Chest Pain
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Chest pain is a significant symptom requiring prompt attention. The differential diagnosis of chest pain is considerable. If a patient complains of chest pain, the first diagnosis to consider is acute coronary syndrome (ACS), such as angina or acute myocardial infarction (MI). There are, however, several other equally serious causes of chest pain that can go undiagnosed if they are not specifically looked for.
NOTE: Patients with significant chest pain must be seen immediately, especially if they have abnormal vital signs or arrhythmia.
Causes of chest pain
Causes of chest pain that pose a major threat to life include:
Myocardial ischaemia or acute MI (ACS) – can result in cardiogenic shock or fatal dysrhythmias
Aortic dissection – causes cardiac tamponade, aortic rupture, and acute aortic incompetence and involves other organ systems, such as the central nervous system, renal system and gastrointestinal tracts as a result of acute vascular compromise
Pulmonary embolus – causes hypoxia, potentially leading to acute right ventricular failure with obstructive shock and death
Tension pneumothorax – compresses the ipsilateral lung, increases intrathoracic pressure and decreases venous return to the heart, resulting in hypotension and hypoxia
Here is a comprehensive list of possible causes of chest pain.
The patients history of chest pain is the most important tool for diagnosing the cause of chest pain, especially if the initial ECG is non-diagnostic.
When examining a patient with chest pain, you will need to check their general appearance, airway and vital signs and review their ECG.
If you suspect acute coronary syndrome or acute myocardial infarction, you should:
- Ensure a constant nursing presence by the patient’s bedside
- Give oxygen to maintain saturations >94% and attach a pulse oximeter and cardiac monitor to the patient
- Urgently request a 12-lead ECG
- Administer GTN SL (0.6 mg tablets or 0.4 mg spray) and repeat every 5–10 minutes provided SBP remains >90 mmHg
- Give aspirin 150–300 mg orally unless contraindicated by hypersensitivity
- Request an IV trolley for the patient’s bedside with two large bore 14–16G cannulae ready for insertion
Guidelines and clinical resources
Guidelines for the management of acute coronary syndrome from the Heart Foundation and the Cardiac Society of Australia and New Zealand
These guidelines were developed by means of a consensus approach which involved an independent assessment of key Australian and international evidence-based clinical guidelines, scientific articles and trial data…
