5 Min In Clinical
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Problem representation
A 59-year-old male with co-morbidities presents via a phone call with acute chest pain associated with nausea. As a regular at your pharmacy, you know he suffers from asthma, GI discomfort and is pre-diabetic, and takes salbutamol, beclometasone and lansoprazole.
Hypothesis generation
A wide range of medical conditions can cause chest pain, making it a relatively common presentation in primary care – 1 to 2 per cent of adults attending primary care each year have a new presentation of chest pain. These can range from mild, vague symptoms through to those that are severe and debilitating. Causes tend to be grouped into cardiac and non-cardiac types.
Acute coronary syndrome (ACS) encompassing unstable angina, ST-elevation myocardial infarction and non-ST-elevation myocardial infarction is a common presentation. Excluding ACS is key to managing chest pain.
Likely diagnosis
• Acute coronary syndrome
• Costochondritis
• Gastro-oesophageal disease (GORD)
• Musculoskeletal pain
• Panic attacks
• Stable angina
Possible diagnosis
• Biliary colic
• Heart failure
• Peptic ulcer disease
• Pneumonia
• Pleurisy
• Shingles
Critical diagnosis
• Acute coronary syndrome
• Acute thoracic aortic dissection
• Perforated oesophagus
• Pericarditis
• Pneumothorax
• Pulmonary embolism.
Continued information gathering
You know Larry has been experiencing the pain for 20-30 minutes. This is useful as long-standing pain (i.e. for days or weeks) is not immediately life-threatening. Such pain is often musculoskeletal or gastrointestinal in origin. Similarly, brief (< 5 seconds), sharp, intermittent pain rarely indicates a serious condition.
Pain lasting minutes to hours is, however, suggestive of a serious problem. This fits with Larry’s presentation and has to be uppermost in your thinking. At this point musculoskeletal causes seem unlikely.
It is important to better understand Larry’s chest pain. Where is the pain located? (Is it localised or diffuse? Does it radiate?) What is the nature of the pain? (Is it sharp, dull, intermittent or continuous?). Has it been experienced before?
Larry tells you that this is the first time he has experienced this type of pain. He describes the pain as constant, situated in his upper chest but not elsewhere, and says he feels as if a weight has been placed on his chest.
This description seems to exclude conditions such as costochondritis and panic attacks as these are associated with ‘sharp’ pain. A cardiac cause or GORD seem most probable, especially as Larry has a history GI-related problems.
Problem refinement
To try and differentiate between these two causes, it is important to see if anything makes the pain better or worse. Larry says the pain just started while he was watching TV. This suggests that nothing exertional precipitated the symptoms and seems to rule out angina as a cause.
When you ask if the pain started after eating food, Larry again says he was just watching TV. A GI cause now also seems less likely.
Given there appears to be no event that has precipitated his symptoms, a cardiac cause has to be suspected, especially due to his age and his pre-diabetic state.
Red flags
There is sufficient evidence to suggest that Larry has chest pain of cardiac origin and there is no need to explore if other red flag signs or symptoms exist.
Management
An ambulance needs to be arranged to attend Larry so paramedics can further assess him and determine if he needs admitting to hospital.
Self-care options
You are aware of Larry’s medical and medication history and do not know of any allergies. As you suspect ACS is the cause of his symptoms, you tell Larry to take 300mg of aspirin if he has any at home and that you will call an ambulance on his behalf.
Key points
• Acute coronary syndrome and GORD are common presentations of chest pain
• All suspected cardiac causes of chest pain need to be referred to hospital
• For suspected ACS the patient could be told to use GTN or aspirin
Now check your knowledge on chest pain by answering the following questions:
1. Chest pain is very common and can be sharp or dull. The sensation may be described as discomfort, tightness, burning or aching. Which ONE of the following leads to chest pain on physical exertion?
a. Blockage of an artery to the lungs by a blood clot
b. Heart attack
c. Pericarditis
d. Pulmonary embolism
e. Stable angina
2. Which ONE of the following situations does not need to be treated as a medical emergency?
a. Chest pain that lasts for 30 seconds or less
b. Chest pain described as radiating to the arm
c. Crushing or squeezing pain in the chest
d. Sensation of a rapid or irregular heartbeat, accompanied by chest pain
e. Shortness of breath, accompanied by chest pain
3. For pain of cardiac origin, which ONE of the following statements is true? Pain associated with:
a. Angina is confined to the chest area
b. Angina is relieved by rest
c. Myocardial infarction is always severe
d. Myocardial infarction always moves to the left arm
e. Pericarditis is worsened when bending forward
4. Cardiac chest pain is best described by which ONE of the following terms?
a. Central and burning
b. Constant and gnawing
c. Crushing
d. Sharp and localised
e. Replicated with palpation
5. A 64-year-old woman presents with chest pain. She describes the pain, which started that evening and has progressively worsened, as a burning sensation that is also felt in the throat. She has no history of heart disease or other medical problems and takes no regular medicines. Which ONE of the following is the most likely cause of her chest pain?
a. Biliary colic
b. Costochondritis
c. Gastro-oesophageal reflux disease
d. Pulmonary embolism
e. Unstable angina
Answers: 1.e 2.a 3.b 4.c 5.c
Possible causes of chest pain
Acute coronary syndrome (unstable angina and myocardial infarction)
This should be suspected when the patient experiences chest pain, described as dull and/or crushing, which lasts longer than 15 minutes. Pain can also be experienced in the jaw, back and arms. Typically, nausea and/or vomiting, sweating and breathlessness are present. Anyone with suspected ACS requires urgent hospital admission.
Costochondritis
Costochondritis is a condition in which the cartilage joining the ribs to the sternum becomes inflamed. Chest pain can mimic that of a heart attack. The pain is sharp and can be reproduced with palpation.
GORD
Classically, GORD presents with burning retrosternal pain, acid regurgitation and a sour or bitter taste in the mouth. However, it can present with chest pain and is the most frequent imitator of cardiac chest pain. This is because the location of the oesophagus runs alongside the heart and both organs convey pain signals via the same sensory nerves.
Musculoskeletal pain
Musculoskeletal injury can cause chest pain. This can be via a traumatic event leading to issues such as bruised or broken ribs or via strenuous physical activity leading to muscle strains. Onset can be sudden causing persistent pain that can vary in intensity and worsens with physical activity.
Panic attacks
The symptoms of a panic attack are similar to those of a heart attack. Typical symptoms include sharp chest pain, difficulty in breathing, sweating, nausea, and elevated heart rate.
Stable angina
Anginal pain is substernal and typically lasts 30 seconds to a few minutes. It is dull or aching and can feel like a pressing or squeezing sensation. The pain may radiate to the upper extremities, neck or jaw. Pain is generally related to physical or emotional stress.
Biliary colic
Typically presents with sudden persistent colicky and severe epigastric pain but can be substernal. Pain usually lasts for 30 minutes but can last hours at a lower intensity. It starts a few hours after a meal, frequently awakening the patient in the early hours of the morning. The pain can radiate to the tip of the right scapula or back. Nausea and vomiting are common. The incidence increases with age and is most common in people 50 years and over. It is also more prevalent in women than in men.
Heart failure
Often the first symptoms patients experience are fatigue, shortness of breath on exertion, orthopnoea and dyspnoea at night, although some will have chest pain. It is rare in those younger than 65 years of age but prevalence rises rapidly with increasing age, affecting one in seven people older than 85 years. As the condition progresses from mild to moderate to severe, patients will show ankle swelling and sometimes develop a productive frothy cough, which may have pink-tinged sputum.
Pneumonia (community-acquired)
This is a cause of chest pain and respiratory symptoms. Symptoms are typically sudden in onset and include cough, fever, general malaise and pleuritic chest pain. Other less common symptoms include headache, fatigue, sweating and wheeze. Older patients are often afebrile and may present with confusion. Examination will show abnormal breath sounds and tachycardia.
Pleurisy
The most common clinical features are a sharp chest pain, which is localised and made worse by coughing or deep inspiration. Sometimes the pain is also felt in the shoulder. Other symptoms can include shortness of breath and cough.
Peptic ulcer disease
Typically, peptic ulcer disease presents with well-localised, mid-epigastric pain described as constant, annoying, gnawing or boring. In gastric ulcers the pain is usually triggered by food and experienced shortly after eating. In duodenal ulcers the pain occurs two to five hours after meals, which is relieved by food and often wakes a person at night.
Shingles
Shingles is characterised by a vesicular rash following a dermatome on one side of the body. However, prior to the rash developing the patient may experience pain, which can manifest in the chest. When associated with shingles it often feels like a band of sharp pain.
Acute coronary syndrome (See Likely diagnoses)
Acute thoracic aortic dissection
Presents as sudden and very severe (the worst ever experienced) chest or back pain, which is described as sharp or tearing. The pain can be so severe that it causes the patient to pass out. They tend to be hypertensive and show signs of neurological deficit such as limb weakness or numbness.
Perforated oesophagus
Symptoms of oesophageal rupture include chest and abdominal pain, fever, vomiting, haematemesis and shock. Other non-specific signs include tachypnoea and tachycardia.
Pericarditis
This is characterised by new onset retrosternal chest pain that worsens with inspiration or when leaning backwards/lying down but eased when sitting forward. Pain may radiate to the left shoulder and/or left arm and/or into the abdomen. Other symptoms may include fever, cough and arthralgia. Cardiac tamponade may have associated breathlessness, dysphagia, cough and hoarseness.
Pneumothorax (collapsed lung)
Clinical presentation of a pneumothorax can range anywhere from asymptomatic to chest pain and shortness of breath. The patient is likely to show signs of distress. The severity of symptoms depends on the extent of lung collapse. It is most common in men. Smoking is the most important risk factor.
Pulmonary embolism
Predominant symptoms are dyspnoea, pleuritic chest pain, fever and leg pain/swelling. Cough can also be present with haemoptysis. There are a number of well-known risk factors such as increasing age, active cancer, recent surgery or trauma. The patient’s skin may appear mottled and pale and he/she might be tachycardic.
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In Clinical
Let’s get clinical. Follow the links below to find out more about the latest clinical insight in community pharmacy.