Chest pain
Table of contents
Assessment and general management of chest pain
History taking
- Onset: When did it start? How did it start (gradual or sudden)? At rest or exertion?
- Provocation/paliation: Does anything make it better or worse? Does breathing, movement or palpation make it worse?
- Quality: Sharp, dull, crushing, burning, tearing, aching, stinging, tight, cramping. Pattern: intermittent (comes and goes), constant, throbbing
- Radiation: Does it go anywhere else?
- Severity: Pain score (0-10/10) - what was it when it came on, what is it now?
- Time: When did it start? Getting better or worse since it started? Has it changed since it came on?
ECG
Any patient reporting a history of chest pain should have a 12 lead ECG performed as a matter of prudent practice within clinical justification noting while minimally invasive in terms in some senses, cultural and gender factors may influence patient comfort with officer performing
Prehospital Blood Collection
Prehospital blood collection has proved to be an effective and low-risk procedure (provided performed with aseptic technique) and samples drawn by paramedics improve patient journey in ED while having minimal error rates (Curtis, 2020)
Tubes to be drawn for WA protocols in order of draw (per Pathwest):
- Sodium Citrate (Blue top)
- Drawn so hospital have the option of running D-Dimer in a chest pain context
- Lithium Heparin (Dark green top)
- Troponin / U&E
- EDTA (Purple top)
- FBP
Causes of chest pain
There is a multitude of causes for chest pain including but not limited to cardiac related causes, given the intention of ruling out life threats as a priority undifferentiated chest pain is often assumed to be of cardiac origin until proven otherwise
Pericarditis
OMI (STEMI/NSTEMI)
Risk stratification in chest pain
RPH use the HEART score while the SCGH protocol uses EDACS
HEART score
| 0 points | 1 point | 2 points | |
|---|---|---|---|
| History | Slightly suspicious | Moderately suspicious | Highly suspicious |
| EKG | Normal | Non-specific repolarisation disturbance | Significant ST deviation |
| Age (years) | <45 | 45–64 | ≥65 |
| Risk factors | No known risk factors | 1–2 risk factors | ≥3 risk factors or history of atherosclerotic disease |
| Initial troponin | ≤normal limit | 1–3× normal limit | >3× normal limit |
- History
- Retrosternal pain, pressure, radiation to jaw/left shoulder/arms, duration 5–15 min, initiated by exercise/cold/emotion, perspiration, nausea/vomiting, reaction on nitrates within mins, patient recognises symptoms.
- Low risk features of chest pain include: well localised, sharp, non-exertional, no diaphoresis, no nausea or vomiting, and reproducible with palpation.
- ECG
- Non-specific disturbances include LBBB, typical changes suggesting LVH, repolarisation disorders suggesting digoxin, unchanged known repolarisation disorders.
- Significant ST-segment deviation without LBBB, LVH, or digoxin.
- Risk Factors
- HTN, hypercholesterolemia, diabetes (T1 or T2), obesity (BMI >30 kg/m²), smoking (current, or smoking cessation ≤3 mo), positive family history (parent or sibling with CVD before age 65).
- Troponin
- Obviously unable to run pre-hospital but if you cover off the rest you’re setting things up well
Source: https://www.mdcalc.com/heart-score-major-cardiac-events
EDACS score
| Variable | Points | |
|---|---|---|
| Age | 18-45 | 2 |
| 46-50 | 4 | |
| 51-55 | 6 | |
| 56-60 | 8 | |
| 61-65 | 10 | |
| 66-70 | 12 | |
| 71-75 | 14 | |
| 76-80 | 16 | |
| 81-85 | 18 | |
| ≥86 | 20 | |
| Sex | Female | 0 |
| Male | 6 | |
| Known coronary artery disease or ≥3 risk factors* | No | 0 |
| Yes | 4 | |
| Symptoms and signs | ||
| Diaphoresis | No | 0 |
| Yes | 3 | |
| Pain radiates to arm, shoulder, neck, or jaw | No | 0 |
| Yes | 5 | |
| Pain occurred or worsened with inspiration | No | 0 |
| Yes | -4 | |
| Pain is reproduced by palpation | No | 0 |
| Yes | -6 |
Than et al (EMA, 2014) define coronary artery disease (CAD) as “previous acute myocardial infarction, coronary artery bypass graft, or percutaneous intervention.”
Risk factors include dislipidaemia, diabetes, hypertension, current smoker, and family history of premature CAD. The risk factors only apply to patients 18-50.
Low risk cohort:
- EDACS <16; and
- EKG shows no new ischemia; and
- 0-hr and 2-hr troponin both negative.
Recommendation for low risk cohort: safe for discharge to early outpatient follow-up investigation (or proceed to earlier inpatient testing).
Not low risk cohort:
- EDACS ≥16; or
- EKG shows new ischemia; or
- 0-hr or 2-hr troponin positive.
Recommendation for not low risk cohort: proceed with usual care with further observation and delayed troponin.