An accurate assessment of chest pain helps identify the likely cause of the pain and leads to prompt and appropriate responses to alleviate the pain and treat the cause.
Chest pain must always be considered cardiac in nature until proven otherwise.
Causes of Chest Pain
- acute myocardial infarction (AMI)
- Aortic Dissection
- Panic Attack or somatoform disorder
Making an Accurate Chest Pain Assessment
A popular method is the ‘PQRST’ pain assessment:
P – Position/Provoking Factors
- Where is the pain? Can you point to it?
- What makes the pain better?
- What makes the pain worse?
- What were you doing when the pain started?
- Does the pain change with repositioning?
Repositioning usually doesn’t change chest pain caused by an AMI.
Q – Quality
- Can you describe the pain or discomfort?
- Is it a dull ache, sharp, stabbing or crushing pain?
Up to 80% of pain associated with an AMI is reported in the sub-sternal region and is often described as “constricting” or a “crushing” sensation. However, sometimes the pain is atypical or even absent (a silent (MI)). Patients with diabetes can present with a silent MI. Every patient is different and they will not all present with the classic sub-sternal chest pain, rather they may experience other symptoms such as shortness of breath, dizziness, nausea, back pain or just unexplained tiredness and fatigue.
Common assumption that reproducible chest pain is not cardiac should be abandoned.
R – Radiation
- Does the pain radiate to any other areas?
- Can you point to it?
- 66% of patients with an AMI will experience radiating pain. Common sites are anterior chest, shoulders and arms. Less common - neck and jaw. Some patients may describe their pain radiating to the jaw and feeling like a dull ache or a tooth ache.
S – Severity/Symptoms
- Can you rate the pain out of ten?
- Any other symptoms?
Accompanying symptoms of an AMI may include nausea, vomiting and diaphoresis. The patient may also experience dizziness, hypotension and bradycardia or a feeling of impending doom and feeling scared.
T – Time
- How long have you had the pain for?
- Is the pain intermittent (starts and stops) or is it continuous (ongoing)?
Angina typically lasts for 2-5 minutes, if the precipitating factor is relieved, for example exercise. Pain associated with AMI is not usually intermittent. Acute coronary syndrome should be presumed when continuous chest pain lasts for over 20 min.
When Chest Pain is Cardiac in Nature
Clinical guidelines on the management of acute coronary syndromes (ACS) state that ‘the routine use of supplemental oxygen is not recommended’
Oxygen therapy is only indicated in the hypoxic patient with a SpO2 less than 93%, or in patients where there is evidence of shock.
Use NTG sublingual tablet to improve coronary perfusion and oxygen supply to the heart.
NTG is usually contraindicated in a patient with hypotension, as it can further decrease blood pressure due to its effect on the reduction on preload and stroke volume.
It is also contraindicated in patients on sildenafil group of medications.
Anti-Platelet Aggregators (Aspirin)
Aspirin may be prescribed (if not contraindicated) in the setting of chest pain to reduce the risk of thrombus formation in blood vessels. Aspirin inhibits the formation of thromboxanes, which mediate vasoconstriction and platelet aggregation.
Consider administering Aspirin 81 mg chewable tablet and NTG even if decision is made to transfer patient to ER for further evaluation.
- Perform and document vital signs, including the ‘PQRST’ pain assessment
- If decision is made to transfer patient to ER - Clearly document in transfer papers the exact time of chest pain onset. Enclose copy of previous EKG if available, along with latest lab results, cardiology consults, H and P, med list and diagnoses list.
- If decision is made to continue monitoring patient in the facility - Perform a 12-lead ECG if available immediately. EKG is non-specific and is negative in about 50% of ACS events.
- Order diagnostic tests CMP, CBC, CXR to rule out other causes.
- DO NOT ORDER TROPONINS - If chest pain is suspected to be cardiac in nature - transfer patient to ER for evaluation and observation.
Created by Nodar Janas, M.D.