IMPORTANT TESTS FOR CHEST PAIN

By | Categories: Medical Articles | Tags: | Date: 18th October 2018

Chest Pain should be investigated properly to exclude any life threatening underlying disorder. In this article will cover tests your doctor should run to evaluate chest pain.

Investigation of chest pain most of the time requires three main tests

  • Electrocardiogram (ECG)
  • Cardiac Biomarkers or Enzymes
  • Chest-X-Ray

Electrocardiogram (ECG)

ECG is the single most important test for evaluating chest pain. It helps in excluding life threatening underlying heart disorders which can be fatal. Patients having chest pain with normal ECG chances of Myocardial Infarction (MI) is around 10 percent while some studies say the number is around 1-2 percent. So if the ECG is normal it is highly unlikely that the chest pain if of cardiovascular origin.

ECG should be done immediately after stabilizing the patient and recording vitals.

Most patients with MI will have abnormal ECG findings, 50% of them will have diagnostic ECG changes (ST segment elevation with Q waves) while 30% can have ECG findings consistent with angina (ST segment depression with or without T wave inversion). Any ECG finding is considered to be a new one until proven otherwise by an old ECG.

Apart from cardiovascular origin a patient presenting with chest pain can have abnormal ECG findings especially in cases of:

Aortic dissection– Non specific changes, while 1-2% of cases have acute ST segment elevation
Pulmonary embolism– S wave in lead 1, Q wave in lead 3, T wave in lead 3
Electrolyte imbalance.

Cardiac Enzymes

Aspartate Transaminase, Lactate Dehydrogenase, Lactate dehydrogenase sub forms are no longer used as they are not specific for cardiac tissue and there delayed elevation does not help in early diagnosis of recent MI.

Creatine Kinase (CK) are found in brain, kidney, lungs and gastrointestinal tract, so they can be elevated in number of diseases involving these tissues like renal insufficiency, trauma, seizures.

Currently we use Cardiac specific Creatine Kinase also known as CK (MB) which is released from injured cardiac tissue into the blood stream and can easily be detected within 4-6 hours after the onset of ischemia.

Therefore CK (MB) is an excellent marker for detecting an acute MI. the level of CK(MB) peaks in about 12-24 hours and normalizes in 2-3 days. The test is usually repeated every 6-12 hours in an emergency department.

Cardiac Troponins T, I, C are found in cardiac and straiated muscles. T & I isoforms for cardiac and skeletal muscles differ they are also called as cardiac troponins. Both cardiac troponins have similar sensitivity and specificity detecting myocardial injury and are the preferred markers for the diagnosis of myocardial injury. It should be noted that Cardiac troponin T might be elevated in some non cardiac conditions like polymyositis, dermatomyositis, renal disease.

Cardiac troponins maybe elevated as long as two weeks after an episode of MI thus making them excellent late markers of recent MI. If CK(MB) eve is normal with increased cardiac troponin the finding is suggestive of minor infarction or sustained minor myocardial damage. If both the markers are elevated the patient have had acute MI.

Chest X Ray

Every patient with chest pain should have chest X ray. The radiological test gives very important clue for any non cardiovascular causes of chest pain like pneumothorax, pneumomediatinum (esophageal rupture), pleural effusion, infiltrates, pneumonia. Aortic dissection shows up in chest x ray as widened mediastinum. Pulmonary embolism may be seen in a chest x ray with loss of lung volume or decreased vascular markings.

Other Tests

  • Arterial blood gas (ABG)
  • BNP (for heart failure)
  • Spiral CT scan etc

Dr. Rahil Ahmad

Dr. Rahil is keen in practicing a holistic approach for the physical and mental well being with importance of preventive medicine and sustainable lifestyle changes of his patients of all ages.

Chest Pain can be caused by many underlying disorder which can be very simple like some gastric trouble to life threatening like angina or aortic dissection. Every patient with chest pain should be treated with utmost care and all possible investigation should be done to exclude any life threatening disorders.

Important causes of chest pain

Pulmonary embolism

Chest pain due to pulmonary embolism is mostly pleuritic , especially when pulmonary infarction develops. Chest pain is associated with dyspnea, tachycardia and hypoxemia. EKG is most of the time nonspecific but may show S wave in lead 1, Q wave in lead 3 and T wave in lead 3 (S1Q3T3). Spiral chest CT lung scan usually confirms the diagnosis. Pulmonary angiogram may also be used.

Pericarditis

Chest pain due to pericarditis is usually sharp, positional and pleuritic in nature. Chest pain may be relieved by leaning forward and pericardial rub is present. Pericarditis may be preceded by any viral illness. EKG changes may be present with ST elevation without formation of Q waves. Cardiac enzyme levels are normal and the pain responds well to anti-inflammatory agents.

Myocarditis

Myocarditis may also be preceded by viral illness as in pericarditis, chest pain is generally vague and mild. CK levels (total) as well as MB fraction (CK-MB) are often elevated. Conduction abnormalities with Q waves might be present.

Aortic Dissection

Chest pain due to aortic dissection is sharp and tearing in nature and extremely severe radiating to back. Loss of pulse or aortic regurgitation murmur often develops. On chest X ray look for midiastinal widening. Diagnosis is usually confirmed by MRI, transesophageal echocardiogram, CT scan or aortogram.

Musculoskeletal Disorders

Osteochondritis, cervical osteoarthritis, radiculitis : Are one of the most common cause of chest pain. Pain is usually stabbing in nature, atypical and localized. Chest pain might be pluritic, changes with motion and palpation. EKG changes are absent.

GastroIntestinal Disorders

Esophageal Reflux: Chest pain due to esophageal reflux is made worse with recumbency or after meals. The pain is associated with regurgitation and relieved by antacids. Episodes of spasms may occur due to ingestion of cold liquids also known as diffuse esophageal spasm or nutcracker esophagus. The chest pain is most of the time relieved by taking nitroglycerin. Diagnosis of esophageal re-flux is made by upper GI series, endoscopy or esophageal manometry.

Peptic ulcer disease, pancreatitis, cholecystitis may sometimes mimic infarction but there is an element of abdominal pain and tenderness as well with radiation to back. USG confirms cholecystitis while in pancreatitis serum level of amylase is raised.

Pneumothorax

Sudden abrupt onset of chest pain which is pleuritic in nature, absent breath sounds with shortness of breath is most of the time due to pneumothorax which can be confirmed by chest X ray.

Myocardial Infarction

Chest pain due to myocardial infarction is more sever and usually more than 20 minutes. It might be associated with radiation to left arm and jaw with diaphoresis, perspiration, dizziness, vomiting and dyspnea. EKG changes are present depending upon the intensity and site of infarction. Cardiac enzymes are raised.

Mitral Valve Prolapse

Chest pain due to mitral valve prolapsed is transient with midsystolic click murmur usually a young female with no risk factor.

Aortic stenosis

Chest pain with typical systolic ejection murmur.

Pleuritis

Pain is sharp and increases with inspiration or while taking deep breaths as in pneumonia, frictional rub or dullness maybe present. Respiratory or lung infection is present with other respiratory symptoms.

Dr. Rahil Ahmad

Dr. Rahil is keen in practicing a holistic approach for the physical and mental well being with importance of preventive medicine and sustainable lifestyle changes of his patients of all ages.

Chest pain is one of the most common problems for which patients visit clinics and hospitals in Sharjah, Dubai, UAE. Patients with chest pain may have may have an underlying cause which is very simple in nature can be treated by painkillers but the reason for chest pain can be because of life threatening problem which should always be excluded.

The setting in which chest pain occurs provides one of the most important clue for the evaluation. The history of chest pain is more important than the actual physical examination. Important features of history of chest pain usually involves following main points:

  • Duration
  • Location
  • Quality
  • Radiation
  • Frequency
  • Aggravating and relieving factors.

There are few important aspects that physician and patient should remember so as to take quick action and come to quick clinical

Pain described as tightness or heaviness, upper abdominal pain, nausea vomiting, bradycardia (decreased rate of heartbeat), fall in blood pressure (dizziness, fainting) can be due to Angina, acute coronary syndrome or inferoposterior wall ischemia.

If the patient can pin point the exact location of the pain which is sharp and knife like associated or reproduced by changes in position or by touching it is less likely that the pain has cardiovascular origin.

Nitroglycerin (dilates the smooth muscles) can worsen the pain (Gastroesophageal reflux disease) or it may decrease the pain within minutes (Transient ischemia, Esophageal spasm).

Physical Examination: Read Causes of Chest Pain

Initial Impression: Diaphoresis, Increased rate of breathing or an anxious patient may give clue about life threatening underlying cause of chest pain.

Blood Pressure: Difference of 20 mm of Hg or more in both the arms maybe suggestive of Aortic dissection.

Hypo-tension: May be due to massive pulmonary embolism or cardiac shock.

Increased rate of breathing (Tachypnea) and Increase heart beat (Tachycardia) is very non specific but is always present in pulmonary embolism. Fever may suggest pneumonia. Esophageal rupture also presents with chest pain and mediastinitis.

If there is pain while palpating (touching the chest wall) the chest pain could of musculoskeletal in origin.

New murmurs and abnormal heart sounds:

RBBB (right bundle branch block) & right ventricular infarction: Wide physiological splitting of second heart sound with inspiration.

LBBB (left bundle branch block), anterior or lateral wall infarction: New paradoxical splitting of second heart sound.

Fourth heart sound: can occur with angina or infarction.

Significant Aortic regurgitation is almost always associated with aortic dissection. Mitral regurgitation can occur in patients with angina or infarction with papillary muscle dysfunction.

Lung Auscultation for Crackles, asymmetrical (spontaneous pneumothorax) or absent breath sounds (pneumothorax and pleural effusion).

Extremities should be examined for swelling (unilateral)- pulmonary embolism or for pulses (absence pf pedal pulse –Aortic dissection)

Tests: Investigations For Evaluating Chest Pain

Read Tests for Chest Pain in detail

ECG (Electrocardiograph) is the single most initial test to rule out cardiac cause of chest pain and should be done with 12 leads immediately after initial assessment and recording of vitals. Patients presenting with acute chest pain and normal ECG the chances of chest pain being cardiac in origin is about 10 percent and in some studies 1-2 percent. So it is very important to record ECG so as to differentiate between cardiac and non cardiac causes of chest pain.

Cardiac Enzymes: CK (MB), cardiac troponins play a vital role in workup of the patient to determine whether the chest pain is cardiac in origin, angina or ischemia. They are also important markers of recent myocardial infarction.

Chest x ray: Can tell the origin of the chest pain, if it is due to some lung infection, aortic dissection, esophageal rupture, pulmonary embolism.

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