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For further information, see CMDT Part 2-05: Chest Pain

KEY FEATURES

Essential Inquiries

  • Pain onset, character, location/size, duration, periodicity, and exacerbating factors

  • Shortness of breath

  • Vital signs; chest and cardiac examination

  • Electrocardiogram and biomarkers of myocardial necrosis

General Considerations

  • Can occur as a result of

    • Cardiovascular, pulmonary, pleural, or musculoskeletal disease

    • Esophageal or other gastrointestinal disorders

    • Herpes zoster

    • Cocaine use

    • Anxiety states

  • Conditions that confer a strong risk for coronary artery disease

    • Diabetes mellitus

    • Hyperlipidemia

    • Untreated hypertension

    • Systemic lupus erythematosus

    • Rheumatoid arthritis

    • Reduced estimated glomerular filtration rate (eGFR)

    • HIV

  • Precocious acute coronary syndrome (ACS)

    • Occurs in patients aged 35 years or younger

    • May represent acute thrombosis independent of underlying atherosclerotic disease

    • Risk factors are obesity, familial hypercholesterolemia, cigarette use, and myocardial bridging (often associated with left ventricular hypertrophy)

  • Because pulmonary embolism (PE) can present with a wide variety of symptoms, consideration of this diagnosis and rigorous risk factor assessment for venous thromboembolism (VTE) is critical

  • Classic VTE risk factors include

    • Cancer

    • Trauma

    • Recent surgery

    • Prolonged immobilization

    • Pregnancy

    • Oral contraceptives

    • Family history

    • Prior history of VTE

    • Heart failure

    • Chronic obstructive pulmonary disease

  • Sickle cell anemia

    • Can cause acute chest syndrome

    • Often with fever and cough

  • Carbon monoxide poisoning

CLINICAL FINDINGS

Symptoms

  • Ischemic cardiac pain symptoms

    • Dull, aching sensation of "pressure," "tightness," "squeezing," or "gas," rather than a sharp or spasmodic pain

    • Usually subside within 5–20 minutes but may last longer

    • May be accompanied by a sense of anxiety or uneasiness

    • Retrosternal or left precordial in location but pain may be referred to the

      • Throat

      • Lower jaw

      • Shoulders

      • Inner arms

      • Upper abdomen

      • Back

    • May be precipitated or exacerbated by exertion, cold temperature, meals, stress, or combinations of these factors

    • Usually relieved by rest

    • Uncommon for pain to reach maximum intensity in seconds

    • Prolonged chest pain episodes might represent myocardial infarction, although up to one-third of patients with acute myocardial infarction do not report chest pain

    • Progressive symptoms or symptoms at rest may represent unstable angina

  • Acute coronary syndrome (ACS)

    • A broader range of symptoms are more common in older adults, women, and persons with diabetes

    • Chest discomfort at rest

      • Most common presenting symptom of ACS, reported by 79% of men and 74% of women

      • Dull, aching sensation of “pressure,” “tightness,” “squeezing,” or “gas,” rather than sharp or spasmodic

      • Up to one-third of patients with acute myocardial infarction do not report chest pain

    • Shortness of breath

    • Dizziness

    • Anxiety, such as a feeling of impending doom

    • Vagal symptoms, such as nausea and diaphoresis

    • In older adults, fatigue is a common presenting complaint of ACS

    • Women with ACS are more likely than men to present with three or more associated symptoms (eg. epigastric symptoms; palpitations; and pain or discomfort in the jaw, neck, arms, or between the shoulder blades)

  • Hypertrophy of either ventricle or aortic stenosis may also ...

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