Critical Care Medicine
Acute myocardial infarction
Acute coronary syndrome
1. Description of the problem
Chest pain may be the result of any number of pathologic and non-pathologic processes. It is important to take a thorough history, as this can often be the key factor in determining the etiology for a patient's chest pain symptoms.
Careful attention should be focused on obtaining a history that may help to establish a diagnosis for the patient's chest pain. Key features of the history include character and quality of the chest pain, location and radiation of the chest pain, precipitating/exacerbating/alleviating factors, chest pain duration, and associated symptoms.
With the history and physical examination, along with ancillary studies (including electrocardiogram, chest x-ray, and laboratory studies), the treating clinician should focus on determining the etiology of symptoms. In particular, one should determine if any high-risk conditions are present, including acute myocardial infarction, acute coronary syndrome, acute pulmonary embolism, pneumothorax, or aortic dissection.
2. Emergency Management
Management largely depends upon the etiology of a patient's chest pain presentation. As in all patients, early management should address hemodynamic stabilization and airway control as necessary. The goal is to evaluate and exclude the possibility of life-threatening diseases, including acute coronary syndrome, pulmonary embolism, and aortic dissection, in particular.
All patients with a history and/or examination concerning for acute myocardial infarction or acute coronary syndrome should get an immediate 12-lead ECG. Patients with possible pneumothorax should have an immediate chest x-ray, or tube thoracostomy if tension pneumothorax is present. Patients with presumed pulmonary embolism often require a confirmatory test, including ventilation-perfusion scan or computed tomography angiography (CTA). Those with possible aortic dissection should be further evaluated with either computed tomography or echocardiography.
Drugs and dosages
Aspirin: Aspirin should be given to all patients with presumed myocardial infarction or acute coronary syndrome; 162-325 mg orally.
Heparin: Either unfractionated or low-molecular-weight heparin should be administed to patients with presumed pulmonary embolism.
As mentioned, an accurate and thorough history is often the key to establishing a definitive diagnosis in patients presenting with chest pain. Ancillary studies, depending upon the pre-test probability of disease, could include ECG, chest x-ray, echocardiogram, computed tomography, or angiography. Other studies often include routine laboratory tests (complete blood count, serum chemistries, creatinine, blood urea nitrogen, liver function tests, cardiac enzymes, d-dimer).
The careful accumulation of data from the history, physical examination, and ancillary studies should help the clinician establish a definitive diagnosis. Often, no diagnosis is determined.
The pathophysiology of chest pain depends upon the exact etiology.
Chest pain is the presenting symptom in over 10% of emergency department visits.
Special considerations for nursing and allied health professionals.
What's the evidence?
Woo, KM. "High-risk chief complaints I: chest pain - the big three". Emerg Med Clin North Am. vol. 27. 2009. pp. 685-712.Overview of chest pain evaluation in the emergency department
Hess, EP. "Derivation of a clinical decision rule for chest radiography in emergency department patients with chest pain and posssible acute coronary syndrome". CJEM. vol. 12. 2010. pp. 128-34.Decision pathway used to differentiate ischemic from non-ischemic causes of chest pain in the emergency department.
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