Chest Pain

Chest Pain

Aug 6, 2014 1
cardiology,intensive care,onthepods

It’s probably the first condition we all learn about at medical school, but how exactly should we manage a case of chest pain?

James talks to Rajesh Puranik about how to approach a patient with chest pain after hours on the wards.

Editor:  James Edwards

Interviewee: Rajesh Puranik

About Dr Rajesh Puranik

Rajesh Puranik is a Consultant Cardiologist and consultant in cardiac MRI at Royal Prince Alfred Hospital and Children’s Hospital Westmead. He is also a clinical senior lecturer at the University of Sydney, leading a research group interested in investigating heart disease in young individuals and those at high absolute risk.

Chest pain on the wards

with Dr Raj Puranik, Cardiologist at Royal Prince Alfred Hospital, New South Wales, Australia

  • Rule out life threatening causes
    • Coronary artery disease – retrosternal chest pressure, may have been previously exertional, radiates to the neck and arm. Diaphoresis. Nocturnal pain is worrying, and also any change from stable symptoms to unstable (for example prolonged periods of angina, or rest angina). Remember non classical symptoms like dyspnoea and pre-syncope
    • Aortic dissection – pain radiating to the back, interscapular back pain, widened mediastinum on CXR
    • Pulmonary embolism – pleuritic pain, SOB
  • Other common causes – GORD, musculoskeletal
  • Vital signs, clinical hx, ECG, attach to oxygen, arrange nitrates and pain relief, does the patient look unwell?
  • Assess the absolute risk of a cardiac event with history and ECG. Look at the past medical history and risk factors– age, male sex, smoking, diabetes, high cholesterol, family history of heart disease. However, don’t dismiss cardiac pain on the basis of risk factors
  • ECG – compare to a previous ECG, identify ST elevation, ST depression, T wave inversion. Look at the rhythm
  • Troponin – useful for confirming diagnosis. Remember, a negative troponin does not exclude a cardiac cause of chest pain. False positives in inflammatory myocarditis/pericarditis, arrhythmia, heart failure, renal impairment, sepsis. Will need serial (6-8 hours) if first is normal
  • Consider oxygen if hypoxic. Controversial role if not hypoxic
  • 300 micrograms of GTN is an appropriate first treatment for pain (check BP, check patient’s history of nitrate sensitivity, and remember that oesophageal spasm will also respond to GTN). Can repeat or use morphine to relieve pain
  • Medical management
  • Anti-anginal (nitrates)
  • Anti-thrombotic (heparin, enoxaparin) – discuss with surgeon in post operative settings
  • Anti-platelet (aspirin, clopidogrel) – discuss with surgeon in post operative settings
  • Call the cardiology/medical registrar to discuss
  • Vitals, nature of chest pain, previous hx of CAD, signs of cardiac failure, ECG, history of echocardiography or angiography (and results), risk factors. You don’t need to wait for a troponin to call
  • If troponin is raised, ECG shows changes, or patient is unstable they will require a monitored bed
  • Rule out life threatening causes of chest pain
  • Apply initial treatment
  • Call for senior help

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Tags: #aortic dissection,#cardiology,#chest pain,#coronary artery disease,#ECG,#ischaemic heart disease,#myocardial infarction,#myocardial ischaemia,#PE,#pulmonary embolism,#troponin

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1 Comment

  1. jane

    April 2, 2020 at 7:51 pm

    this topic was very informative, We don’t need to be a doctor to be knowledgeable in managing and escalating deteriorating patient. this is recommended to all nursing staff to help in thorough assessment prior to calling the attending doctor.

    Reply

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