Chest Pain and Palpitations

Chest Pain

Urgent and Emergent

Acute coronary syndrome
- Age ≥ 55 years with history of angina, coronary arterial disease, stroke
- Non-reproducible crushing chest pain radiating to both arms (LR+ 7.1), hypotension (LR+ 3.1), diaphoresis, third heart sound (LR+ 3.2)
- Evaluate troponin level I levels and EKG for STEMI including Q waves (LR+ 3.9), ST elevation > 1 mm (LR+ 6 to 54), new onset T wave inversions (LR+ 3.1) or LBBB (LR+ 6.3)
- Management
  - Ischemia: Aspirin 325 mg, nitroglycerin 0.4 mg sublingual, oxygen, heparin 60 u/kg IV bolus (maximum 4,000 u), morphine 4 mg IV
  - STEMI (ACCF/AHA 2013): Elevated troponin + EKG changes → PCI (stenting) OR fibrinolytic therapy (tPa) and transfer to PCI facility
  - Hemodynamically unstable: Refer to ACLS protocol
Stable angina: Chest pain with activity that resolves with rest
- Evaluate EKG and stress echocardiogram for signs of ischemia
- Evidence of ischemia: Start nitrates or a beta blocker, refer to cardiology
Pneumonia: Dyspnea, fever (LR+ 2.1), productive cough, egophony (LR+ 8.6), dullness to percussion. Obtain CXR, treat if positive.

Non-Urgent

Viral pleuritis, e.g. due to adenovirus, influenza, RSV, parainfluenza, CMV, EBV
Gastrointestinal
- Gastroesophageal reflux disease
  - Burning retrosternal pain with acid regurgitation and/or sour mouth taste
  - Improves with PPI (e.g. omeprazole) x 1 week (LR+ 3.1)
- Reflux esophagitis
- Esophageal spasm
Musculoskeletal (chest wall pain): Best predicted by absence of cough, stinging pain, pain reproducible with palpation, localized muscle tension (LR+ 3.0 if 3-4 are present)
- Costochondritis: Parasternal/costochondral joint pain reproducible with palpation +/- affected joint swelling (Tietze syndrome)
- Rib fracture
Anxiety: Panic attack within the past week (LR+ 4.2)

Urgent

Cardiac
- Heart failure
- Cardiomyopathy
- Cardiac tamponade
- Aortic dissection: Tearing sensation radiating to back/abdomen and upper extremity radial pulse discrepancy (LR+ 5.3)
Pleural: Presents with pleuritic chest pain
- Spontaneous pneumothorax: Sudden onset dyspnea, hypotension, locally decreased breath sounds, air space on CXR
- Pulmonary embolism
  - Previous DVT/PE, malignancy, recent immobilization/surgery, hemoptysis, oral estrogen use, HR > 100 BPM, SPO2 < 95%, unilateral leg swelling
  - Calculate Wells’ Criteria +/- PERC and consider D-Dimer, LE DVT U/S, VQ scan vs. CT-angiography
- Pleural effusion: Transudative (e.g. heart failure, cirrhosis) vs. exudative (pneumonia, PE, malignancy, recent surgery) per Light’s criteria
- Lung cancer: Older patient with history of tobacco use, night sweats, unintentional weight loss, locally decreased breath sounds

Non-urgent

Pericarditis: Recent viral infection, pain worse when supine, pericardial friction rub
Pleuritic
- Tuberculosis: Fever, night sweats, hemoptysis, unintentional weight loss
- Rheumatoid arthritis

Cardiac chest pain
- Risk factors: Male ≥ 55 years or female ≥ 65 years, patient assumes cardiac origin, pain worse with exercise and not elicited by palpation
- Identifying pain due to CAD in the primary care setting
  - One point for each: Male age ≥ 55 years or female ≥ 65 years, known cardiovascular disease, pain worse with exercise, pain not reproducible with palpation, patient assumes cardiag origin
  - Score ≥ 4 points = LR+ 4.52 for CAD
- Obtain CBC, troponin, EKG +/- echocardiogram
Pleuritic chest pain
- Sudden/intense stabbing/burning pain with deep inhalation/exhalation best controlled with NSAIDs
- Repeat CXR in 6 weeks to document resolution for patients with persistent symptoms, active smoking, age ≥ 50 years with PNA

Cardiac
- Atrial fibrillation
- Atrial flutter (Flutter waves at 300 bpm with ratio conduction, e.g. 3:1)
- Ventricular tachycardia
Endocrine
- Graves disease
- Toxic multinodular goiter
Psychiatric: Anxiety