What are the red flags for chest pain?

Chest pain is a common complaint that 20€“40% of the general population will experience in their lives.¹  It accounts for approximately 5% of visits to the emergency department, and up to 40% of emergency hospital admissions.^2-4  It is therefore important for physicians to manage it correctly.

There are many differentials of chest pain that vary from life threatening to more benign causes.

Cardiological: the acute coronary syndromes (ST elevation myocardial infarctions, non-ST myocardial infarctions and unstable angina), pericarditis and cardiac tamponade.

Vascular: pulmonary emboli (PE) and aortic dissection.

Respiratory: pneumonia, pneumothorax and pleurisy.

Gastrointestinal: oesophageal spasm and gastro-oesophageal reflux.

The critically ill patient with chest pain will require rapid assessment, starting with assessment of the airway, breathing, circulation and review of basic observations before obtaining a detailed history.

The questions asked should be the same as for both younger and older patient, although some elderly patients may have cognitive impairment or dysphasia making it difficult to obtain an accurate history. In these circumstances cardiac risk, past medical history, examination findings and investigations will be valuable. The patient should be assessed for cardiovascular disease risk factors: the most important are advancing age, male gender and family history of premature coronary artery disease.⁵

Questions to ask a patient with chest pain

Onset: Ask what the patient was doing. Also whether the chest pain was abrupt and immediately severe or gradual with increasing severity? This is useful for cardiac markers as exertional pain suggests ischaemia, aortic dissection, pneumothorax or PE whereas gradual suggests myocardial ischaemia.

Site: A pain localised to a small area suggests PE or pleurisy whereas intrascapular or anterior chest pain is typical of aortic dissection.

Character: A tight heavy pressure is typical for ischaemia. Pleuritic character suggests PE, pneumothorax, or pneumonia. A sharp, tearing character could suggest aortic dissection.

Radiation: Radiation from the neck, shoulder, arm(s) or jaw suggests myocardial ischaemia. Radiation from the back, abdomen or legs suggests aortic dissection.

Severity: If chest pain increases over 5€“10 minutes this is suggestive of MI.

Exacerbating factors: Activity, cold, or stress suggests myocardial ischaemia. Inspiration or coughing suggests a pleuritic cause whereas movement or pressure suggests musculoskeletal.

Relieving factors: Exertional pain relieved by rest suggests angina, whereas relief from an upright position or leaning forwards is suggestive of pericarditis. Nitroglycerine (GTN) relief is non-specific.

Associated symptoms: Breathlessness, nausea, diaphoresis could suggest myocardial ischaemia whereas a productive cough could suggest pneumonia and neurological signs could be important for aortic dissection.

Duration: If the pain lasts only for seconds or is unremitting for weeks, this is not typical for ischaemic pain.

Red flags to alert a possible diagnosis of heart attack

Acute coronary syndromes include ST elevation, myocardial infarctions (STEMI), non ST MI (NSTEMI) and unstable angina. Red flags for acute coronary syndromes include:

• Known coronary artery disease
• Clammy, unwell patient
• Exertional chest pain
• Heavy, tight, pressure type chest pain
• Pain radiating to left arm, right shoulder or both arms
• Association with nausea or vomiting
• Known history of coronary artery disease
• Family history of premature coronary artery disease
• Male sex
• New ECG changes: ST elevation, pathological Q waves, LBBB, ST depression, T wave inversion
• Positive troponin.

Which people with chest pain should be admitted to hospital?

According to NICE, most people with a serious cause of chest pain require hospital admission and will need initial pre-hospital management prior to transfer. Patients should be admitted with clinical features that suggest a serious cause of chest pain, such as:

• Respiratory rate of more than 30 breaths per minute.
• Tachycardia greater than 130 beats per minute.
• Systolic blood pressure less than 90mmHg, or diastolic blood pressure less than 60mmHg (unless this is normal for them).
• Oxygen saturation less than 92%, or central cyanosis (if the person has no history of chronic hypoxia).
• Altered level of consciousness.
• High temperature (especially if it is higher than 38.5°C).

Chest pain is one of the most frequent complaints presenting to hospital and a comprehensive assessment with high clinical suspicion is required to improve patient care.

Professor Jerry Murphy Consultant Cardiologist, Darlington Memorial Hospital and Professor of Cardiovascular Medicine, Durham University

References

1. Ruigomez A, Rodriguez LA, Wallander MA, et al. Chest pain in general Practice. Family Practice 2006; 23(2): 167€“ 74
2. Murphy NF, Macintyre K, Capewell S. Hospital discharge rates for suspected Acute Coronary Syndromes between 1990 and 2000: Population based analysis. BMJ 2004: 328(7453): 1413€“14
3. Goodacre S, Cross E, Arnold J et al. The health care burdon of acute chest pain. Heart 2005: 91(2): 229€“30
4. Blatchford O, Capewell S, Murry S. Emergency admissions in Glasgow: general practices vary dispite adjustments for age, sex and deprivation. The British Journal of General Practice 1999: 49(444): 551€“54
5. Konotos MC. Evaluation of the emergency department chest pain patient. Cardiol Rev 2001; 9: 266€“75