Assessment of Chest Pain:
Chest pain happens to be a common presentation in the Emergency and Primary care settings due to the growing numbers of awareness in nature among the population. It is estimated that in the Northern European country of Denmark, 10% of the population are diagnosed with AMI on presentation at the Emergency unit.
Let’s walk you through the case of our patient, a 50-year-old woman named Maia, who was brought to the Emergency department by the ambulance presenting with a constricting central chest pain radiating to her jaw, arm, and shoulders. She also complains of nausea, and vomiting. She stated the pain and the symptoms started about 2 hours ago, which became unbearable and then resorted to calling the ambulance. She was given sublingual Nitroglycerin for immediate pain relief on her way to the hospital.
She reveals her mum passed away at the age of 60 years old and has had an abnormal lipid profile (Cholesterol at 6.0mmol/l) for which she takes statins and antiplatelets.
At the emergency unit she was placed on the monitor for vital signs capturing. HR-120, BP126/80mmHg, SPO2-96%, t-36.6. Physical examination reveals breath sounds on lung auscultation were normal along with other studies.
What should be the proper management of our patient in line with clinical guidelines in place?
It is estimated that 3.5% of patients with ACS have their diagnosis missed due to various reasons. What then is ACS? It is simply the occlusion of the coronary vessels by atherosclerotic plaque which leads to acute myocardial ischemia and then myocardial infarction if not timely managed.
ACS consists of four types: ST-elevation MI, Non-ST elevation MI, unstable angina, and a rare spontaneous coronary dissection. In order to exclude the diagnosis ACS, we must understand other causes of chest pain.
Other causes of chest pain: Pneumothorax; pneumonia, Pericarditis, Aortic dissection, acute cholecystitis, acute pancreatitis, GORD, esophageal spasm, peptic ulcer, cocaine usage and shingles, pulmonary embolism, Tietze syndrome.
In the assessment of a patient with chest pain , it is important not to underestimate the importance of understanding their medical history, in order to rule out coronary artery disease (CAD). We must ask the patient in relation to the pain to: describe; tell us the onset and duration; locate; tell us the aggravating or associated symptoms and then the relieving factors.
How do we then manage our patient? It is important that ECG should be first carried out to rule out ST-elevation MI or any abnormal cardiac rhythms that can point to CAD. If she presents to the clinic >3 hours after onset of symptoms and without an abnormal ECG cardiac rhythm, Cardiac Troponin test should be ordered immediately to rule in/out non-ST elevation MI. We should also consider Chest X-ray and full blood count for routine analysis.
We can also use the HEART score to determine major adverse cardiovascular event, with (0-3) for low risk and (7-10) for high risk of CAD, which then should prompt immediate investigation with coronary angiography.
In cases of results pointing towards myocardial infarction after presentation, prompt coronary angiography with PCI should also be started for timely and efficient management. If will be delayed >2 hrs, then fibrinolytics should be used abruptly.
In conclusion, our patient Maia was diagnosed with a non-ST MI, which prompted PCI with balloon angioplasty and endovascular stenting. She was later discharged after 2 weeks with a good prognosis and recommendations by her Cardiologist, all thanks to the accurate assessment of her chest pain.
Reference:
Adult Basic and Advanced life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.
AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain.
Bmj.com
Management of Cocaine-Associated Chest Pain and Myocardial Infarction: A Scientific Statement from the American Heart Association Acute Cardiac Care Committee of the Council on Clinical Cardiology
A prospective validation of the HEART score for chest pain patients at the emergency department. Int. Journal of Cardiology 2013 Oct 3;168(3):2153-8
Pope JH, Aufderheide TP, Ruthazer R, et al. Missed diagnoses of acute cardiac ischemia in the emergency department. N Engl J Med. 2000 Apr 20;342(16):1163-70.
Lindskou TA, Andersen PJ, Christensen EF, et al. More emergency patients presenting with chest pain. PLoS One. 2023 Mar 23;18(3):e0283454.
`
Leave a Reply