Chest Pain

00:01 All right.

00:02 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 - inpatient/outpatient, certainly in the emergency department, but even on the street, on an airplane, you’ll see patients with chest pain.

00:17 It’s happened to me several times.

00:19 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.

00:29 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.

00:42 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.

00:53 What do they have instead? A lot of them have chest wall pain or costochondritis, a lot of them have gastroesophageal reflux disease.

01:01 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.

01:14 But even in the emergency department, most cases of chest pain there turn out to not to be cardiac related as well.

01:20 Of course, we’re worried about an acute myocardial infarction first and foremost.

01:26 And so, one of the things you want to consider is that pain is usually radiating.

01:30 It's not - it doesn't just stay in the chest.

01:32 It goes to the shoulder, arms, neck, jaw.

01:36 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.

01:47 But you can also see hypertension in other conditions such as an aneurysm or a pulmonary embolism too.

01:54 Much more common, chest wall pain.

01:56 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.

02:11 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.

02:19 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.

02:30 Patients could have angina and chest wall pain at the exact same time.

02:35 And if you feel some muscle tension, though, all those are reassuring that this is not something that’s more serious.

02:41 Like those diagnoses I mentioned, it’s simple chest wall pain, which can be managed oftentimes with analgesics and a little bit of heat.

02:50 GERD has its own symptomatology, obviously.

02:52 This is burning, retrosternal type pain.

02:55 And oftentimes, patients will try something on their own, either an antacid or a proton pump inhibitor.

03:02 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.

03:15 So, this just shows a very gross description of what a heart attack is.

03:21 It makes sense. Block in artery equals muscle damage.

03:24 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? Male sex.

03:31 Even though women have higher rates of cardiovascular disease overall, males have that more frequent presentation of stable angina.

03:39 As said before, while men continue to have higher rates of cardiovascular disease compared with women, the risk of cardiovascular disease continues to be underrecognized among women.

03:48 Women and men die of cardiovascular disease at roughly similar rates.

03:53 Of course, the older you get, your risk of angina and cardiovascular disease goes up.

03:58 There is a huge difference between primary CVD and secondary cardiovascular disease.

04:04 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.

04:15 As I mentioned, pain radiating, so you're going to take a good history for that.

04:20 And then, you’re going to look at all the patients’ cardiovascular risk factors.

04:23 That includes whether they’re smoking, comorbid illnesses, diabetes, hypertension, hyperlipidemia, race can be a factor as well there.

04:33 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.