CHEST PAIN   16A

A 55-year-old man presents to the clinic complaining of chest pain. For the past 5 months, he has noted intermittent substernal chest pressure radiating to his left arm. The pain occurs primarily when exercising vigorously and is relieved with rest. He has no associated shortness of breath, nausea, vomiting, or diaphoresis. His medical history is significant for hypertension and hyperlipidemia. He is on atenolol and a low-fat diet. His father had died of a myocardial infarction (MI) at age 56 years. He has a 50-pack-year smoking history and is currently trying to quit. His physical examination is normal except for a blood pressure of 145/95 mm Hg; his heart rate is 75 beats/min.

What are the salient features of this patient’s problem? How do you think through his problem?

Salient features: Middle-aged man; intermittent pain with exercise and relieved with rest; substernal location with radiation to the arm; risk factors: hyperlipidemia, hypertension, family history, cigarette smoking

How to think through: When evaluating a patient with chest pain, first determine if the pain is acute in onset (or progressive) with features concerning for acute coronary syndrome (ACS), pulmonary embolism, aortic dissection, pneumothorax, or another emergency. But most patients with chest pain do not require emergent evaluation. This patient’s chest pain has characteristics of typical angina, including substernal location, exertional onset, radiation to the arm, and relief with rest. Risk factors for coronary artery disease (CAD) are weighed along with history, examination, and electrocardiogram (ECG). What are the major CAD risk factors? (Age, sex, family history, tobacco use, diabetes mellitus, hypertension, low high-density lipoprotein [HDL] cholesterol, high non-HDL cholesterol.) Could this be aortic stenosis? (Based on history alone, it could be. Cardiac and carotid pulse examination will help distinguish.) While other causes (esophageal spasm or musculoskeletal pain) are possible, the symptoms, long smoking history, and family history confer a high pretest probability of CAD. There are several noninvasive CAD testing options; all involve a stressor (exercise or pharmacologic) and a detector (ECG, echocardiography, nuclear medicine). Is medical therapy indicated at this point? (Yes: aspirin, statin, β-blocker, and nitroglycerin therapy, given the high suspicion for CAD.)

CHEST PAIN   16B

What are the essentials of diagnosis and general considerations regarding chest pain?

Essentials of Diagnosis

Chest pain onset, character, location, duration, frequency, and exacerbating and alleviating factors

Presence of shortness of breath; vital signs; chest and cardiac examination

ECG and cardiac biomarkers

General Considerations

Can signify cardiovascular, pulmonary/pleural, esophageal/gastrointestinal, musculoskeletal, or psychiatric disease

Life-threatening causes: ACS, pericarditis, aortic dissection, pulmonary embolism, pneumonia, tension pneumothorax, and esophageal perforation

HIV, systemic lupus erythematosus, and rheumatoid arthritis predispose to coronary disease

Cancer, trauma, recent surgery, immobilization, and history of thrombosis predispose to pulmonary embolism

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