stable angina
- Thoracic outlet syndrome
- Valvular heart disease
- Muscle sprain
- Psychologic / Somatic Chest Pain
- Spinal Root Compression
- Tumor
Evaluation
Workup
Younger patients/less concerning story
Older patients/more concerning story
Diagnosis
Consider differential diagnosis (see above) and rule out emergent causes
- ACS: Consider using HEART Pathway
- PE: See Pulmonary embolism by pretest probability
Management
- Based on underlying cause
Disposition
- Based on underlying cause
- HEART score may assist in determining low risk discharge vs admission for further ACS evaluation
See Also
References
- ↑ Body R, Carley S, Wibberley C, et al. The value of symptoms and signs in the emergent diagnosis of acute coronary syndromes. Resuscitation. 2010;81(3):281–286. PMID: 20036454
- ↑ Panju AA, Hemmelgarn BR, Guyatt GH, et al. The rational clinical examination. Is this patient having a myocardial infarction? JAMA. 1998;280(14):1256–1263. PMID: 9786377
- ↑ Swap CJ, Nagurney JT. Value and limitations of chest pain history in the evaluation of patients with suspected acute coronary syndromes. JAMA. 2005;294(20):2623–2629. PMID: 16304077
- ↑ 4.0 4.1 4.2 4.3 4.4 4.5 Mehta LS, et al. Acute myocardial infarction in women: A scientific statement from the American Heart Association. Circulation. 2016; 133:916-947.
- ↑ Gimenez MR, et al. Sex-specific chest pain characteristics in the early diagnosis of acute myocardial infarction. JAMA Intern Med. 2014; 174(2):241-249.