Acute chest pain is a regular visitor to general practice: It may generate more adrenaline in the physician than the patient. In spite of a constellation of causes, a good basic clinical approach will determine the diagnosis in nearly all cases, long before any necessary investigations are complete.
- Anxiety (Da Costa’s Syndrome)
- Pulled Muscle
- Tietze’s Syndrome (Costochondritis)
- Pleurisy (e.g. From Pneumonia or Pulmonary Embolus)
- Peptic Ulcer
- Biliary Colic
- Bornholm Disease
- Pulmonary Infarct
- Hypertrophic Obstructive Cardiomyopathy
- Fractured Ribs
- Dissecting Aortic Aneurysm
Key distinguishing features of the most common diagnoses
|Angina||GORD||Anxiety||Pulled Muscle||Tietze’s Syndrome|
|Worse on Exertion||Yes||Possible||Possible||Possible||Possible|
|Worse Lying Down||No||Yes||Possible||No||No|
|Eased by Rest||Yes||Possible||Possible||Yes||Possible|
|Swelling at Tender Point||No||No||No||No||Yes|
Possible: FBC, CXR, pulse oximetry, secondary care cardiac investigations, OGD, ultrasound of abdomen.
Small Print: Helicobacter tests, hospital-based investigations for pulmonary embolus.
- ECG: May show evidence of cardiac ischaemia, pericarditis or pulmonary embolism.
- FBC: WCC raised in pleurisy and may be raised in Tietze’s syndrome.
- CXR: May reveal chest infection, rib fracture, heart disease, cardiomyopathy or pneumothorax.
- Pulse oximetry: Hypoxia a sign of significant cardiac or respiratory problem in the acute setting.
- Secondary care cardiac investigations: To clarify whether a cardiac cause.
- Ultrasound of abdomen: To check for gallstones.
- OGD: To confirm peptic ulcer or oesophagitis.
- Helicobacter tests useful in the presence of duodenal ulcer.
- Hospital-based investigations for pulmonary embolus: If this diagnosis is suspected.
- The history is all-important and will usually provide the diagnosis. Except in an obvious emergency, take your time getting the facts straight.
- If you feel worried enough to obtain an urgent ECG then you ought to consider whether the patient really requires an urgent medical opinion or admission.
- Watching the patient’s hand as the symptoms are being described can provide very helpful clues. A clenched fist on the chest is worrying; a single pointing finger much less so.
- Musculoskeletal pain and pleurisy both cause pain on deep inspiration – but the former usually also displays muscle or rib tenderness.
- Tietze’s syndrome is distinguished from costochondritis by the presence of a palpable swelling, caused by oedema, at the site of maximal tenderness. However, management is largely the same.
- Always encourage the patient to contact you if the problem persists or deteriorates.
- If in doubt, play safe: Give aspirin (if not allergic) and admit.
- If the diagnosis remains unclear, examine the abdomen, especially for significant epigastric tenderness.
- Don’t delay if the symptoms clearly suggest an infarct; admit the patient (via the telephone if necessary).
- A normal ECG does not exclude an infarct. Treat the patient, not the test.
- Symptoms of genuine and significant pathology may be clouded by various ensuing anxiety symptoms. Take time to tease them out.
- Performing unnecessary tests when the diagnosis is clearly anxiety is likely to exacerbate the situation.
- Be especially careful dealing with acute chest pain in patients with asthma or COPD, especially if they are suddenly more short of breath than usual, too – remember, they are more prone to developing a pneumothorax.