Acute Chest Pain

Objectives

By reading this material you should be able to

- Appreciate the importance of chest pain as a presenting symptom

- Feel more confident about the recognition and early management of chest pain

- Recognise common clinical symptoms associated with cardiac disease

Background
Chest pain accounts for up to 50% of all acute medical admissions and a significant
proportion of these will be due to cardiac causes. Despite advances in both
pharmacological and interventional strategies, ischaemic heart disease still remains
the biggest cause of death in the UK. The early and correct diagnosis of cardiac
chest pain and the subsequent initiation of appropriate therapies have been shown to
significantly reduce both morbidity and mortality.

It is important to be aware of the differential diagnosis, to help to differentiate

cardiac pain from other causes of chest pain. The more common are listed below, in
table 1.

Table 1 -Causes of chest pain

Cardiac
Acute coronary syndrome
ST elevation MI
Non ST elevation MI
Unstable angina
Aortic dissection
Pericarditis
Myocarditis

Respiratory
Pulmonary embolism
Pneumothorax

Gastrointestinal
Peptic ulcer disease
Oesophageal perforation

Musculoskeletal
Costochondritis
The initial management of all patients presenting with chest pain should always start
with ABCDE assessment. You will be able to carry this out on an actor on your
study day.

Remember: if the patient is presenting acutely unwell, there is sometimes not time
to elicit a full history prior to commencing treatment. Under these circumstances

A. The airway should be checked and oxygen administered

B. The breathing and ventilation status of the patient should be assessed. Apply
pulse oximetry.
C. The circulation should be assessed by feeling the peripheries, instituting i.v.
access and measuring pulse and blood pressure.
D. Assess the patients disability in this case their conscious level
E. Make sure the patient is undressed to facilitate examination. Make sure the
patient is neither too hot or too cold.

The cause of the pain should then be quickly sought so as to commence the
appropriate treatment, such as thrombolysis, rapidly.

History
After assessing the patients in the ABCDE approach, specific points in the history
should be sought in order to elicit the likely cause. These include:
nature - type, location, radiation, severity, aggravating and relieving factors
Associated symptoms eg. Breathlessness, nausea, sweating.
time of onset
duration
risk factors eg. Diabetes, smoking, hypertension, family history
prior history of ischaemic heart disease
previous treatment with and contraindications to angioplasty and
thrombolysis

Myocardial ischaemia is typically associated with a heavy or crushing sensation that

may radiate to the neck and jaw. There may also be heaviness or tingling in the left
arm and patients may complain of nausea, vomiting, breathlessness or sweating.
Atypical pain should not exclude ischaemia but alternate diagnoses, for example
pericarditis, should also be considered. Heartburn is a common presentation of an
inferior myocardial infarction.

Examination
Clinical examination can often be normal in patients presenting with an acute
coronary syndrome (ACS). Examination is therefore directed towards identifying
complications of the ACS (eg. Arrhythmias, acute heart failure), or establishing an
alternative diagnosis.
Signs of an arrhythmia: -irregular pulse
-fast or slow heart rate
-low blood pressure
-Reduced conscious level if blood pressure is very
low
Signs of heart failure:
Right heart -peripheral oedema
-pulsatile liver edge
-raised JVP
Left heart -reduced air entry or crackles in the lung bases.
-tachycardia (because the heart is unable to pump
much blood out with each beat, so it beats faster to
compensate)
-cool peripheries with a prolonged capillary refill
time.
-In severe heart failure, the blood pressure may be
low.
Alternative diagnosis
Aortic dissection - differential pulses (depends on level of dissection, but may
be difference between left and right radial, or radial and
femoral pulses)
- differential blood pressure between left and right arms
- acute aortic regurgitation
- signs of cardiac tamponade (muffled heart sounds, raised
JVP)
Pericarditis - audible pericardial friction rub
Pneumothorax - hyper-resonance to percussion on affected side
- reduced or absent breath sounds on affected side
- tracheal deviation in a tension pneumothorax
Pulmonary embolism - signs of a DVT (swollen, oedematous leg)
- occasionally raised JVP (in massive PE)
Perforated oesophagus- surgical emphysema
- signs of sepsis
Musculo-skeletal - tenderness to palpation or movement (the presence of this
does not rule out a more serious pathology be very careful
when attributing chest pain to the musculoskeletal system)

Investigations

ECG
A 12 lead ECG should be performed on all patients immediately. If the initial ECG
is normal and the pain is ongoing then repeat ECGs should be performed at 10-
minute intervals to quickly identify any evolving changes. Treatment options
dichotomise to those with ST elevation / new Left bundle branch block (LBBB)
versus all other changes (normal, ST depression, T wave inversion). The patient
should be continuously monitored for arrhythmias.

Bloods
Blood tests should include full blood count, urea and electrolytes, glucose, lipids
and appropriately timed cardiac enzymes. Troponin T or I are sensitive and specific
markers of myocardial damage and allow the detection of more subtle volumes of
myocyte damage than creatine kinase (CK). Current SIGN guidelines recommend
checking troponin on arrival at hospital as a positive result can help guide treatment.
A troponin level should also be taken 12 hours after onset of pain, as this is when
the troponin level should be at its highest, therefore most likely to be detected.

Arterial blood gases are rarely required, only being indicated in severely unwell
patients (eg. following cardiac arrest, cardiogenic shock, severe pulmonary
oedema). It should be remembered that access to the arterial system for
percutaneous coronary intervention is often via the radial artery, so avoiding
damaging the vessel by repeated punctures is advisable. Additionally, if a patient is
thrombolysed they are liable to bleed from sites of previous arterial puncture.

X-ray
The chest x-ray is likely to be normal in an acute coronary syndrome, so is not
generally essential. However, it can be useful where diagnosis is in doubt - eg. if
aortic dissection or respiratory/oesophageal pathology is suspected. It is also useful
if pulmonary oedema is thought to be present.

Classification of Acute Coronary Syndromes

Acute coronary syndrome (ACS) is used to describe a range of clinical conditions
including acute ST elevation myocardial infarction, non-ST elevation myocardial
infarction and unstable angina.

There is often confusion into the definition of a myocardial infarction. Here the
definition proposed by the European Society of Cardiology, the American College
of Cardiology and the American Heart Association is used. This is a more sensitive
definition than those used previously and requires a typical clinical syndrome plus a
rise and fall in troponin (or CK-MB if troponin not available).

Table 2: comparison of definition and prognosis by Troponin T concentration (from

SIGN guideline 93)

(BCS British Cardiac Society; ESC European Society of Cardiology; ACC

American College of Cardiology; WHO World Health Organisation)

Management of Acute Coronary Syndromes

The aims of the acute management of ACS are:
1. Rapidly establish a diagnosis
2. Treat any haemodynamic and acute arrhythmic complications
3. Provide prompt pain relief and adequate arterial oxygen
concentrations
4. Initiate rapid reperfusion to limit infarct size and minimise the
risk of pump failure and arrhythmias
 5. Treat any early complications
6. Risk assessment for longer term management and commence
secondary prevention
Patients should be rapidly assessed on arrival to hospital as previously described.
All patients (unless strongly contra-indicated) should be treated with aspirin 300mg,
followed by 75mg daily.
Sublingual GTN spray can be used for pain control. The effects of this are short
lived.
Patients should be placed on cardiac monitoring to allow prompt identification of
arrhythmias.
Any patient with any ECG changes consistent with ischaemia (ST changes, T-wave
inversion) or a raised troponin should also be treated with clopidogrel 300mg
(ticagrelor in GG&C)
The ECG findings are used to further divide patients into the STEMI or
NSTEMI/Unstable angina groups, which dictates further treatment.

ST Elevation Myocardial Infarction (STEMI)

STEMI occurs when a coronary artery becomes acutely occluded with thrombus
following the rupture of an atheromatous plaque.

The diagnosis of a STEMI is confirmed by:

history of cardiac sounding chest pain
a limited examination for shock / murmurs / complications
12 lead ECG criteria:
1mm ST elevation in 2 contiguous limb leads
2mm ST elevation in 2 contiguous chest leads
New left bundle branch block
True posterior infarct (dominant R wave and ST depression in V1 +
V2).

Primary percutaneous coronary intervention

Reperfusion by primary percutaneous coronary intervention (PPCI), if performed
promptly and by an experienced team, has been shown to be superior to
thrombolysis in terms of:
overall mortality
reinfarction rates
improved left ventricular systolic function
stroke.3

PPCI also has the advantage of giving visual evidence that the occluded artery has
been reopened and normal flow has been restored, as well as information about
disease in other coronary arteries.

Thrombolysis
The greatest benefit is gained within the first 2 hours of onset of pain with a
subsequent progressive decrease of 1.6 deaths per hour of delay, per thousand
patients treated.1 The benefit does persist up to 6 hours though with some evidence
for giving it up to 12 hours in the presence of persistent pain and ECG changes.
Beyond 12 hours there is no clear evidence whether the benefit outweighs the risk
of major bleeding.
Table 2 Contraindications to Thrombolysis

Absolute Relative
Haemorrhagic CVA at any time Severe, uncontrolled hypertension
Any CVA within 1 year Current use of anticoagulants
Known intracerebral neoplasm Known bleeding diathesis
Active internal bleeding Recent trauma e.g. head trauma,
Suspected aortic dissection prolonged CPR
Major surgery within 3 weeks
Non-compressible vascular punctures
Recent internal bleeding
Pregnancy
Active peptic ulcer
History of chronic severe hypertension

Figure 2 Acute ST elevation myocardial infarction (inferior)

Optimal Reperfusion for STEMI West of Scotland

The aim of this service is to restore myocardial perfusion quickly and effectively in
all STEMI patients. PPCI is more effective and associated with less complications
assuming it can be delivered quickly.

If the patient presents within 6 hours of pain (i.e. they are a candidate for PPCI or
thrombolytic):
PPCI is the preferred strategy if the patient can get to the
interventional centre within 60mins (assumes total 90 mins to
open vessel)

Otherwise thrombolyse and transfer

If the patient presents outwith 6 hours they are not a candidate for thrombolytic and
should be transferred immediately for PPCI

All patients with cardiogenic shock should be transferred immediately for PPCI and
not thrombolysed

Some contraindications to thrombolytic may also be relative contraindications to

PPCI (esp. active bleeding as aspirin, clopidogrel and heparin are the minimum
some patients may also require GPIIbIIIa depending on the clot burden / lesion)

All patients with STEMI should be discussed with the interventional centre
GJNH for most of the West of Scotland
Hairmyres for Lanarkshire / Ayrshire + Arran

Failed Reperfusion
The REACT study has clarified the management of patients who fail to respond to
thrombolysis (as evidenced by continuing chest pain and failure of ECG resolution).
In patients where the ECG at 90 minutes after thrombolysis demonstrates that the
ST segment in the worst lead has failed to reduce by 50%, rescue angioplasty
should be considered.

This means it is important that all thrombolysed patients are transferred to the
interventional centre as soon as possible, such that rescue PCI can be carried out
should they fail to reperfuse.

Other Acute Coronary Syndromes

This includes both non-ST elevation myocardial infarctions (NSTEMI) and unstable
angina (troponin negative ACS). These are usually mediated by platelet activation
rather than thrombin formation. More often they are due to an incomplete occlusion
of a coronary artery.

Diagnosis
The first priority is to establish a working diagnosis based upon:
The clinical picture
ECG
Cardiac biomarkers including troponin.

The ECG may be normal but typical ischaemic changes are ST depression, dynamic
ST elevation and T wave inversion.

Management
The risks of a NSTEMI or unstable angina continue over time, with the maximum
risk being in the first 3 months, as a result of further thrombotic events. Whilst in
hospital it is important to regularly check for further pain. Any further pain should
prompt further ECG and repeat cardiac enzymes. The patient should be
continuously monitored for arrhythmias and any haemodynamic compromise.

Pharmacological Treatment
1. Reduce platelet aggregation as for all acute coronary syndromes.
 Aspirin 300mg once then 75mg daily
Clopidogrel 300mg once then 75mg daily: guidelines now
recommend use of this in addition to aspirin in all NSTEMIs for
at least 3 months.

2. Reduce thrombin formation

Either low molecular weight heparin (eg. enoxaparin, dalteparin)
or fondaparinux.

3. Increase oxygen delivery to the heart

IV GTN (dilates coronary vessels)
Oxygen (if saturations low)

4. Reduce the work of the heart

Beta-blockers (only if no evidence of heart failure, bradycardia or
hypotension)
If blood pressure is high, reducing this will reduce the work the
heart needs to do (again IV GTN works well)

5. Analgesia
Morphine/Diamorphine

6. Secondary prevention
Statins
ACE inhibitors

There is debate over the timing of the use of glycoprotein IIb/IIIa receptor blockers
in acute coronary syndromes. Most of their benefit occurs when they are used
during percutaneous coronary intervention, rather than when they are administered
as part of medical therapy before possible angioplasty (so called upstream use)

Figure 3 Acute management of NSTEMI / unstable angina

Suspected ACS
No ST elevation

Serial ECGs
Oxygen & analgesia
Aspirin/clopidogrel/heparin/ blocker
Secondary prevention

Presence of high risk features* Absence of high risk features

Refer to cardiology as in patient Exercise tolerance test

Coronary angiogram +/- PCI

Intermediate / high risk result Low risk result

Unlikely to be cardiac pain

Discharge home
High risk features
Prolonged pain
Raised troponin
Significant ECG changes
Haemodynamic instability
Rhythm instability
Aortic Dissection
Aortic dissection occurs because of a tear in the intimal lining, which then
propagates along the media of the aorta and its branches. This should be suspected
especially in patients with known hypertension or connective tissue disease.

Presentation
Symptoms are usually of severe, tearing retrosternal chest pain, often radiating
through to the back and intrascapular region. More rarely it can present with
dyspnoea, sudden paralysis if the cerebral or spinal arteries are affected, or limb
ischaemia. The patient is usually tachycardic and the pulse may be of low volume.
Blood pressure may or may not be raised and there may be a pulse and blood
pressure deficit between the arms. If the dissection extends to the aortic root an
early diastolic murmur of aortic regurgitation may be heard, or there may be
evidence of tamponade or ST elevation on the ECG - NB thrombolysing this is
likely to be fatal!

Investigations
Diagnostic investigations choice depends on clinical condition, and availability:
Contrast CT
Transoesophageal echo

Other investigations
Chest X-ray look for widened mediastinum (present in 60% cases)
Transthoracic echo only proximal aorta seen, therefore lacks
sensitivity & specificity in the detection of a flap, but will identify
pericardial fluid and aortic regurgitation if present

Management
If the dissection affects the ASCENDING aorta urgent referral to the cardiothoracic
surgeons is required.

If only the DESCENDING aorta is affected the mainstay of treatment is analgesia

and maintenance of systolic blood pressure 100 110mmHg (e.g. with IV
labetalol). The patient should be continuously monitored either on a coronary care
or high dependency unit. It is important to watch for signs of haemodynamic
compromise or extension of dissection (often heralded by more pain), that may lead
to loss of peripheral pulses, renal or cerebral infarction etc.

Acute Pericarditis
The commonest causes of pericarditis are viral (most frequently parvovirus B19 or
coxsackie) and post myocardial infarction.

The presentation is typically of sharp, substernal chest pain that is relieved by sitting
forward and made worse by lying down. The pain may be aggravated by movement
and inspiration. On examination the patient may be pyrexial and there may be a
friction rub audible.

The ECG is diagnostic in pericarditis. In the acute phase there is concave ST

elevation (so called saddle shaped) in a number of leads (those facing the
epicardial surface). This elevation later normalises and T wave inversion may
develop. Cardiac enzymes may be elevated if there is associated myocarditis.

Treatment is anti-inflammatory drugs e.g. indomethacin 50mg tds.

Myocarditis
Myocarditis may present in association with pericarditis or as an acute disease
characterised by a febrile illness and heart failure. The cause is frequently
unidentified and can be idiopathic, infective (viral, bacterial or protozoal) or
autoimmune.

An ECG may demonstrate ST and T wave changes, again affecting a number of

leads. There may also be arrhythmias and occasionally heart block. Cardiac
enzymes will be elevated due to inflammation of the myocardium. Investigations
include viral antibody titres, transthoracic echo which may show a regional wall
motion abnormality and rarely, endomyocardial biopsy.

The mainstay of treatment is the management of heart failure and arrhythmias.

SUMMARY

Chest pain is a very common symptom in medical patients

Dont forget airway, breathing and circulation!

In the acute ST elevation MI - TIME IS MUSCLE. The goal is to open the artery as
quickly as possible, with PPCI or thrombolysis if there is a delay to PPCI.

Primary angioplasty is a more effective treatment for acute MI.

References

1. Collins R, Baigent C, et al. Aspirin, heparin and thrombolytic therapy in

suspected acute myocardial infarction. N Eng J Med 1997; 333: 847-60

2. The Gusto Investigators. An international randomised trial comparing four

thrombolytic strategies for acute myocardial infarction. N Eng J Med 1993; 329:
673-82

3. Keeley EC, Boura JA, Grines CL. Primary angioplasty versus thrombolytic
therapy for acute myocardial infarction: a quantitative review of 23 randomised
trials. Lancet 2003; 361:13-20

Further Reading

1. The ECG Made Easy. John Hampton. Chapter 4 Abnormalities of the p, qrs and
T waves.
2. National Service Framework Coronary Heart Disease. Chapter 3; Treating
heart attack and other acute coronary syndromes.

3. Task Force on the Management of Acute Coronary Syndromes of the European

Society of Cardiology. Management of acute myocardial infarction in patients
presenting with ST segment elevation. Eur Heart J 2003;24:28-66

4. Scottish Intercollegiate Guidelines Network (SIGN). Acute coronary syndromes:

a national clinical guideline. Guideline 93. Published February 2007
www.sign.ac.uk