chest pain in brief

20/05/2015 www.medscape.com/viewarticle/557161_print

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IntroductionPharmacistsareinauniquepositionwithinthehealthcarecommunity.Patientsfeelfreetoquestionpharmacistsaboutvarioussymptomstheyortheirfamilymembersareexperiencing.Manycomplaintsaretrivialandeasilytreatedwithnonprescriptionproducts,butsomearepossiblemanifestationsofseriousdisease.Chestpain(usuallyinthesubsternalarea)isoneofthelatter,asitmayindicatecardiacpathology,andheartdiseaseistheleadingcauseofdeathintheUnitedStates.[1]

Prevalence

Chestpainisexperiencedby25%ofpeopleintheU.S.[2]Atleast1%to2%ofvisitstophysiciansarecausedbyconcernaboutchestpain.[1,3]Chestpainisresponsiblefor5.5to5.8millionvisitstoemergencyroomseachyear.[4]

Despitethepotentialgravityofthissymptom,perhaps77%ofpatientswhoexperienceitrefusetomakeanappointmentwithaphysician.[5]

CardiacVersusNoncardiacChestPain

Chestpainhasanextensivedifferentialdiagnosis.Thetypicalpatientwiththefirstboutofchestpainimmediatelyfearstheonsetofcardiacpathology,suchasischemiccardiacdisease,butonly11%to39%ofthesepatientsareeventuallyfoundtohavecoronaryarterydisease.[2]Furthermore,onlyabout45%to50%ofpatientsvisitingemergencyroomsforchestpainactuallyhavecardiacrelatedchestpain.[2,3]Thebalanceofpatients(50%to55%)experiencenoncardiacchestpain.[5]

Therelativerisksofeithercardiacornoncardiacchestpainaremarkedlydifferentwhenpatientspresentingtoemergencydepartmentsandthoseseeninoutpatientprimarycareareexaminedseparately.Inemergencycarepatients,overhalfofthosewithchestpainreceiveadiagnosisofmyocardialinfarction,angina,pulmonaryembolism,andheartfailure.[1]Inoutpatientprimarycare,ontheotherhand,themostcommoncauseisgastroesophagealrefluxdisease(GERD),followedbymusculoskeletalconditions,othergastrointestinalconditions,psychiatricconditions(e.g.,panicdisorder),pulmonarydisease,orstablecoronaryarterydisease.[1,6]Someoftheconditionscausingchestpainarelessseriousbutstillrequirephysiciandiagnosis(e.g.,GERDuncontrolledbynonprescriptionproducts,panicdisorder,pepticulcerdisease,chestwallpain).Othersposegreaterrisktothepatient'slife,suchasstableorunstablecoronaryarterydisease,pulmonaryembolism,andpneumonia.Virtuallyallrequirephysicianreferral.Thesoleexceptionmightbeheartburnorgastroesophagealreflux,potentiallyselftreatablewithomeprazole,H2antagonists,orantacids,assumingallFDArequiredlabelsarefollowedclosely.

ChestPainRequiringEmergencyCare

Severalpotentialcausesofchestpainrequireemergencycare,[7]whichareincludedhereinordertostressthatallrequireanimmediatephysicianvisit.Onesuchdiagnosisisacutecoronarysyndrome,includingacutemyocardialinfarctionandunstableanginabothrequireanelectrocardiogramfordiagnosis.Typicalanginalpainhasthreecharacteristics:Itissubsternal,itisbroughtonbyexertion,anditisrelievedbyeitherrestornitroyglycerin.[1]Anginalpainisalsobrief,withadurationoffiveto15minutes.[4]Amyocardialinfarctionismorelikelyifthepatienthasdiaphoresis,painradiatingtobotharms,andlowbloodpressure.[1]Alternatively,thepatientmayhaveahypertensioninducedaorticdissection,inwhichthereisatearinanaorticwall.Thechestpainofaorticdissectionisaripping,tearing,orknifelikepainthatbeginssuddenlyatpeakintensity,alongwithneurologicalorpulseabnormalities.[1,4]

aorticdissectionmaybetreatedwithmedicationorsurgery,dependingonthenatureofthetear.

ThePatientWithChestPainW.StevenPray,PhD,DPhUSPharmacist.200732(2)



Chestpaincanbecausedbyacutepericarditis,perhapsfollowingaviralillness.Inthiscondition,chestpainradiatestotheback,neck,orshouldersandoftenworsenswhenthepatientinhales.Itimprovesifthepatientsitsuprightorleansforward.Thepainistraditionallyaccompaniedbydyspneaandfever.

Pulmonaryembolismmaycauseasuddenonsetofpleuriticchestpain.[4,7]Additionalmanifestationsarefatigue,dyspnea,fainting,spittingupblood,andcardiacarrest.AnEKGhelpsconfirmthediagnosis.

Pneumothoraxisapotentialcauseofpleuritic,sharp,andsuddenchestpain,usuallyaccompaniedbyshortnessofbreath.[7]Patientsoftenhaveahistoryofcigaretteuseorhavechronicobstructivepulmonarydisease.[8]

Severechestpaincanoccurfollowingperforationoftheesophagus,mostofteninpatientsages63to71.7Additionalmanifestationsincludevomiting,shortnessofbreath,dyspnea,cough,fever,andabdominalpain.AchestXray,endoscopy,orotheremergencydiagnosticprocedureisneededtoconfirmperforationpromptconfirmationcanbelifesaving.

Approximately5.6millionindividualseachyearintheU.S.contractcommunityacquiredpneumonia,anotherpotentialdiagnosisforthosewithchestpain.[9]Pneumoniapainmaybepleuritic,sharp,dull,orsubsternal.[7]Othermanifestationsaredyspnea,fever(over100.4F),malaise,fatigue,cough(productiveornonproductive),alteredbreathsounds,wheezing,andrales.[4,7]AchestXray,CATscan,orbronchoscopycanconfirmthisdiagnosis,allowingthecliniciantobeginantibacterialtherapy.



Figure1.

NonemergencyChestPain

Thereareothercausesofchestpainthatrequirephysiciancare,althoughanimmediatevisittotheemergencyroomis



notnecessary.Theseincludepanicdisorder,depression,variousgastrointestinaldiseases,chestwallsyndrome,andnerverootcompression.[6,7]Panicdisordercausesabroadsetofsymptomssuchaspalpitations,diaphoresis,tremor,dyspnea,choking,nausea,dizziness,fearoflosingcontrolordying,tinglingoftheextremities,hotflashes,andchills.Somegastrointestinalconditionsthatcancausechestpainarereflux,spasmoftheesophagus,pancreatitis,andpepticulcer.Iftheproblemisduetoreflux,thepatientwillalsodescribethepostprandialsensationoffoodmovingupwardfromthestomach.[1,4]Chestwallpainisoftenacute,localized,andsharp,worseningwithmovementoradeepbreath,anddyspneaisoftenpresent.[1]Patientswithchestwallpainmayhaveahistoryofrheumatoidarthritisorosteoarthritis.[1]Ifthecervical/thoracicnerverootsbecomecompressed,theycauseananginalikepainthatisworseifthepatientmovestheneck,coughs,orsneezes.

ChestPaininYoungAthletes

Pharmacistsareoccasionallyapproachedbyaworriedyoungathleteorhisorherparent(s).Inatypicalscenario,theyouthhasexperiencedsubsternalchestpainduringanathleticevent.[10]Thefamilyisunderstandablybewildered,sincepriortotheepisode,theyouthappearedtobeatthepeakofability,inexcellentshape,andwithnoapparenthealthproblems.Undoubtedly,thepatientwasclearedforexercisebyaphysician.Thefamilymaybeinthemidstofrecriminationsandguiltforallowingtheyouthtoengageinsportsinthefirstplace,supposingthattheyouthhasnowdevelopedaseriouscardiacconditionasaresult.

Figure2.

Theprognosisisactuallyquitefavorable,becauseonlyaboutadozenyoungathletesdieeachyearfromundetectedcardiacdisease.Inthosewhodo,theprobablecausesarerareconditions,suchashypertrophiccardiomyopathyorcongenitalcoronaryarteryanomalies.[10]Thelowriskofseriouspathologyislargelymisunderstoodbythelaypublic,asthefewunfortunatesuddendeathsinyoungathletesseemtogarnerwidespreadpublicity.Firstandforemost,thepharmacistmusturgethefamilytovisitaphysician.Themostfrequentdiagnosisisexerciseinducedasthma,andthemostcommonvenueforitsoccurrenceisacold,dryambientenvironment,suchasahockeyrink.Thepatientmayhavealsoexperiencedgastroesophagealreflux,aproblemforthoseengaginginsportswithpronouncedverticalmovement,suchasrunningandjumping.Thecausemayalsobethewellknown"stitch"intheside.Thisisacommon



painlocatedoverthelowerleftribcageitmaybecausedbystrainoraspasmofthemusclessupportingthediaphragm.

CocaineInducedChestPain

Chestpainistheleadingmedicalcomplaintamongcocaineabusers.Inurbanareas,itisthoughttoberesponsiblefor14%to25%ofchestpainepisodestheestimateinsuburbanareasisonly7%.[11]However,patientsarenotlikelytorevealahistoryofillicitdrugabusetothepharmacistorphysician.

Conclusion

Pharmacistsarelikelytobeapproachedbypatientswhocomplainofchestpain.Thedifferentialdiagnosisofchestpainisextensive,includingmanylethaldiagnoses.Invirtuallyeverycase,theprudentpharmacistwillencouragethepatienttoseekemergencymedicalcare.

ReprintAddress

Tocommentonthisarticle,[email protected].

USPharmacist.200732(2)2007JobsonPublishing

References

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2. KachintornU.Howdowedefinenoncardiacchestpain?JGastroenterolHepatol.200520Suppl:S2S5.

3. ShepsDS,CreedF,ClouseRE.Chestpaininpatientswithcardiacandnoncardiacdisease.PsychosomMed.200466:861867.

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6. FassR,DickmanR.Noncardiacchestpain:Anupdate.NeurogastroenterolMotil.200618:408417.

7. RingstromE,FreedmanJ.Approachtoundifferentiatedchestpainintheemergencydepartment:Areviewofrecentmedicalliteratureandpublishedpracticeguidelines.MtSinaiMed.200673:499505.

8. NiewoehnerDE.Theimpactofsevereexacerbationsonqualityoflifeandtheclinicalcourseofchronicobstructivepulmonarydisease.AmJMed.2006119(Suppl1):3845.

9. LutfiyyaMN,HenleyE,ChangLF,etal.Diagnosisandtreatmentofcommunityacquiredpneumonia.AmFamPhysician.200673:442450.

10. RowlandTW.Evaluatingcardiacsymptomsintheathlete:Isitsafetoplay?ClinJSportMed.200515:417420.

11. JonesJH,WeirWB.Cocaineinducedchestpain.ClinLabMed.200626:127146.

12. CavaJR,SaygerPL.Chestpaininchildrenandadolescents.PediatrClinNorthAm.200451:15531568.

chest pain in brief

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