Red Flag Symptoms - Chest pain

There is a wide differential diagnosis for this symptom, says Dr Asim Safdar.

An ECG can aid diagnosis in patients with chest pains (Photograph: SPL)
An ECG can aid diagnosis in patients with chest pains (Photograph: SPL)

Chest pain has a large number of causes, some of which are not so serious. The most obvious diagnosis is that of cardiac causes, for example, myocardial ischaemia. A clear history is paramount and will provide the key to diagnosis.

If the pain is central, crushing in nature, with radiation to the left side of the jaw, neck or arm and associated with nausea and/or sweatiness, this is the classic description of angina or acute coronary syndrome. Not all of the above features may be present and patients with diabetes can even present with 'silent' MIs.

Angina is classically triggered by exertion, emotional stress or cold, windy weather, but may occur at rest if severe coronary disease is present.

It is important to elicit risk factors in the history and this will increase the suspicion of ischaemia, if present. These include:

  • Hypertension.
  • High cholesterol.
  • Family history or previous history of IHD.
  • Smoker.
  • Diabetes.
  • Age (≥55 years or ≥35 years with other risk factors).
  • Male.

An ECG will aid the diagnosis and if an ischaemic cause is to be ruled out, the patient will need to be admitted to have their troponin level checked 12 hours after onset of pain.

If MI is diagnosed, the patient will need close monitoring in a coronary care unit, oxygen, anti-emetics and urgent angiogram and possible angioplasty. Severe or multiple blockages may need bypass grafting. Echocardiography is also needed to gauge left ventricular function.

POSSIBLE CAUSES
  • MI/acute coronary syndrome.
  • Pulmonary embolus.
  • Pneumothorax/pleurisy/pneumonia.
  • Gastro-oesophageal reflux.
  • Musculoskeletal problem.
  • Pericarditis.
  • Myocarditis.
  • Cervical root pain.
  • Oesophageal causes.
  • Upper GI problems.
  • Aortic dissection.
  • Hyperventilation/anxiety.

    Differential diagnosis
    The differential diagnosis includes pulmonary embolus, pneumothorax, pneumonia, gastro-oesophageal reflux, musculoskeletal pain, pericarditis, myocarditis, cervical root pain, oesophageal inflammation/spasm, upper GI problems, aortic dissection, pleurisy, hyperventilation and anxiety. Coronary embolism and mitral valve prolapse are also causes.

    These need to be ruled out by history and examination. Serial ECGs, chest X-rays and blood tests (FBC, U&Es, LFT, creatine kinase and 12-hour troponin) all aid in diagnosis but the main pillar of diagnosis will be the history and examination, for example, tenderness on chest palpation for musculoskeletal pain and reflux symptoms in gastro-oesophageal reflux disease.

    • Dr Safdar is a locum GP in Luton, Bedfordshire

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