Chest Pain in a Patient Paper

This was the beginning of the therapeutic relationship as we engaged in a conversation where he explained he was feeling scared about going to operation theatre the next day. I didn’t dismiss his feelings and concerns, yet I assured him that he was in the best hands and would be taken care of. I discussed with him the management approach such as our treatment policy, in a very relaxed manner, maintained a smile as encouraged by Galanti (2014), and gave reassurance that the team looking after him was professional. He seemed to become less nervous and I continued to explain the treatment plan and carry out observations. Care pathways utilize multi-disciplinary teams to ensure integration between healthcare professionals (National Health Service, 2009), thus ensuring that the holistic approach to patient wellbeing has been adopted. This care is also consistent with the American College of Critical Care Medicine (2009) guidelines for the provision of intensive care services.Chest Pain in a Patient Paper

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Before going off my shift, the heart rate of my patient tended to fluctuate, on occasions he was tachycardic recorded at 95 to 110, and eventually developed tachyarrhythmia. Conover (2003) identified a state, arrhythmia, is the term used to describe “abnormal heart rhythm and beat”. Carey (2008) said it is a serious and potentially life-threatening condition if uncorrected as it can lead to cardiac arrest and death. I monitored my patient’s pulse and blood pressure using continuous cardiac monitor. At this point his pulse was 250, blood pressure was 110/70 and respiratory rate 20. I was on my way to give antiarrhythmic drug, when the patient appeared to lose consciousness, but I was uncertain of the right one. At this stage I called for cardiologist to assist and explain the clinical changes that had occurred, as I am aware of my own limitations and accountability. He instructed to give intravenous amiodarone 150 mg to stop ventricular tachycardia (V-tach). Schmitt, Deisenhofer and Zrenner (2006) described ventricular tachycardia as a type of rapid heartbeat and rhythm that arises from improper electrical activity at the bottom chambers of the heart, called the ventricles. Amiodarone can be used in hemodynamically stable patients with V-tach, regardless of the underlying heart function and the type of ventricular tachycardia. (Vassallo and Trohman, 2007)

Furthermore, on the next day after admission the patient was assessed by a physiotherapist and occupational therapist. They worked as part of the multidisciplinary team (MDT) who delivered care to patients with various health problems. Honestly, this was the first time I have ever managed a patient from admittance to discharge with professional support. Having been directly involved in the assessment of this patient with other colleagues, I have become familiar with the management of critically ill patients.Chest Pain in a Patient Paper

Although this patient did not recover well and there were some problems afterwards, this proved to be a good learning experience. I followed the instructions of the hospital treatment pathway guided by the Royal College of Physicians Acute Care toolkit (2011), which was used by MDT’s, to ensure a simple and smooth in-hospital management. From being involved in the care of this patient and exploring the surrounding literature, I now have developed a more in-depth understanding of the complexity of inter-professional team working. For future learning I will continue to develop my knowledge regarding communication with specialist colleagues and will be looking at how patient is assessed to establish high quality care.

The third learning outcome is to demonstrate the ability to apply key concepts and theories utilizing a range of cognitive and transferable skills and problem solving strategies in the management of a patient with acute care needs. Sellman and Snelling (2009) stated that everyone is accountable for his actions, omissions, and decisions, further stating that he or she must work in a professional manner. To demonstrate my achievement of this learning outcome, I will be exploring the clinical decision and management of my patient who had chest pain and hypotension post-operatively as a result of poor coronary reperfusion.

Post-operative observations are used to establish baseline references to compare future measurements and a marker of physiological changes after surgery. (Liddle, 2012) In my patient’s case, due to the baseline pulse being around 85 and blood pressure being recorded at 100/65, ward nurse reported no concerns as observations were the same as pre-operative. On receiving handover I was initially not concerned due to his baseline observations being much the same as reported by the nursing staff. However, hospital policy stated observations must be done on arrival to the ward. I monitored my patient’s pulse and blood pressure using continuous cardiac monitor. Electrocardiogram (ECG) was another helpful tool which showed ischemic changes suggestive of new coronary blockage. I responded to this initiative by contacting the treating cardiologist and discussed with him the possible treatment decisions. At this stage we decided to stop the nitrate drip and started infusing the patient with 250 ml of Volplex and followed by another 250 ml as no changes in observations were noted. Volplex according to the British National Formulary (BNF) (2014, p. 657) is a “plasma substitute”. It is a colloidal plasma substitute which increases cardiac output, blood pressure and urine output, thus protects the kidneys from the effect of hypovolaemia. As well as Volplex, Bivalirudin and Abciximab infusions were also given as there was a thrombus started to build up at the stenting area. Bivalirudin is antithrombotic agent that inhibits thrombin-mediated platelet activation and aggregation while Abciximab is a glycoprotein IIb/IIIa inhibitor given after coronary angioplasty to prevent platelets from sticking together and causing intracoronary thrombus. Chest Pain in a Patient Paper

Chest pain appears in many forms, ranging from a sharp stab to a dull ache. Sometimes chest pain feels crushing or burning. In certain cases, the pain travels up the neck, into the jaw, and then radiates to the back or down one or both arms.

Many different problems can cause chest pain. The most life-threatening causes involve the heart or lungs. Because chest pain can indicate a serious problem, it's important to seek immediate medical help.

Symptoms

Chest pain can cause many different sensations depending on what's triggering the symptom. Often, the cause has nothing to do with your heart — though there's no easy way to tell without seeing a doctor.

Heart-related chest pain

Although chest pain is often associated with heart disease, many people with heart disease say they experience a vague discomfort that isn't necessarily identified as pain. In general, chest discomfort related to a heart attack or another heart problem may be described by or associated with one or more of the following:Chest Pain in a Patient Paper

• Pressure, fullness, burning or tightness in your chest
• Crushing or searing pain that radiates to your back, neck, jaw, shoulders, and one or both arms
• Pain that lasts more than a few minutes, gets worse with activity, goes away and comes back, or varies in intensity
• Shortness of breath
• Cold sweats
• Dizziness or weakness
• Nausea or vomiting

Other types of chest pain

It can be difficult to distinguish heart-related chest pain from other types of chest pain. However, chest pain that is less likely due to a heart problem is more often associated with:

• A sour taste or a sensation of food re-entering your mouth
• Trouble swallowing
• Pain that gets better or worse when you change your body position
• Pain that intensifies when you breathe deeply or cough
• Tenderness when you push on your chest
• Pain that is persistently present for many hours

The classic symptoms of heartburn — a painful, burning sensation behind your breastbone — can be caused by problems with your heart or your stomach.

When to see a doctor

If you have new or unexplained chest pain or suspect you're having a heart attack, call for emergency medical help immediately.Chest Pain in a Patient Paper

Causes

Chest pain has many possible causes, all of which need medical attention.

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Heart-related causes

Examples of heart-related causes of chest pain include:

• Heart attack. A heart attack results from blocked blood flow, often from a blood clot, to your heart muscle.
• Angina. Angina is the term for chest pain caused by poor blood flow to the heart. This is often caused by the buildup of thick plaques on the inner walls of the arteries that carry blood to your heart. These plaques narrow the arteries and restrict the heart's blood supply, particularly during exertion.
• Aortic dissection. This life-threatening condition involves the main artery leading from your heart (aorta). If the inner layers of this blood vessel separate, blood is forced between the layers and can cause the aorta to rupture.
• Pericarditis. This is the inflammation of the sac surrounding your heart. It usually causes sharp pain that gets worse when you breathe in or when you lie down.

Digestive causes

Chest pain can be caused by disorders of the digestive system, including:

• Heartburn. This painful, burning sensation behind your breastbone occurs when stomach acid washes up from your stomach into the tube that connects your throat to your stomach (esophagus).
• Swallowing disorders. Disorders of the esophagus can make swallowing difficult and even painful.
• Gallbladder or pancreas problems. Gallstones or inflammation of your gallbladder or pancreas can cause abdominal pain that radiates to your chest.Chest Pain in a Patient Paper

Muscle and bone causes

Some types of chest pain are associated with injuries and other problems affecting the structures that make up the chest wall, including:

• Costochondritis. In this condition, the cartilage of your rib cage, particularly the cartilage that joins your ribs to your breastbone, becomes inflamed and painful.
• Sore muscles. Chronic pain syndromes, such as fibromyalgia, can produce persistent muscle-related chest pain.
• Injured ribs. A bruised or broken rib can cause chest pain.

Lung-related causes

Many lung disorders can cause chest pain, including:

• Pulmonary embolism. This occurs when a blood clot becomes lodged in a lung (pulmonary) artery, blocking blood flow to lung tissue.Chest Pain in a Patient Paper
• Pleurisy. If the membrane that covers your lungs becomes inflamed, it can cause chest pain that worsens when you inhale or cough.
• Collapsed lung. The chest pain associated with a collapsed lung typically begins suddenly and can last for hours, and is generally associated with shortness of breath. A collapsed lung occurs when air leaks into the space between the lung and the ribs.
• Pulmonary hypertension. This condition occurs when you have high blood pressure in the arteries carrying blood to the lungs, which can produce chest pain.

Other causes

Chest pain can also be caused by:

• Panic attack. If you have periods of intense fear accompanied by chest pain, a rapid heartbeat, rapid breathing, profuse sweating, shortness of breath, nausea, dizziness and a fear of dying, you may be experiencing a panic attack.
• Shingles. Caused by a reactivation of the chickenpox virus, shingles can produce pain and a band of blisters from your back around to your chest wall.Chest Pain in a Patient Paper

Chest pain doesn't always signal a heart attack. But that's what emergency room doctors will test for first because it's potentially the most immediate threat to your life. They may also check for life-threatening lung conditions — such as a collapsed lung or a clot in your lung.

Immediate tests

Some of the first tests your doctor may order include:

• Electrocardiogram (ECG). This test records the electrical activity of your heart through electrodes attached to your skin. Because injured heart muscle doesn't conduct electrical impulses normally, the ECG may show that you have had or are having a heart attack.
• Blood tests. Your doctor may order blood tests to check for increased levels of certain proteins or enzymes normally found in heart muscle. Damage to heart cells from a heart attack may allow these proteins or enzymes to leak, over a period of hours, into your blood.Chest Pain in a Patient Paper
• Chest X-ray. An X-ray of your chest allows doctors to check the condition of your lungs and the size and shape of your heart and major blood vessels. A chest X-ray can also reveal lung problems such as pneumonia or a collapsed lung.
• Computerized tomography (CT scan). CT scans can spot a blood clot in your lung (pulmonary embolism) or make sure you're not having aortic dissection.

Follow-up testing

Depending upon the results from these initial tests, you may need follow-up testing, which may include:

• Echocardiogram. An echocardiogram uses sound waves to produce a video image of your heart in motion. A small device may be passed down your throat to obtain better views of different parts of your heart.
• Computerized tomography (CT scan). Different types of CT scans can be used to check your heart arteries for blockages. A CT coronary angiogram can also be done with dye to check your heart and lung arteries for blockages and other problems.Chest Pain in a Patient Paper
• Stress tests. These measure how your heart and blood vessels respond to exertion, which may indicate if your chest pain is heart-related. There are many kinds of stress tests. You may be asked to walk on a treadmill or pedal a stationary bike while hooked up to an ECG. Or you may be given a drug intravenously to stimulate your heart in a way similar to exercise.
• Coronary catheterization (angiogram). This test helps doctors identify individual arteries to your heart that may be narrowed or blocked. A liquid dye is injected into the arteries of your heart through a long, thin tube (catheter) that's fed through an artery, either through your wrist or your groin, to arteries in your heart. As the dye fills your arteries, they become visible on X-rays and video.Chest Pain in a Patient Paper

Treatment

Treatment varies depending on what's causing your chest pain.

Medications

Drugs used to treat some of the most common causes of chest pain include:

• Artery relaxers. Nitroglycerin — usually taken as a tablet under the tongue — relaxes heart arteries, so blood can flow more easily through the narrowed spaces. Some blood pressure medicines also relax and widen blood vessels.
• Aspirin. If doctors suspect that your chest pain is related to your heart, you'll likely be given aspirin.
• Thrombolytic drugs. If you are having a heart attack, you may receive these clot-busting drugs. These work to dissolve the clot that is blocking blood from reaching your heart muscle.
• Blood thinners. If you have a clot in an artery feeding your heart or lungs, you'll be given drugs that inhibit blood clotting to prevent the formation of more clots.Chest Pain in a Patient Paper
• Acid-suppressing medications. If your chest pain is caused by stomach acid splashing into your esophagus, the doctor may suggest medications that reduce the amount of acid in your stomach.
• Antidepressants. If you're experiencing panic attacks, your doctor may prescribe antidepressants to help control your symptoms. Psychological therapy, such as cognitive behavioral therapy, also might be recommended.

Surgical and other procedures

Procedures to treat some of the most dangerous causes of chest pain include:

• Angioplasty and stent placement. If your chest pain is caused by a blockage in an artery feeding your heart, your doctor will insert a catheter with a balloon on the end into a large blood vessel in your groin, and thread it up to the blockage. Your doctor will inflate the balloon tip to widen the artery, then deflate and remove the catheter. In most cases, a small wire mesh tube (stent) is placed on the outside of the balloon tip of the catheter. When expanded, the stent locks into place to keep the artery open.Chest Pain in a Patient Paper

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• Bypass surgery. During this procedure, surgeons take a blood vessel from another part of your body and use it to create an alternative route for blood to go around the blocked artery.
• Dissection repair. You may need emergency surgery to repair an aortic dissection — a life-threatening condition in which the artery that carries blood from your heart to the rest of your body ruptures.
• Lung reinflation. If you have a collapsed lung, doctors may insert a tube in your chest to reinflate the lung.

Chest pain is a common occurrence in primary, acute, and urgent care settings, and it is one of the most cited reasons for which people seek medical attention.¹ Chest pain accounts for an estimated 5% of all emergency department visits and 1% to 2% of outpatient visits.^2-4 Additionally, chest pain is a leading cause of hospital admission and a common complaint in the acute care setting.⁵

SIGNIFICANCE OF CHEST PAIN

Chest pain has varied etiologies, from life-threatening conditions to benign pathologies and simple muscle strains. A broad differential diagnosis is necessary, leading to challenges in the evaluation and management of chest pain. Additionally, the assessment of chest pain is complicated by the disassociation between the intensity of the signs and symptoms and the seriousness of the underlying cause of chest pain, as well as by the often vague presentation and indistinct localization of the pain.^{1,2Chest Pain in a Patient Paper}

In general, pain is a complex, subjective experience. Visceral pain, including chest pain, is difficult to localize, diffuse in character, and usually referred to somatic structures.^1,2 Visceral pain is also associated with more autonomic and motor responses than somatic pain. Specifically, chest pain is usually characterized by an unpleasant sensation localized to the thorax.¹ Descriptions of chest pain vary widely, involving terms like “burning,” “aching,” “stabbing,” or “pressure.”²

One of the most significant factors in the appraisal of chest pain is the distinction between cardiac and noncardiac chest pain. It is often difficult to discriminate between these two types of pain, and patients may have simultaneous cardiac and noncardiac causes.^6,7 Noncardiac causes are common, but cardiac causes must not be overlooked, since cardiac chest pain may be an indicator of cardiovascular disease (CVD).⁴ Heart disease remains the leading cause of death in the United States; each year, 36% of deaths (roughly 870,000 cases) in the U.S. are attributed to CVD.^2-4 In 2009, the direct and indirect costs of CVD totaled more than $165 billion in the U.S.³ Early detection of cardiac chest pain and early intervention are critical for decreasing the morbidity and mortality associated with CVD.^{8Chest Pain in a Patient Paper}

EVALUATING CHEST PAIN

A thorough medical history and physical examination are essential in the evaluation of chest pain.^2,3 In order to recognize patients in need of prompt and potentially life-saving intervention, the National Heart Attack Alert Program recommends the immediate assessment of patients with the following symptoms: chest pain, pressure, tightness, or heaviness, or pain that radiates to the neck, jaw, shoulders, back, or arms; indigestion, heartburn, or nausea and/or vomiting associated with chest pain; persistent shortness of breath; or weakness, dizziness, lightheadedness, or loss of consciousness.⁶

If the symptoms do not warrant immediate intervention for life-threatening causes, the initial evaluation should include a medical history that emphasizes the characteristics and location of the pain, time of pain onset, activity at time of onset, duration of symptoms, alleviating or aggravating factors, history of prior pain, presence of risk factors, and other associated symptoms.^1,2,4,6 Coronary risk factors should also be evaluated, as well as the possibility of illegal drug use.⁶ Common risk factors for coronary artery disease (CAD) include advanced age, male gender, family history of CAD, and comorbid illnesses such as diabetes mellitus, hypertension, hypercholesterolemia, and tobacco use.^{3,9Chest Pain in a Patient Paper}

In addition to a medical history and physical examination, most adults with chest pain should have an ECG and a chest radiograph, unless an obvious non–life-threatening cause of chest pain is determined in the initial investigation.^2,4 Also, blood markers for myocardial injury, decision aids to stratify patients according to their risk of complications, early exercise testing, and various imaging techniques and clinical pathways provide enhanced accuracy and efficiency of chest pain evaluation. For patients with a low risk of complications or CVD, the benefit of further testing and evaluation must be balanced against the costs and inconvenience that accompany tests and procedures with a low probability of improving outcomes and a risk of false-positive results.⁶

MANAGEMENT OF CHEST PAIN

Common causes of chest pain and their descriptions are listed in TABLE 1. The goal of chest pain management, as with all pain control, is to find the cause and treat it appropriately, with the right medication at the lowest effective dose with the fewest possible side effects.^1,10 The general principles of respiratory, cardiac, musculoskeletal, gastrointestinal (GI), and psychological disorders apply to the treatment of both cardiac and noncardiac chest pain.^{1Chest Pain in a Patient Paper}

Cardiac Chest Pain

Several life-threatening causes of chest pain require immediate attention and must be ruled out before other causes can be determined. These conditions include acute coronary syndrome (ACS), pulmonary embolism (PE), and aortic dissection.^1-3,9 ACS is the most significant potentially fatal diagnosis of chest pain.² Fifteen percent to 25% of patients who present with chest pain are diagnosed with ACS, a broad diagnosis that includes any condition that results in myocardial ischemia, ranging from unstable angina to acute myocardial infarction (AMI). Myocardial ischemia usually occurs in the presence of coronary atherosclerosis, but ischemia may accompany any disease or process that occludes a coronary artery or decreases myocardial perfusion, such as a thrombus or embolism, aortic stenosis, or cardiomyopathy.^{6Chest Pain in a Patient Paper}

Angina, the classic manifestation of myocardial ischemia, is usually described as heavy chest pressure or a squeezing or burning sensation and is often accompanied by difficulty breathing. Angina often radiates to the left shoulder, neck, or arm and builds in intensity over a period of several minutes.⁶ While exercise or psychological stress can trigger angina, the condition most commonly occurs without obvious precipitating factors.^3,6 The typical presentation includes pain that is substernal, provoked by exertion, and relieved by rest or nitroglycerin.^3,4 Anginal chest pain indicates a high risk of CAD.⁴

An atypical presentation of chest pain lessens the likelihood that the chest pain is due to ischemia. The American College of Cardiology and American Heart Association (ACC/AHA) guidelines list several descriptors that are not characteristic of myocardial ischemia: pleuritic pain (sharp pain caused by respiratory movements or cough); pain or discomfort located primarily in the middle or lower abdomen; pain localized to the tip of one finger; pain reproduced with movement or by palpation of the chest wall or arms; constant pain persisting for many hours; brief pain lasting a few seconds; and pain that radiates to the lower extremities.⁶ However, atypical symptoms cannot rule out the presence of ACS and should be only one consideration in the diagnosis of chest pain.^6,8,11

Oxygen supplementation is routine for all patients with chest pain related to ACS. It is recommended for all AMI patients during the first 6 hours after symptom onset, and longer if other disease states causing hypoxemia are present.⁹ Also, in patients presenting with chest pain consistent with ACS, aspirin should be administered as soon as possible and continued indefinitely if no aspirin allergy exists. Clopidogrel should be substituted in the case of an aspirin allergy or GI intolerance.^{9,12Chest Pain in a Patient Paper}

Glycoprotein IIb/IIIa inhibitors block platelet aggregation and are recommended for patients with unstable angina and non–ST-elevation myocardial infarction.^9,12 Currently available agents include abciximab, tirofiban, and eptifibatide.⁸ Additionally, the ACC/AHA guidelines recommend anticoagulation with unfractionated heparin (UFH) or low-molecular-weight heparin (LMWH) added to antiplatelet therapy for the treatment of ACS.¹² Currently available LMWHs include enoxaparin, dalteparin, and tinzaparin.⁸ UFH should be adjusted to maintain a partial thromboplastin time of 1.5 to 2.0 times control.⁹ LMWH is an alternative to UFH in patients younger than 75 years with stable renal function; LMWH is preferred over heparin as an anticoagulant in the absence of renal failure.^9,12

Nitroglycerin, the cornerstone of antianginal treatment, provides symptom relief in patients with ongoing cardiac chest pain.^9,11 Morphine may also be used to control pain in AMI patients, but should be administered cautiously at low doses.⁹ Also, IV or oral beta-blockers should be given to AMI patients without a contraindication to such treatment, such as ST-elevation myocardial infarction and moderate left ventricular failure, or bradycardia, hypotension, shock, active asthma, or reactive-airway disease.^8,9

Acute aortic dissection is the most common and most lethal aortic emergency, and it has the highest mortality rate among life-threatening causes of chest pain.⁹ Acute aortic dissection causes the sudden onset of excruciating, ripping pain whose location reflects the site and progression of dissection.^6,9 Aortic dissection may also present with stroke, heart failure, syncope, lower-extremity pain or weakness, back and flank pain, and abdominal pain.^{9Chest Pain in a Patient Paper}

Aortic dissection usually occurs in the presence of risk factors such as hypertension, pregnancy, atherosclerosis, illegal drug use, connective-tissue disease, and conditions that lead to the degeneration of aortic tissue.^6,9,11 Aortic dissection is treated by eliminating factors that are favorable to the progression of dissection, including elevated blood pressure. Appropriate interventions include sodium nitroprusside administered IV to achieve a systolic blood pressure between 100 and 120 mmHg, and oral or IV beta-blockers to avoid reflex tachycardia secondary to sodium nitroprusside. Prompt surgical consultation is recommended for patients with suspected aortic dissection.⁹

The annual incidence of PE is estimated to be 200 cases per million people.¹⁰ The mortality rate for untreated PE is 18.4%, accounting for up to 200,000 deaths annually in the U.S.^9,11 PE often causes dyspnea and pleuritic chest pain, but PE may be asymptomatic. Larger emboli cause severe and persistent substernal pain, whereas smaller emboli cause lateral pleuritic chest pain.⁶ Anticoagulant therapy with UFH, LMWH, or fondaparinux effectively reduces mortality in PE.^{11Chest Pain in a Patient Paper}

Non cardiac Chest Pain

Non-cardiac chest pain may be caused by musculoskeletal disorders, abnormalities of the abdominal viscera, and psychological conditions, among other anomalies.^6,13 Even more than cardiac chest pain, non cardiac chest pain is difficult to define, diagnose, and manage.^1,14

Approximately 20% to 30% of patients with chest pain are classified as having non cardiac chest pain based on normal findings of cardiac catheterization or other diagnostic evaluations. Each year, approximately 200,000 new cases of non cardiac chest pain occur in the U.S.¹⁴ Morbidity among non cardiac chest pain patients is considerable, and these patients tend to have a high use of health care services and empiric therapies and report a general dissatisfaction with care received.^7,14

Respiratory and pleuropulmonary disorders are common causes of non cardiac chest pain. Pleuritis and pleural effusions occur frequently in connective-tissue diseases, and the pain is often relieved by nonsteroidal anti-inflammatory drugs (NSAIDs); corticosteroids may reduce inflammation in patients who remain symptomatic after NSAID treatment. Pneumonia frequently presents with chest pain localized over the area of infection. Pneumonia treatment is based on antimicrobial therapy guided by local surveillance reports.¹⁰

GI disorders are a common source of non cardiac chest pain. Gastroesophageal reflux disease (GERD), one of the most common causes of non cardiac chest pain, presents with pain resembling angina.¹⁴ GERD may be associated with a squeezing or burning type of subaltern pain that radiates to the neck, back, or arms.^6,14 The pain is generally worse after meals and in the supine position, and exercise and emotional stress can precipitate GERD-associated pain.¹¹ GERD has been reported in as many as 60% of people with chest pain.^13,14

Chest pain associated with GERD is manageable, most often with a proton pump inhibitor. Additionally, weight loss is recommended for overweight or obese patients with GERD and non cardiac chest pain. Other lifestyle modifications, including avoiding trigger foods and raising the head of the bed, may not completely relieve chest pain associated with GERD.^{14Chest Pain in a Patient Paper}

Psychological factors are significant in the diagnosis and management of chest pain. Approximately 30% of patients with non-cardiac chest pain experience panic or anxiety disorders.¹³ There is a high rate of anxiety and depression among patients with cardiac and non cardiac chest pain, so the pain should not be immediately attributed to psychological factors before organic etiologies are ruled out.¹⁵ Treatment of psychogenic causes of chest pain is not specific to chest pain and includes cognitive behavioral therapy and anxiolytic and antidepressant therapy.⁷

Musculoskeletal conditions are the cause in 25% to 35% of patients with non cardiac chest pain.¹³ Chest pain reproducible by palpation is most likely musculoskeletal in origin. One common cause of noncardiac chest pain is costochondritis, the inflammation of a rib or cartilage attached to a rib. This condition is relieved by analgesics, local anesthetics, or anti-inflammatory agents. Infectious diseases such as herpes zoster may also cause diffuse chest pain. The pain usually resolves once the infection is adequately treated with antiviral agents.^{7Chest Pain in a Patient Paper}

Treatment

With a broad differential diagnosis, a definitive cause is not always established for chest pain, and continued evaluation is often the best course.² In the absence of a definitive diagnosis, systemic analgesia for chest pain is appropriate. First-line analgesics, including acetaminophen and NSAIDs, may be used safely for mild pain in most patients. Opioids and adjuvant analgesics may be added if first-line therapy does not relieve the pain. Doses of analgesic agents should be adjusted individually based on level of pain, medication history, and allergies.^7,8

Appropriate evaluation and management of chest pain, whether its origin is cardiac or non cardiac, involves treating the underlying cause of the pain while improving patient outcomes and minimizing drug interactions and adverse events. For patients in the acute care setting, chest pain may occur as part of the symptoms or sequelae that require attention and pharmacologic management.⁸

ROLE OF THE PHARMACIST

Pharmacists are well positioned to provide comprehensive management of multiple disease states to improve quality of life, reduce chest pain recurrence, and minimize complications. Pharmacists should review medications and make recommendations to prescribers based on the best available evidence. Since the pace of clinical research is rapid, pharmacists must be vigilant about being up-to-date on current evidence-based recommendations and act on those recommendations in clinical practice. Pharmacists also play an important role in educating patients about their medications and reinforcing lifestyle modifications as part of comprehensive treatment. Acute care pharmacists can facilitate a smooth transition to the community setting for patients who will remain on chronic therapy for conditions causing chest pain. By improving medication therapy management and optimizing quality of care, pharmacists are important members of the multidisciplinary health care team.Chest Pain in a Patient Paper

Causes of chest pain can vary from minor problems, such as indigestion or stress, to serious medical emergencies, such as a heart attack or pulmonary embolism. The specific cause of chest pain can be difficult to interpret.

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Finding the cause of your chest pain can be challenging, especially if you've never had prior symptoms. Even doctors may have a difficult time deciding if chest pain is a sign of a heart attack or something less serious, such as indigestion.

If you have unexplained chest pain lasting more than a few minutes, seek emergency medical help right away rather than trying to diagnose the cause yourself.

Heart attack

A heart attack occurs when an artery that supplies oxygen to your heart muscle becomes blocked. A heart attack may cause chest pain that lasts a few minutes or longer, or it can also be silent and produce no signs or symptoms.

Many people who experience a heart attack have warning signs hours, days or weeks in advance. The earliest warning sign of blocked heart arteries may be ongoing episodes of chest pain that start when you're physically active and are relieved by rest. However, during a heart attack those symptoms appear even without any physical activity.Chest Pain in a Patient Paper

Someone having a heart attack may experience none, any or all of the following:

• Uncomfortable pressure, fullness or squeezing pain in the center of the chest lasting more than a few minutes
• Pain spreading to the shoulders, back, neck, jaw or arms
• Lightheadedness, fainting, cold sweating, nausea or shortness of breath

If you or someone else may be having a heart attack:

• Call 911 or emergency medical assistance. Don't tough out the symptoms of a heart attack. If you don't have access to emergency medical services, have a neighbor or friend drive you to the nearest hospital.Drive yourself only as a last resort, and realize that driving yourself puts you and others at risk if your condition suddenly worsens.
• Chew a regular-strength aspirin. Aspirin reduces blood clotting, which can help blood flow through a narrowed artery that's caused a heart attack. However, don't take aspirin if you are allergic to aspirin, have bleeding problems or take another blood-thinning medication, or if your doctor previously told you not to do so.
• Take nitroglycerin, if prescribed. If you think you're having a heart attack and your doctor has previously prescribed nitroglycerin for you, take it as directed. Don't take anyone else's nitroglycerin.
• Begin CPR on the person having a heart attack, if directed. If the person suspected of having a heart attack is unconscious, a 911 dispatcher or another emergency medical specialist may advise you to begin cardiopulmonary resuscitation (CPR).Chest Pain in a Patient PaperIf you haven't received CPR training, doctors recommend performing only chest compressions (about 100 to 120 compressions a minute).The dispatcher can instruct you in the proper procedures until help arrives.
• If an automated external defibrillator (AED) is immediately available and the person is unconscious, follow the device instructions for using it.

Angina

Angina is chest pain or discomfort caused by reduced blood flow to your heart muscle. The term angina is generally used when you've already been given the diagnosis of heart disease.

Angina is referred to as stable or unstable. Stable angina can be persistent, recurring chest pain that usually occurs with exertion and is relatively predictable. Unstable angina occurs when the chest pain is sudden, new, or changes from the typical pattern, and may signal an impending heart attack.Angina is relatively common, but can be hard to distinguish from other types of chest pain, such as the pain or discomfort of indigestion.Chest Pain in a Patient Paper

If you're having angina with any of the following signs and symptoms, it may indicate a more serious condition, such as a heart attack:

• Pain in your arms, neck, jaw, shoulder or back accompanying chest pain
• Nausea
• Fatigue
• Shortness of breath
• Anxiety
• Sweating
• Dizziness or fainting spells

The severity, duration and type of angina can vary. If you have new or changing chest pain, these new or different symptoms may signal a more dangerous form of angina (unstable angina) or a heart attack. If your angina gets worse or changes, seek emergency medical help immediately.

Pulmonary embolism

Pulmonary embolism occurs when a clot — usually from the veins of your leg or pelvis — lodges in a pulmonary artery of your lung. The lung tissue served by the artery doesn't get enough blood flow, causing problems with the oxygenation of the blood. This makes it more difficult for your lungs to provide oxygen to the rest of your body.

Signs and symptoms of pulmonary embolism may include:

• Sudden, sharp chest pain often accompanied by shortness of breath
• Sudden, unexplained shortness of breath, even without pain
• Cough that may produce blood-streaked spit
• Rapid heartbeat associated with shortness of breath
• Fainting
• Severe anxiety
• Unexplained sweating
• Swelling of one leg only, caused by a blood clot in the leg

Pulmonary embolism can be life-threatening. If you have symptoms of a pulmonary embolism, seek emergency medical help immediately.Chest Pain in a Patient Paper

Aortic dissection

An aortic dissection is a serious condition in which a tear develops in the inner layer of the aorta, the large blood vessel branching off the heart. Blood surges through this tear into the middle layer of the aorta, causing the inner and middle layers to separate (dissect). If the blood-filled channel ruptures through the outside aortic wall, aortic dissection is usually fatal.

Typical signs and symptoms include:

• Sudden severe chest or upper back pain, often described as a tearing, ripping or shearing sensation, that radiates to the neck or down the back
• Loss of consciousness (fainting)
• Shortness of breath
• Sudden difficulty speaking, loss of vision, weakness or paralysis of one side of your body, such as having a stroke
• Sweating
• Weak pulse in one arm compared with the other

If you are experiencing any of these signs or symptoms, they could be caused by an aortic dissection or some other serious condition. Seek emergency medical help immediately.

Pneumonia with pleurisy

Frequent signs and symptoms of pneumonia are chest pain accompanied by chills, fever and a cough that may produce bloody or foul-smelling sputum. When pneumonia occurs with an inflammation of the membranes that surround the lung (pleura), you may have considerable chest discomfort when taking a breath or coughing. This condition is called pleurisy.Chest Pain in a Patient Paper

One sign of pleurisy is that the pain is usually relieved temporarily by holding your breath or putting pressure on the painful area of your chest. This isn't usually true of a heart attack.

If you've recently been diagnosed with pneumonia and then start having symptoms of pleurisy, contact your doctor or seek immediate medical attention to determine the cause of your chest pain. Pleurisy alone isn't a medical emergency, but you shouldn't try to make the diagnosis yourself.

Chest wall pain

One of the most common varieties of harmless chest pain is chest wall pain. One kind of chest wall pain is costochondritis. It causes pain and tenderness in and around the cartilage that connects your ribs to your breastbone (sternum).Chest Pain in a Patient Paper

In costochondritis, pressing on a few points along the edge of your sternum often results in considerable tenderness in those small areas. If the pressure of a finger causes similar chest pain, it's unlikely that a serious condition, such as a heart attack, is the cause of your chest pain.

Other causes of chest pain include:

• Strained chest muscles from overuse or excessive coughing
• Chest muscle bruising from minor injury
• Short-term, sudden anxiety with rapid breathing
• Peptic ulcer disease
• Pain from the digestive tract, such as esophageal reflux, peptic ulcer pain or gallbladder pain that may feel similar to heart attack symptoms
• Pericarditis

Although chest pain can sometimes be a symptom of a heart problem, there are many other possible causes. While some of these are serious conditions, most are not harmful.

Chest pain is the second biggest cause of emergency room (ER) visits in the United States, leading to more than 8 million ER visits every year. Worldwide, chest pain affects 20 to 40 percent of the general population.

In this article, learn about many potential causes of chest pain and the other symptoms they cause.Chest Pain in a Patient Paper

Possible causes of chest pain

1. Muscle strain

Inflammation of the muscles and tendons around the ribs can result in persistent chest pain. If the pain becomes worse with activity, then it may be a symptom of a muscle strain.

2. Injured ribs

Injuries to the ribs, such as bruises, breaks, and fractures, can cause chest pain. A person may have heard a crack or felt extreme pain at the time of injury if they have a broken rib.

3. Peptic ulcers

Peptic ulcers, which are sores in the stomach lining, do not usually cause intense pain. However, they can result in a recurring discomfort in the chest.

Taking antacids, which are available to purchase online and in pharmacies, can usually relieve pain caused by peptic ulcers.

4. Gastroesophageal reflux disease (GERD)

GERD refers to when the contents of the stomach move back up into the throat. It can cause a burning feeling in the chest and a sour taste in the mouth.Chest Pain in a Patient Paper

5. Asthma

Asthma is a common breathing disorder characterized by inflammation in the airways, which can cause chest pain. Other symptoms include shortness of breath, coughing, and wheezing.

6. Collapsed lung

When air builds up in the space between the lungs and ribs, a lung can collapse, causing sudden chest pain when breathing. If someone has a collapsed lung, they will also experience shortness of breath, tiredness, and a rapid heart rate.

7. Costochondritis

Costochondritis is inflammation of the cartilage of the rib cage. This condition can cause chest pain. Costochondritis pain may get worse when sitting or lying in certain positions, as well as when a person does any physical activity.

8. Esophageal contraction disorders

Esophageal contraction disorders are spasms or contractions in the food pipe. These disorders can also cause chest pain.

9. Esophageal hypersensitivity

Changes in pressure in the food pipe or the presence of acid can sometimes cause severe pain. At present, experts are not sure what causes this sensitivity.

10. Esophageal rupture

If the food pipe bursts, this can result in sudden, intense chest pain. An esophageal rupture may occur after intense vomiting or an operation involving the esophagus.

11. Hiatal hernia

A hiatal hernia is when part of the stomach pushes up into the chest. This type of hernia is very common and may not cause any symptoms. However, if the top of the stomach pushes into the lower part of the chest after eating, it can cause symptoms of GERD, such as heartburn and chest pain.

12. Hypertrophic cardiomyopathy

Hypertrophic cardiomyopathy is when the heart grows too thick due to genetic factors. The thickening of the heart prevents blood from flowing from the heart properly, causing the muscle to work very hard to pump blood.

Symptoms of hypertrophic cardiomyopathy include chest pain, shortness of breath, dizziness, lightheadedness, and fainting.Chest Pain in a Patient Paper

13. Tuberculosis

Tuberculosis bacteria growing in the lungs can cause symptoms such as a bad cough, coughing up blood or sputum, or pain in the chest.

14. Mitral valve prolapse

Chest pain, palpitations, and dizziness are all symptoms of mitral valve prolapse, which is when a valve in the heart is unable to close fully. In mild cases, this condition may have no obvious symptoms.

15. Panic attack

A panic attack may cause chest pain in addition to nausea, dizziness, sweating, rapid heartbeat, and fear.

16. Pericarditis

Pericarditis is inflammation of the sac around the heart. It can result in sharp chest pain that is made worse by intakes of breath or lying down.

17. Pleurisy

Pleurisy is inflammation of the membrane that covers the lungs. It can result in sharp chest pain when breathing deeply.

Chest pain associated with an MI is usually more severe and lasts longer. This is due to the pathophysiologic differences between angina and MI. Angina is only a temporary reduction of blood flow to the heart, whereas an MI causes permanent damage. Furthermore, an MI may occur at any time and may not be related to any particular activity.Chest Pain in a Patient Paper

Pericarditis. Pericarditis is an inflammation of the tissue layers surrounding the heart. The chest pain of pericarditis is usually sharp and stabbing. It can radiate to the back, neck, or arm. The pain may worsen when taking a deep breath or lying flat and lessen when leaning forward.

Mitral valve prolapse. Fatigue is the most common complaint associated with mitra valve prolapse. However, sharp chest pains are reported in some patients with this condition. Chest pain related to mitral valve prolapse is different from that of angina in that it rarely occurs during or after exercise. In addition, nitroglycerin may have little effect in relieving this pain.

Aortic stenosis. Described as substernal pressure brought on by exertion and relieved by rest, chest pain caused by aortic stenosis is similar to the type experienced by patients with coronary artery disease. Pain in aortic stenosis is caused by the heart muscle having to pump blood through a narrowed aortic valve.

Aortic dissection. This condition results in a sudden or tearing type of pain in the anterior or posterior chest. The pain may radiate into the arms, abdomen, and legs.Chest Pain in a Patient Paper

Premature ventricular contractions. Patients may experience a sharp, stabbing pain over the heart with premature beats. A brief choking sensation may also be described. Another contributing factor to chest pain with premature beats is the fact that the heartbeat immediately after a premature ventricular contraction is usually stronger as the ventricle contracts more forcefully than normal.

Pulmonary causes of chest pain

Pneumonia. In simple terms, pneumonia is an infection of lung tissue. Inflammation of the lining of the lungs may produce pain in the chest.Chest Pain in a Patient Paper

Pulmonary thromboembolism (PTE). A common, serious complication of thrombus formation within the deep venous circulation, PTE can cause chest pain on inspiration.

Pneumothorax. Also known as a collapsed lung, pneumothorax refers to the accumulation of air within the pleural space. Chest pain on the affected side can range from very minor to quite severe.

Pleurisy. Inflammation of the lining of the lungs and chest can result in pain when the individual takes a deep breath or coughs. The pain is usually very sharp.

Pulmonary hypertension. Patients with this condition have increased vascular resistance in the pulmonary artery, pulmonary vein, or pulmonary capillaries. Pain is described as a dull retrosternal discomfort similar to angina.

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Pneumomediastinum. This condition occurs when air leaks from any part of the lung or airway into the middle of the chest (mediastinum). Pneumomediastinum can be caused by a traumatic injury or disease. As a result, a patient may experience pain below the breastbone that may radiate into the arms or neck. The pain may worsen when the patient takes a deep breath or swallows.

Lung cancer. Patients with lung cancer may have nonspecific chest pain. Because of metastases, the primary discomfort may be in the ribs, vertebrae, or pelvis.

Symptoms

Lung-Related Causes

Heart-Related Causes

Musculoskeletal Causes

Diagnosis

Treatment