Chest Pain - Diagnostic Approach

Diagnostic Approach

In the emergency department the typical approach to chest pain involves ruling out the most dangerous causes: heart attack, pulmonary embolism, thoracic aortic dissection, esophageal rupture, tension pneumothorax and cardiac tamponade. By elimination or confirmation of the most serious causes, a diagnosis of the origin of the pain may be made. Often, no definite cause will be found and reassurance is then provided.

If acute coronary syndrome ("unstable angina") is suspected, many people are admitted briefly for observation, sequential ECGs, and determination of cardiac enzymes over time. On occasion, further tests on follow up may determine the cause. TIMI score performed at time of admission may help stratify risk.

As in all medicine, a careful medical history and physical examination is essential in separating dangerous from trivial causes of disease, and the management of chest pain may be done on specialised units (termed medical assessment units) to concentrate the investigations. A rapid diagnosis can be life-saving and often has to be made without the help of X-rays or blood tests (e.g. aortic dissection). Occasionally, invisible medical signs will direct the diagnosis towards particular causes, such as Levine's sign in cardiac ischemia. Generally, however, additional tests are required to establish the diagnosis.

Knowing a patient's risk factors can be extremely useful in ruling in or ruling out serious causes of chest pain. For example, heart attack and thoracic aortic dissection are very rare in healthy individuals under 30 years of age, but significantly more common in individuals with significant risk factors, such as older age, smoking, hypertension, currently smoking, diabetes, history of coronary artery disease, stroke, or past heart attack. A focus on recent health changes, family history (premature atherosclerosis, cholesterol disorders), heart attack at early age, tobacco smoking, diabetes and other risk factors is often useful in determining a patient's individual risk.

Features of the pain suggestive of cardiac ischaemia are describing the pain as heaviness; radiation of the pain to the neck, jaw or left arm; sweating; nausea; palpitations; the pain being felt upon exertion; dizziness; shortness of breath; and a "sense of impending doom."

On the basis of the above, a number of tests may be ordered:

• X-rays of the chest and/or abdomen (CT scanning may be better but is often not available). Routine X-rays and CT may however not be needed.
• An electrocardiogram (ECG)
• V/Q scintigraphy or CT pulmonary angiogram(when a pulmonary embolism is suspected)
• Blood tests:
  • Complete blood count
  • Electrolytes and renal function (creatinine)
  • Liver enzymes
  • Creatine kinase (and CK-MB fraction in many hospitals)
  • Troponin I or T (to indicate myocardial damage)
  • D-dimer (when suspicion for pulmonary embolism is present but low)
  • serum lipase to exclude acute pancreatitis