Atypical chest pain

Clinico-Epidemiological Profile of Patients Presenting With Acute Chest Discomfort in Emergency Medicine Department of a Tertiary Care Hospital in Uttarakhand, India: A Prospective Observational Study

Background Acute chest discomfort is a common presenting complaint in the emergency department. There is a paucity of studies related to clinico-epidemiological profile of patients with acute chest discomfort in the emergency department (ED). Hence, we intended to conduct the study to address the dearth of research in this field. Aims and objectives The primary objective of this study was to study the clinico-epidemiological profile of patients with acute chest discomfort presenting to the ED. The secondary objectives were to assess the prevalence of premature acute coronary syndrome (ACS), to study the ED disposition and final hospital discharge diagnosis, and to assess the predictors of 24-hour mortality in such patients. Methods A prospective observational study of patients presenting with acute chest discomfort was conducted in the emergency medicine department of a tertiary care hospital. We included adults above the age of 18 years from December 2021 to December 2022 and excluded trauma patients. A standardized form was used to document patient demographic patterns, comorbidities, chest discomfort description, physical findings, investigations, consultations, ED management, and disposition. Variables having p-value ≤ 0.05 were considered to be significant. Results A total of 200 patients were included. The most common cause of chest discomfort in the ED was cardiac, accounting for 48.5% (n = 97) of patients. The most common cardiac cause of acute chest discomfort was ST-elevation myocardial infarction (STEMI) ~ 21% (n = 42). Cardiac diagnosis was associated with the maximum number of admissions (≈80%; n = 78). The prevalence of premature ACS was 13.9% (n = 10). A 24-hour mortality was significantly associated with male gender, ambulance transport, history of coronary artery disease, and hypoxia and hypotension at the initial presentation. Conclusions ACS followed by respiratory causes are the predominant etiologies of acute chest discomfort in the ED. Knowledge of the differential diagnosis of acute chest discomfort in the ED can aid in prompt diagnosis and delivery of lifesaving treatment to these patients.

(Epicardial and microvascular) angina or atypical chest pain: differential diagnoses with cardiovascular magnetic resonance

Angina pectoris is a chest discomfort caused by myocardial ischaemia, and it is classified as ‘typical’ or ‘atypical’ if specific features are present. Unfortunately, there is a heterogeneous list of cardiac diseases characterized by this symptom as onset sign. Mostly, angina is due to significant epicardial coronary artery stenosis, which causes inadequate oxygen supply increase after raised myocardial oxygen demand. In the absence of significant epicardial stenoses, another potential cause of angina is microvascular dysfunction, related to inadequate response of resistance coronary vessels to vasodilator stimuli. The unique capability of cardiovascular magnetic resonance (CMR) in providing extremely detailed morphological and functional information, along with precise stress perfusion defects and wall motion abnormalities depiction, translates it into the test with one of the best diagnostic performance and prognostic stratification among non-invasive cardiac imaging modality. Moreover, CMR is also extremely accurate in detecting non-ischaemic cardiac causes of chest pain (such as myocardial and pericardial inflammation, or stress-related cardiomyopathy), and is very useful in helping physicians to correctly approach patients affected by chest pain.

Unusual cause of chest pain, Bornholm disease, a forgotten entity; case report and review of literature

Chest pain is a common symptom culminating in hospital admissions and specialist referrals. Although cardiac work up is pursued in most of the cases, cardiac etiology is found to be the culprit in minority of the cases. Acute chest pain is a clinical syndrome that may be caused by almost any condition affecting the thorax, abdomen, or internal organs. On occasions this extensive and expensive diagnostic work up can be avoided with awareness of commoner and non-lethal reasons. We report a case of a woman with Bornholm disease secondary to Coxsackievirus B5 (CB5) infection and supplementary review of literature till date.

Cause and Outcome of Atypical Chest Pain in Patients Admitted to Hospital

In patients with acute chest pain the prime need, usually, is to diagnose and treat myocardial infarction or ischaemia. When a cardiac origin for the pain has been excluded, patients are commonly discharged without either a diagnosis or a plan for follow-up. We studied a group of such patients to see how far causation was pursued and how their mortality compared with that of patients with a proven cardiac cause for their symptoms. The study population was 250 patients admitted over five weeks with chest pain suspected of being cardiac in origin. Initial assessment included an electrocardiogram and measurement of troponin T. If neither of these indicated a cardiac event, the patient was deemed to have ‘atypical’ chest pain and the cause, where defined, was recorded. Outcomes at one year were determined by questionnaire and by assessment of medical notes.

Of the 250 patients, 142 had cardiac pain (mean age 79 years, 58% male) and 108 atypical chest pain (mean age 60 years, 55% male). Of those with atypical pain, 40 were discharged without a diagnosis; in the remaining 68 the pain was thought to be musculoskeletal (25), cardiac (21), gastrointestinal (12) or respiratory (10) in origin. 41 patients were given a follow-up appointment on discharge. At one year, data were available on 103 (96%) patients. The mortality rate was 2.9% (3 patients) compared with 18.3% in those with an original cardiac event. Half of the patients with atypical pain had undergone further investigations and 14% had been readmitted. The yield of investigative procedures was generally low (20%) but at the end of the year only 27 patients remained undiagnosed.

Patients with atypical chest pain form a substantial proportion of emergency admissions. The symptoms often persist or recur. The commonest causation is musculoskeletal, but a sizeable minority remain undiagnosed even after follow-up.

Chest pain prevalence, causes, and disposition in the emergency department of a regional hospital in Pretoria

Background

Chest pain is a common clinical syndrome. However, there is a paucity of African studies describing the causes, prevalence, aetiology, and disposition of patients with chest pain presenting in the emergency department (ED).

Aim

The aim of this retrospective descriptive study was to determine the prevalence, causes, demographics, and disposition of all adult patients with the main complaint of chest pain presenting at the ED of a regional hospital in South Africa.

Methods

Records of all patients 18 years and older presenting with the complaint of chest pain from 1 December 2011 through 10 April 2012 were assessed. A data collection sheet capturing patient demographics and disposition from the ED was used. The diagnosis was subdivided into groups: cardiovascular, respiratory, gastrointestinal, musculoskeletal, psychiatric/psychogenic, other, and unknown.

Results

Of the 312 patients presenting with chest pain, 210 patient files were retrieved. The prevalence of non-traumatic chest pain was 1.66%. Respiratory disease was the most common cause (36.19%), with pneumonia the most common diagnosis (24.40%). Logistic regression showed diagnoses of acute cardiovascular disease or respiratory disease, older age, and transport by ambulance as being associated with admission.

Conclusion

The main cause of acute chest pain was found to be respiratory disease, followed by musculoskeletal disorders. In the African context, the aetiology of acute chest pain differs from that in first world countries. Health workers should therefore pay special attention to respiratory conditions during diagnosis and management in African patients with acute chest pain.

Chest Pain: Physician Perceptions and Decisionmaking in a London Emergency Department

STUDY OBJECTIVE

We describe physician perceptions of decision-making for acute coronary syndromes in the emergency department (ED) and the ways in which patient characteristics influence diagnosis.

METHODS

This is a qualitative analysis of semistructured interview data from physicians practicing at an ethnically diverse and lower-income London ED. All physicians working more than 3 shifts in the department during a 1-month period were approached for interview.

RESULTS

Four themes emerged from the interviews: (1) physicians emphasized the medical history when diagnosing acute coronary syndrome; (2) physicians reported communication barriers as an impediment to diagnosis; (3) physicians cited both epidemiologic data and cultural beliefs when explaining presentation differences between patient groups; (4) physicians interpreted patient complaints by comparing their clinical impressions to a "classic" or "textbook" norm.

CONCLUSION

In most cases, physicians relied on the clinical history when making decisions for patients with suspected acute coronary syndromes. In reaching judgments, physicians elicited features of the presentation they thought were salient, interpreted those features in light of epidemiologic knowledge and cultural beliefs, and compared their overall impression of the patient to a "classic" or "textbook" norm. At each step, physicians' perceptions about patients influenced the data gathered and the interpretation of that data. In addition, the expected features of acute coronary syndrome were thought to differ for some patient groups. These results highlight the need for further research into the role of provider beliefs in medical decision-making.

Evaluating the Patient With Chest Pain

Chest pain is one of the most common presenting symptoms in healthcare settings and one of the most difficult diagnostic challenges. A comprehensive history is the cornerstone of evaluation and diagnosis and one of the most important skills in distinguishing among the many causes of chest pain. Because the differential diagnosis for chest pain ranges from conditions as minor as muscle strain to life-threatening conditions, such as an acute myocardial infarction or dissecting thoracic aortic aneurysm, the advanced practice nurse must quickly and systematically assess the patient.

Cause and outcome of atypical chest pain in patients admitted to hospital

In patients with acute chest pain the prime need, usually, is to diagnose and treat myocardial infarction or ischaemia. When a cardiac origin for the pain has been excluded, patients are commonly discharged without either a diagnosis or a plan for follow-up. We studied a group of such patients to see how far causation was pursued and how their mortality compared with that of patients with a proven cardiac cause for their symptoms. The study population was 250 patients admitted over five weeks with chest pain suspected of being cardiac in origin. Initial assessment included an electrocardiogram and measurement of troponin T. If neither of these indicated a cardiac event, the patient was deemed to have 'atypical' chest pain and the cause, where defined, was recorded. Outcomes at one year were determined by questionnaire and by assessment of medical notes. Of the 250 patients, 142 had cardiac pain (mean age 79 years, 58% male) and 108 atypical chest pain (mean age 60 years, 55% male). Of those with atypical pain, 40 were discharged without a diagnosis; in the remaining 68 the pain was thought to be musculoskeletal (25), cardiac (21), gastrointestinal (12) or respiratory (10) in origin. 41 patients were given a follow-up appointment on discharge. At one year, data were available on 103 (96%) patients. The mortality rate was 2.9% (3 patients) compared with 18.3% in those with an original cardiac event. Half of the patients with atypical pain had undergone further investigations and 14% had been readmitted. The yield of investigative procedures was generally low (20%) but at the end of the year only 27 patients remained undiagnosed. Patients with atypical chest pain form a substantial proportion of emergency admissions. The symptoms often persist or recur. The commonest causation is musculoskeletal, but a sizeable minority remain undiagnosed even after follow-up.

Atypical presentations among Medicare beneficiaries with unstable angina pectoris

Chest pain is a hallmark symptom in patients with unstable angina pectoris (UAP). However, little is known regarding the prevalence of an atypical presentation among these patients and its relation to subsequent care. We examined the medical records of 4,167 randomly sampled Medicare patients hospitalized with unstable angina at 22 Alabama hospitals between 1993 and 1999. We defined typical presentation as (1) chest pain located substernally in the left or right chest, or (2) chest pain characterized as squeezing, tightness, aching, crushing, arm discomfort, dullness, fullness, heaviness, pressure, or pain aggravated by exercise or relieved with rest or nitroglycerin. Atypical presentation was defined as confirmed UAP without typical presentation. Among patients with confirmed UAP, 51.7% had atypical presentations. The most frequent symptoms associated with atypical presentation were dyspnea (69.4%), nausea (37.7%), diaphoresis (25.2%), syncope (10.6%), or pain in the arms (11.5%), epigastrium (8.1%), shoulder (7.4%), or neck (5.9%). Independent predictors of atypical presentation for patients with UAP were older age (odds ratio 1.09, 95% confidence interval 1.01 to 1.17/decade), history of dementia (odds ratio 1.49, 95% confidence interval 1.10 to 2.03), and absence of prior myocardial infarction, hypercholesterolemia, or family history of heart disease. Patients with atypical presentation received aspirin, heparin, and beta-blocker therapy less aggressively, but there was no difference in mortality. Thus, over half of Medicare patients with confirmed UAP had "atypical" presentations. National educational initiatives may need to redefine the classic presentation of UAP to include atypical presentations to ensure appropriate quality of care.

Chest pain in the emergency department: the broad spectrum of causes

We performed a prospective study to describe the broad spectrum of causes of chest pain in patients presenting to the emergency department and to compare the diagnoses in referred patients, self-referred patients and patients rushed in by ambulance. The final diagnosis in a consecutive case series of 578 chest pain patients was established after discharge from the hospital. The underlying disorders were grouped into cardiac, respiratory, gastro-oesophageal disorders, musculoskeletal pathology, somatization disorders, other diseases and unknown. For comparison of the frequencies of the disease categories the Chi-squared test was used. Out of 578 patients, 161 (27.9%) were self-referred, 369 (63.8%) were referred by the general practitioner and 48 (8.3%) were rushed in by ambulance. Cardiac diseases represented 51.7% of the cases, myocardial infarction and unstable angina 19% and 12.8% respectively Cardiac diseases were statistically significantly less common in self-referred patients (p<0.0005). Pulmonary diseases encompassed 14.2% of the population, followed by somatization disorders (9.2%), musculoskeletal pathology (7.1%) and other causes (4.3%). In 11.1% of the cases no definite final diagnosis could be established. Somatization disorders were significantly more frequent in self-referred and ambulance patients. Cardiac and pulmonary problems are the most frequent underlying disorders in acute chest pain patients in the emergency department. Somatization disorders and musculoskeletal pathology represented respectively 19.1% and 14.8% of the non-cardiac causes. The referral pattern influenced significantly the distribution of the disease categories with more cardiac and less psychiatric disorders in referred patients.