Chest Pain, Atypical
Chest Pain, Atypical: Excerpt from The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter
Jim Nuovo
Atypical chest pain is defined as pain that does not have a characteristic anginal quality (heaviness or squeezing sensation), precipitating factors (e.g., exertion), or location (substernal and radiating).
Approach
The highest priority is generally given in distinguishing cardiac from noncardiac causes. Studies have demonstrated that 10% to 30% of patients with chest pain who undergo coronary arteriography have no arterial abnormalities.
A. Common noncardiac causes. The most common diagnostic findings in those whose pain is not likely to have a cardiac cause include:
1. Gastrointestinal (gastritis, esophagitis, and esophageal motility disorders).
2. Musculoskeletal (costochondritis).
3. Psychiatric (panic attacks, major depression, or both). Be wary for warning signs for less-common, life-threatening conditions such as pulmonary embolism, aortic dissection, and pneumothorax.
History
A. Characteristics of the chest pain. Important questions to ask: What is the quality of pain? Where is it located? What is its duration and intensity? What symptoms accompany the pain? Does anything trigger the chest pain or make the pain better or worse? Is there any relationship between exertion and the pain?
B. Determining the likelihood of ischemic heart disease. Four major features in the initial history and physical examination can be used to determine the likelihood of IHD. They are in order of importance:
1. Angina description (definite angina, probable angina, probably not angina, and not angina).
2. Prior myocardial infarction [by history, or electrocardiographic (EKG) findings].
3. Age (risk of IHD increases with age).
4. Number of risk factors (e.g., diabetes, smoking, hypercholesterolemia, and hypertension).
C. Features suggesting nonanginal pain. Features suggesting nonanginal pain include pleuritic pain (sharp or knifelike pain brought on by respiratory movements or cough), pain localized with one finger, pain reproduced by movement or palpation of the chest wall or arms, constant pain lasting for days, and very brief episodes of pain lasting a few seconds (1).
D. Other key considerations. Key considerations in the history include the following:
1. All presentations of chest pain should be taken seriously until proven to be benign.
2. The description of pain can be greatly influenced by socioeconomic status, education, culture, and personality.
3. A review of cardiac risk factors is appropriate for all patients who present with chest pain.
4. Red flags suggesting a noncardiac, life-threatening condition include tachypnea, dyspnea, and hypoxemia.
5. Sharp, stabbing, or pleuritic qualities do not completely exclude an ischemic cause (Chapter 8.5). In the Multicenter Chest Pain Study, IHD was diagnosed in 22% of patients coming to the emergency room with a sharp quality pain (2).
Physical examination
No reliable physical signs can be used to determine whether a patient with atypical chest pain has ischemic heart disease. The main purpose of the examination is to assess the patient for evidence of complications from atherosclerotic disease (e.g., peripheral vascular disease, cerebrovascular disease, and congestive heart failure). Pay attention to findings on the vascular examination (e.g., peripheral artery bruits, retinal arteriolar changes, the presence of a cardiac gallop) and for signs of the consequences of diminished myocardial contractility (e.g., lower extremity edema or pulmonary crackles) (Chapter 7.5).
Testing
A. Probability of IHD based on history. Prior to testing, the probability of IHD can be inferred by the estimates made by Diamond and Forrester (3). Examples of these estimates include (a) high probability situations (probability > 75%)—men aged more than 40 years and women aged more than
50 years with typical anginal symptoms; (b) moderate probability situations (probability > 50%)—men aged more than 40 years and women aged more than 60 years with atypical features; (c) low probability situations (probability < 20%)—men aged less than 40 years and women aged less than 50 with atypical features.
B. Response to nitroglycerin (NTG). Response of chest pain to sublingual NTG can be used (with caution) as an adjunct for determining whether a patient’s chest pain is from IHD. For example, a prompt response (< 3 minutes) increases the probability of IHD; however, it should be noted that esophageal spasm and biliary colic may also respond favorably to this intervention. Conversely, failure to respond to NTG should not be used to exclude the possibility of IHD.
C. Response to a gastrointestinal (GI) cocktail. It is common practice in many emergency room and urgent care settings to give a patient a GI cocktail that typically contains a liquid antacid, xylocaine, and an antispasmodic. No reliable studies exist on the diagnostic accuracy of this intervention.
D. Resting ECG. A normal resting ECG cannot be used as the sole criterion to rule out the presence of ischemic heart disease.
E. Exercise testing. The standard provocative test for patients with atypical chest pain who have at least a moderate risk for IHD is the exercise treadmill test. During exercise, the patient is monitored for symptoms of chest pain, heart rate, blood pressure response to exercise, arrhythmias, and ST-segment changes. A significant test includes an ST-segment depression of at least
1.0 mm below the baseline. It is important that the patient achieve a vigorous heart rate response to exercise. Approximately 20% of patients with an abnormal exercise tolerance test (ETT) have significant ST-segment changes occurring only at maximal or near-maximal heart rate changes. Therefore, when reviewing an ETT report, if the maximal heart rate achieved was less than 85% of the predicted heart rate, the results of the test should be interpreted more cautiously.
F. Other diagnostic tests. Some patients should not undergo the standard ETT for a number of reasons. These include the inability to exercise because of gait or instability problems and underlying ECG abnormalities that make the standard ETT unreadable (e.g., left ventricular hypertrophy with strain and left bundle branch block). If the patient is able to exercise, the preferred test will be either an exercise echocardiogram or an exercise thallium test. If the patient is unable to exercise, test options include a dobutamine echocardiogram and a dipyridamole (Persantine) thallium test. A divergence of opinion is seen as to which of these tests is best; however, each has higher sensitivity and specificity than the standard ETT.
Diagnostic assessment
The key to the diagnosis of atypical chest pain remains in the clinical history. An assessment of the probability of ischemic heart disease should be made on all patients. Those with a very low probability of IHD should not undergo diagnostic testing because, given the problems of sensitivity and specificity, the results will have little or no impact on the management of the patient. Critical pathways for triage have been proposed to help identify intermediate and high risk patients (4,5).
References
1. Panju AA, Hemmelgard BR, Guyatt GH, Simel DL. Is this patient having a myocardial infarction? JAMA 1998;280:1256–1263.
2. American College of Emergency Physicians. Clinical policy for the initial approach to adults presenting with a chief complaint of chest pain, with no history of trauma. Ann Emerg Med 1995;25:274–299.
3. Diamond GA, Forrester JS. Analysis of probability as an aid in the clinical diagnosis of coronary-artery disease. N Engl J Med 1979;300:1350–1358.
4. Nichol G, Walls R, Goldman L, et al. A critical pathway for management of patients with acute chest pain who are at low risk for myocardial ischemia: recommendations and potential impact. Ann Intern Med 1997;127:996–1005.
5. Braunwald E, Mark DB, Jones RH. Diagnosing and managing unstable angina: quick reference guide for clinicians, Number 10. AHCPR Publication No.94-0603. Rockville, MD: US Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research and National Heart, Lung, and Blood Institute; 1994.>>
Book Source Details
- Book Title: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter
- Author(s): Robert B. Taylor (editor)
- Year of Publication: 2000
- Copyright Details: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, Copyright © 2000 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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