Chest pain

From Citizendium
Jump to: navigation, search
This article is developing and not approved.
Main Article
Discussion
Related Articles  [?]
Bibliography  [?]
External Links  [?]
Citable Version  [?]
 
This editable Main Article is under development and subject to a disclaimer.

In medicine, chest pain is "pressure, burning, or numbness in the chest."[1] Chest pain can be caused by an extremely wide range of conditions, including some, such as myocardial infarction, which, if untreated, could lead to death within minutes or hours. Other causes may be less urgent, while others can indicate self-limiting disease. There are idiopathic chest pain syndromes that have no apparent cause.

Diagnosis

Workup of emergent chest pain

See also: Acute coronary syndrome

Patients with all of the following findings have sufficiently low risk that even an electrocardiogram is not needed:[2]

  • "sharp or stabbing pain"
  • "no history of angina or myocardial infarction"
  • "pain with pleuritic or positional components or pain that was reproduced by palpation of the chest wall"

In ED patients with chest pain, a structured diagnostic approach with time-focused ED decision points, brief observation, and selective application of early outpatient provocative testing appears both safe and diagnostically efficient, even though some patients with acute coronary syndrome may be discharged for outpatient stress testing on the index ED visit.". [3]

A normal electrocardiogram has been reported not to exclude acute coronary syndrome, even when the electrocardiogram is taken during pain.[4] Although this study defined unstable angina as either a coronary stenosis or positive stress test and so likely includes patients without true acute coronary syndrome as defined by the American Heart Association[5], the study was still not able to show that a normal electrocardiogram helped exclude a NSTEMI.

Computed tomographic cardiac angiography may reduce the rate of hospital admissions according to a randomized controlled trial:[6]

First categorization

Non-emergent chest pain

Treatment

Strong analgesics such as morphine are usually indicated in sudden, severe chest pain, with care to avoid depressing respiration. If the etiology is cardiac, morphine may improve survival as well as relieve pain.

Since chest pain is a symptom rather than a disease, diagnosis and treatment need to focus on the underlying disease(s).

Idiopathic chest pain

Among patients who have chest pain without any identifiable cause, antidepressants, either tricyclic antidepressants[7] or second-generation antidepressants[8] may reduce pain.

References

  1. Anonymous (2021), Chest pain (English). Medical Subject Headings. U.S. National Library of Medicine.
  2. Lee TH, Cook EF, Weisberg M, Sargent RK, Wilson C, Goldman L (1985). "Acute chest pain in the emergency room. Identification and examination of low-risk patients.". Arch Intern Med 145 (1): 65-9. PMID 3970650[e]
  3. Scheuermeyer FX, Innes G, Grafstein E, Kiess M, Boychuk B, Yu E et al. (2012). "Safety and efficiency of a chest pain diagnostic algorithm with selective outpatient stress testing for emergency department patients with potential ischemic chest pain.". Ann Emerg Med 59 (4): 256-264.e3. DOI:10.1016/j.annemergmed.2011.10.016. PMID 22221842. Research Blogging.
  4. Turnipseed, Samuel D.; William S. Trythall, Deborah B. Diercks, Erik G. Laurin, J. Douglas Kirk, David S. Smith, David N. Main, Ezra A. Amsterdam (2009). "Frequency of Acute Coronary Syndrome in Patients with Normal Electrocardiogram Performed during Presence or Absence of Chest Pain". Academic Emergency Medicine 16 (6): 495-499. DOI:10.1111/j.1553-2712.2009.00420.x. Retrieved on 2009-06-13. Research Blogging.
  5. Anderson JL, Adams CD, Antman EM, et al. (August 2007). "ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-Elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction) developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine". J. Am. Coll. Cardiol. 50 (7): e1–e157. DOI:10.1016/j.jacc.2007.02.013. PMID 17692738. Research Blogging.
  6. Litt HI, Gatsonis C, Snyder B, Singh H, Miller CD, Entrikin DW et al. (2012). "CT angiography for safe discharge of patients with possible acute coronary syndromes.". N Engl J Med 366 (15): 1393-403. DOI:10.1056/NEJMoa1201163. PMID 22449295. Research Blogging.
  7. Cannon RO, Quyyumi AA, Mincemoyer R, Stine AM, Gracely RH, Smith WB et al. (1994). "Imipramine in patients with chest pain despite normal coronary angiograms.". N Engl J Med 330 (20): 1411-7. PMID 8159194.
  8. Lee H, Kim JH, Min BH, Lee JH, Son HJ, Kim JJ et al. (2010). "Efficacy of venlafaxine for symptomatic relief in young adult patients with functional chest pain: a randomized, double-blind, placebo-controlled, crossover trial.". Am J Gastroenterol 105 (7): 1504-12. DOI:10.1038/ajg.2010.82. PMID 20332772. Research Blogging.