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Chest Pain Differential Diagnosis Case Study

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A 57-year-old male presents to his local A&E department complaining of chest pain.


Presenting complaint

“Doctor, my chest, it’s still hurting. What’s going on?”


History

Use SOCRATES to gather further information about the chest pain:

  • Site – where exactly is the pain?
  • Onset – sudden or gradual?
  • Character – sharp / dull / crushing?
  • Radiation – does it move anywhere?
  • Associated symptoms – shortness of breath / pre-syncope / syncope
  • Timing – duration of chest pain?
  • Exacerbating & Relieving factors – what makes it worse or better?
  • Severity – on a scale of 1-10 – useful when later assessing impact of treatment

 

Patient’s response

“The pain is in the middle of my chest and came on suddenly an hour ago whilst I was watching TV. It feels like I’ve got an elephant sat on my chest doctor, it’s awful. I had a bit of tingling in my neck and jaw, but that’s gone now. I feel really nauseated, I vomited once at home before the ambulance arrived. I do feel a little short of breath, which is weird, I’ve never had that before, maybe I’m just anxious. The pain isn’t affected by my position or by taking in a deep breath, it’s just always there. The pain has improved but it’s still aching and feels heavy, I’d say it was 8/10 at the start and it’s now about 5/10.”

Past medical history

Has the patient had chest pain in the past?

  • When was the first episode?
  • How frequently do the episodes occur?
  • Is there an obvious trigger – e.g. exertion 
  • Have they been investigated for the chest pain?
  • Do they have a diagnosis of any cardiac problems?

 

Any other medical problems? (specifically cardiac risk factors)

  • Diabetes
  • Hypertension
  • Hypercholesterolaemia
  • Ischaemic heart disease
  • Family history of cardiac issues?

Social history

Smoker?

Exercise tolerance?

Alcohol intake?

Patient’s response

“I’ve never had chest pain like this before, maybe a few niggles every few months, over the last few years, but nothing like this! I didn’t bother going to the doctor about the niggles, as they always settled on their own and I’ve never been diagnosed as having any heart trouble.”

“I’ve got high blood pressure and cholesterol, I’m on tablets for those though.”

“I do smoke, about 20 a day and have done for the last 30 years”

“I’m not a drinker doctor, I like to stay healthy so I stay away from it”

“I don’t really do much exercise, but I get from the shops and back without any trouble”


Examination

  • Cardiovascular examination
  • Respiratory examination
  • Abdominal examination

The patient has a regular pulse, is tachycardic at 105 bpm and is hypertensive with a BP of 160/110

He has some xanthelasma around his eyes and also has corneal arcus.

Heart sounds are normal and his chest is clear.

There is no evidence of peripheral oedema.

The abdomen is soft and non-tender. There is no organomegaly. There is no expansile mass on palpation of the aorta.


Diagnosis

Acute coronary syndrome

Pulmonary embolism

Pericarditis

Dissecting aortic aneurysm

Oesophageal spasm

12 Lead ECG – looking for ischaemic changes

Bloods:

  • FBC – severe anaemia can cause an MI / raised WCC in pericarditis
  • U&E – abnormal electrolytes could cause arrhythmias 
  • Troponin  – baseline + 6hrs from presentation – >20% rise significant
  • Lipid profile – not as important acutely, but used in long-term management
  • Glucose – same as lipid profile – long-term management of risk factors

.

CXR –assess for signs of heart failure  – heart size / pulmonary oedema

 

An ECG was recorded

ECG¹

Anterior ST-elevation myocardial infarction (STEMI).

The ECG demonstrates significant ST elevation in the anterior leads.

This suggests the presence of full-thickness myocardial infarction in the anterior portion of the heart.

Left coronary artery

The left coronary artery provides the blood supply to the anterior portion of the heart.

Therefore in this circumstance, it is likely that this vessel in the one affected.

Below is a guide to which vessels are most likely affected in each type of myocardial infarction.

  • Anterior – Left coronary artery
  • Posterior – Left circumflex artery (usually) / Right coronary artery
  • Inferior – Right coronary artery
  • Lateral – Left circumflex artery
  • Antero-septal – Left anterior descending (LAD)

Management

Initially, an ABCDE approach should be adopted to ensure any immediate threats to life are recognised and treated.

Next steps in immediate management 

  • Morphine – 5-10mg IV (can also give anti-emetic to reduce nausea)
  • Oxygen – if saturation less than 94%
  • Glyceryl trinitrate (GTN) – avoid if hypotensive
  • Aspirin 300mg + Clopidogrel 300mg (or other antiplatelet e.g. Ticagrelor)
  • Fondaparinux 2.5mg subcutaneous

The on-call interventional cardiologist should be contacted as soon as possible, in this scenario time is muscle, so the longer the delay to definitive treatment, the worse the outcome.

Primary percutaneous coronary intervention (PCI)

  • This is the best choice of treatment for recent onset STEMI
  • Ideally should be done within 90 minutes of chest pain onset
  • Involves widening of affected coronary arteries by a balloon catheter
  • A stent is then put in place to keep the vessel patent
  • This allows restoration of blood flow to the myocardial tissue
.

Antiplatelets :

  • Dual antiplatelet therapy is often continued for 12-24 months after PCI
  • A single antiplatelet agent is then continued long-term

 

Address other cardiac risk factors:

  • Hyperlipidaemia – give a long term statin (e.g. Atorvastatin)
  • Hypertension – initiate appropriate antihypertensive medication
  • Beta blocker  
  • Smoking cessation

 

Lifestyle advice:

  • Regular exercise
  • Low-fat diet

.

Cardiac rehabilitation


References

1. ECG image – http://999medic.com/tag/ekg/

2. Unstable angina and NSTEMI: early management – https://www.nice.org.uk/guidance/cg94


 

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