Wednesday Workshop Recap: Chest Pain Challenges

Chest pain is a frequent and often concerning reason for patients to visit the emergency department (ED). As one of the leading causes of ED visits, chest pain can be a manifestation of a wide spectrum of conditions ranging from benign musculoskeletal pain to life-threatening myocardial infarction (MI).

Initial Approach to Chest Pain

When assessing a patient with chest pain, the primary goal is to rapidly identify any life-threatening conditions. The ABCDE approach serves as a foundational method to ensure that no immediate interventions are overlooked:

• Airway: Ensure the patient's airway is patent and protected.
• Breathing: Assess for adequate respiratory effort and look for signs of distress or asymmetry in chest movement.
• Circulation: Evaluate hemodynamic stability by checking the pulse, blood pressure, and signs of poor perfusion.
• Disability: Quickly assess neurological status to rule out any impairment that might suggest a stroke or other neurological condition.
• Exposure: Perform a thorough examination while ensuring the patient remains warm, looking for any signs of trauma, skin changes, or additional clues.

This structured assessment helps prioritize patients who need urgent intervention from those who can be managed more conservatively.

Triage of Chest Pain

Triage is an essential step in managing patients with chest pain, allowing healthcare providers to allocate resources appropriately:

• GREEN: The patient appears comfortable, with stable vital signs and no alarming features on history or examination. These patients might have conditions such as costochondritis or mild gastroesophageal reflux disease (GERD).
• YELLOW: The patient shows moderate distress, possibly due to conditions like stable angina or mild respiratory issues. These patients require prompt but not immediate evaluation.
• RED: The patient is in severe distress, with signs that may indicate myocardial infarction, aortic dissection, pulmonary embolism, or other critical conditions. These patients need immediate intervention and advanced cardiac life support (ACLS) protocols.

Parsing by Presentation

The evaluation of chest pain must be systematic, considering the patient’s age, sex, risk factors, and specific pain characteristics. Let’s consider a case of a 60-year-old male presenting with sudden onset of severe, crushing substernal chest pain that radiates to the left arm, accompanied by diaphoresis and shortness of breath:

• Acute Onset: Pain that begins suddenly, especially if severe and associated with exertion or stress, raises concerns for an acute coronary syndrome (ACS), including unstable angina or myocardial infarction. The classic presentation includes crushing chest pain that radiates to the arm or jaw, along with autonomic symptoms like sweating and nausea.
• Subacute Onset: Pain developing over hours to days, often less severe and more stable, may suggest stable angina, pericarditis, or less acute presentations of pulmonary conditions.

Look for Breadcrumbs, Not Buzzwords

Clinical scenarios often provide more than just keywords to steer toward a diagnosis—they give context. In this patient’s case, the description of crushing substernal pain radiating to the left arm and accompanied by diaphoresis is highly suggestive of an acute myocardial infarction (MI).

Additional information such as a history of coronary artery disease, diabetes, hypertension, and hyperlipidemia increases the pre-test probability of an ACS. EKG findings showing ST-segment elevation or new left bundle branch block would further confirm the diagnosis of an acute MI. Meanwhile, normal troponin levels on initial presentation do not rule out an MI, especially if obtained early in the course of the presentation.

Differential Diagnoses

While acute coronary syndrome is a primary concern with this presentation, a comprehensive differential diagnosis should include:

• Pulmonary embolism (PE): Often presents with pleuritic chest pain, shortness of breath, and tachycardia. Risk factors include recent surgery, immobility, or known hypercoagulable states.
• Aortic dissection: Characterized by severe, sharp chest pain that radiates to the back and is often described as tearing. It can be associated with pulse deficits and blood pressure discrepancies between limbs.
• Pneumothorax: Sudden onset of unilateral chest pain and dyspnea, often in a young, healthy person or those with a history of chronic lung disease.
• Gastroesophageal reflux disease (GERD): Can mimic cardiac chest pain but is usually associated with a burning sensation and may be relieved by antacids.

Continued Learning

Understanding chest pain in its many presentations is crucial for timely and accurate diagnosis. As clinicians, we must use every available tool, from clinical judgment to advanced imaging and biomarkers, to ensure that we are delivering the best care possible.

Reflecting on this case through the DDQX Learning framework helps to reinforce our approach:

• What additional information could alter the management plan?
• How might this presentation differ in a younger or female patient?
• What are the key clinical findings that drive decision-making in this scenario?

By continually refining our approach to chest pain, we can improve patient outcomes, ensuring that those who need urgent care receive it without delay.