Chest Pain Clinic
What is the occurrence (rate of incidence) of Chest pain?
- 20-40% of all medical admissions are for acute chest pain.
- Coronary heart disease remains the principal cause of death in the UAE and a fifth of these deaths occur below retirement age.
- The main risk factors are smoking, hypertension, hyperlipidemia, diabetes and obesity
Appearance or Presentation of Chest pain
- Chest pain due to cardiac ischemia typically tends to be retrosternal or epigastric, tight and crushing in quality, and may radiate to the arms, shoulders, neck or jaw.
- Aortic dissection tends to cause pain with a tearing quality; pericarditis and pulmonary pain tend to be worse on inspiration (pleuritic) and esophageal reflux pain has a burning quality.
- Stable angina is likely if chest discomfort or breathlessness is associated with effort, emotion, food or cold weather, symptoms are relieved by rest and/or glyceryl trinitrate (GTN) and one or more risk factors for coronary artery disease are present. such as smoking history, past history of cardiovascular disease and comorbidities, especially diabetes, hypertension and hyperlipidemia
- In patients with acute coronary syndrome
- Chest pain may be associated with sweating, nausea, vomiting, dyspnea, fatigue, and or palpitations
- Shortness of breath may be the main symptom of cardiac ischemia, associated with angina pain, or a symptom of heart failure
- Atypical presentations are common (especially in women, older men, people with diabetes, and people from ethnic minorities), e.g. abdominal discomfort or jaw pain; elderly patients may present with altered mental state.
Examination: Many patients will have entirely normal examination findings. However, a thorough cardiovascular examination is essential.
Common causes of Chest pain (Differential diagnosis)
Chest pain can be cardiac as well as non-cardiac too. The main causes of chest pain include:
- Angina, acute coronary syndrome (ACS) (including myocardial infarction).
- Acute pericarditis
- Pneumonia, pulmonary embolus, pneumothorax
- Gastro-esophageal reflux, esophageal spasm
- Peptic ulcer disease
- Gallstones, cholecystitis
- Acute pancreatitis
- Chest wall pain, e.g. Tietze's syndrome, trauma, shingles, rib secondaries, osteoporosis
- Aortic dissection
- Anxiety, depression
Investigations needed for Chest pain
Depending on the clinical state of the patient and any suspicion of myocardial infarction, the patient may require immediate transfer to hospital before any investigations are performed.
- Investigations may be required to exclude non-cardiac causes of chest pain, e.g. chest X-ray (pneumonia), abdominal ultrasound (gallstones), serum amylase (acute pancreatitis)
- Initial blood investigations include cardiac enzymes, fasting lipids, fasting glucose and full blood count (to exclude anemia, and high white cell count may suggest pneumonia)
- Resting ECG - a resting ECG is normal in over 90% of patients with recent symptoms of angina
- Chest x-ray - this may be useful in evaluating the presence of heart failure or an alternative diagnosis, e.g. aortic aneurysm, pneumonia, rib fractures, rib secondaries or osteoporosis
- Exercise ECG testing should not be used to diagnose or exclude stable angina for people without known coronary artery disease. See separate article on angina pectoris for further discussion on diagnosis of angina
- Depending on the presentation, further investigations may include echocardiogram,coronary angiography, V/Q scan or pulmonary angiography (pulmonary embolus), CT aortography (aortic dissection) or upper gastrointestinal endoscopy (gastro-esophageal reflux disease, peptic ulcer)
What does NMC Chest Pain clinic do?
- For those patients not requiring immediate hospital admission, chest pain clinics enable rapid confirmation of the diagnosis, initiation of treatment, and, where considered appropriate, further investigation and intervention
- Our Chest pain clinic encouraged, that prompt assessment and management actually reduces cardiac morbidity and mortality
- Patients should understand that further assessment may lead to a recommendation for more invasive treatment