So, now, we’re going to discuss the
evaluation of the patient with chest pain,
and this is something that's
important for clinical practice
when you're seeing patients
certainly in the emergency department,
but even on the street, on an airplane,
you’ll see patients with chest pain.
It’s happened to me several times.
So, it's important to understand
some of the key elements in the history as well as
the management and workup for patients with chest pain.
So, overall, chest pain is a complaint of only
about 1% of primary care patients,
but if you think about all the primary
care visits across the United States,
that's millions of people coming
in complaining of chest pain.
And you think of –
oh, geez, this could be angina,
this could be coronary artery disease,
a minority – a very small minority of patients with
chest pain in primary care practice have angina.
What do they have instead?
A lot of them have chest wall pain or costochondritis,
a lot of them have gastroesophageal reflux disease.
So, there are a number of diagnoses which can mimic angina,
which can make you think this could be something
really serious like a pulmonary embolism,
but usually it is a more benign diagnosis,
particularly in primary care settings.
But even in the emergency department,
most cases of chest pain there turn out
to not to be cardiac related as well.
Of course, we’re worried about an acute
myocardial infarction first and foremost.
And so, one of the things you want to
consider is that pain is usually radiating.
It's not – it doesn't just stay in the chest.
It goes to the shoulder, arms, neck, jaw.
If there is a new third heart
sound that wasn't there previously,
that is actually fairly specific
for acute myocardial infarction,
as is hypertension.
But you can also see hypertension
in other conditions such as
an aneurysm or a pulmonary embolism too.
Much more common, chest wall pain.
So, this is a stinging or sharp pain that's persistent,
maybe it’s brought on by a minor trauma,
maybe lifting something or a new exercise
or just coughing hard after an upper respiratory infection,
all those things can promote chest wall pain.
When it’s reproducible on palpation,
you can’t write it off and say,
absolutely, this is benign and therefore
we don't need to worry about it.
Say, if the pain was also radiating up to their jaw
and they’re getting sweaty and nauseous when it happened
and it was related exercise,
just being reproducing pain on palpation,
that's not enough.
Patients could have angina and
chest wall pain at the exact same time.
And if you feel some muscle tension,
though, all those are reassuring that
this is not something that’s more serious.
Like those diagnoses I mentioned,
it’s simple chest wall pain, which can be managed
oftentimes with analgesics and a little bit of heat.
GERD has its own symptomatology, obviously.
This is burning, retrosternal type pain.
And oftentimes, patients will try something on their own,
either an antacid or a proton pump inhibitor.
And if they know it gets better with that,
I mean, certainly angina does not,
a pulmonary embolism does not,
a chest wall does not,
the only thing that responds to an
antacid agent would be GERD.
So, this just shows a very gross
description of what a heart attack is.
It makes sense. Block in artery
equals muscle damage.
So, what about factors that increase the risk of angina
and so things you want to be looking for in
evaluating for the patient with chest pain?
Even though women have higher rates
of cardiovascular disease overall,
males have that more frequent
presentation of stable angina.
Of course, the older you get,
your risk of angina and cardiovascular disease goes up.
There is a huge difference between primary
CVD and secondary cardiovascular disease.
So, any history of a cardiovascular event previously,
that's what really elevates,
I think much more than these sociodemographic
factors your risk of the next cardiovascular event.
As I mentioned, pain radiating,
so you're going to take a good history for that.
And then, you’re going to look at all
the patients’ cardiovascular risk factors.
That includes whether they’re smoking,
race can be a factor as well there.
So, there's a lot of different factors
that need to be evaluated
in generating the calculus of whether this patient
might have angina or probably does not have angina.