Hospital Medicine

Chest pain

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Chest Pain

I. Problem/Condition.

Chest pain accounts for approximately 5 million emergency department visits annually, and can be a difficult diagnostic challenge.

II. Diagnostic Approach.

A. What is the differential diagnosis for this problem?

Cardiac causes of chest pain

  • Ischemia - stable angina, unstable angina, acute myocardial infarction*, coronary artery spasm, aortic stenosis

  • Non ischemia - aortic dissection*, myocarditis, pericarditis

Pulmonary causes of chest pain

  • Pleuritis, pneumonia, pulmonary embolus*, pneumothorax*, pulmonary hypertension

Gastrointestinal causes of chest pain

  • Esophageal - reflux, spasm, esophagitis, rupture*

  • Biliary - colic, cholecystitis, choledocholithiasis, cholangitis

  • Pancreatitis

  • Peptic ulcer disease - non perforating, perforating*

Chest wall causes of chest pain

  • Costocondritis, fibrositis, rib fracture, sternoclavicular arthritis, herpes zoster (before the rash), cervical disc disease

Psychiatric causes of chest pain

  • Anxiety disorders - hyperventilation, panic disorder, primary anxiety

  • Affective disorders - depression

  • Somatoform disorders - thought disorder (fixed delusions)

*Potentially life threatening/emergent conditions.

B. Describe a diagnostic approach/method to the patient with this problem.

When the chief complaint is chest pain the first differentiation that has to be made it between emergent and non-emergent causes of chest pain. The evaluation for emergent causes of chest pain includes: focused history and physical, 12-lead electrocardiogram (EKG) and chest radiograph (CXR). Once this quick evaluation for emergent causes of chest pain has been completed, a more detailed history and physical should be obtained along with pertinent lab data and diagnostic testing.

1. Historical information important in the diagnosis of this problem.

Description of the Pain

Location

Ischemic pain can be substernal. Pulmonary causes of chest pain can localize to the chest wall. Esophageal causes of chest pain are often in the epigastric area. Chest wall causes of chest pain are often localized to a specific area.

Radiation

Ischemic pain can radiate to the jaw and left arm. Aortic dissection pain can radiate to the back, intrascapular region or abdomen. Cervical disc disease pain can radiate into the arms.

Quality

Certain causes of chest pain have a different quality. Ischemic chest pain is characterized by pressure, tightness and squeezing. Aortic dissection is characterized by a tearing or ripping pain going to the back. Pulmonary embolism is associated with pleuritic chest pain. Pneumothorax is associated with sudden sharp and pleuritic pain. Esophageal reflux pain can be associated with a burning sensation. Biliary and pancreatic causes of chest pain often have abdominal pain associated with them.

Severity

While this is very variable, pain associated with aortic dissection, esophageal rupture, perforating ulcer, and tension pneumothorax is severe.

Onset

Aortic dissection, esophageal perforation and tension pneumothorax have a sudden onset of pain. Ischemic pain can be associated with increased activity. Rib fractures can be associated with trauma.

Exacerbating and Relieving Factor

Ischemic pain may be relieved by rest. Pericardial pain may be improved by sitting up and leaning forward or made worse with inspiration and lying down. Rib fracture pain can be positional. Cervical disc disease pain can be worsened with neck movement, coughing or sneezing. Of note, response to antacids and nitroglycerin is not reliable.

Associated Symptoms

  • Shortness of breath? Ischemic heart disease, pulmonary causes of chest pain, esophageal rupture, and anxiety can be associated with shortness of breath.

  • Syncope? Pulmonary embolism can cause syncope. Aortic dissection can present atypically with syncope.

  • Hemoptysis? Pulmonary embolism and pneumonia can cause hemoptysis.

  • Nausea? Ischemic heart disease can cause nausea and is associated with increased risk. Gastrointestinal causes of chest pain can cause nausea.

  • Vomiting? Esophageal rupture is often (but not always) preceded by vomiting.

  • Abdominal pain? Gastrointestinal causes of chest pain, especially biliary and pancreatic, are often associated with concomitant abdominal pain.

  • Fever? Pneumonia, pericarditis and myocarditis can have associated fever. Low-grade fever may be associated with pulmonary embolism.

  • Upper respiratory symptoms? Pericarditis and myocarditis may be associated with preceding upper respiratory infection (URI) symptoms.

  • Anxiety? Seen in anxiety disorders that cause chest pain.

  • Fear of losing control or dying? Seen in anxiety disorders that cause chest pain.

  • Diaphoresis? Ischemic heart disease.

Do you have the following medical diagnoses?

  • Hypertension? Hypertension is a risk factor for ischemic heart disease and aortic dissection.

  • Diabetes? Diabetes is a risk factor for ischemic heart disease.

  • Peripheral vascular disease? Peripheral vascular disease can be a marker for ischemic heart disease.

  • Malignancy? Malignancy is a risk factor for pulmonary embolism.

Have you recently had any?

  • Trauma? Trauma is a risk factor for aortic dissection, pulmonary embolism, pneumothorax, esophageal rupture, and rib fracture.

  • Major surgery or medical procedure? Major procedures are a risk for pulmonary embolism; however, specific procedures increase risk for specific kinds of chest pain (endoscopy can be associated with esophageal problems).

  • Periods of immobilization? Prolonged immobilization is a risk for pulmonary embolism.

2. Physical Examination maneuvers that are likely to be useful in diagnosing the cause of this problem

Physical exam can often be relatively normal in a patient with chest pain. Specific maneuvers (in alphabetical order) that can aid you are:

  • Absence of breath sounds - pneumothorax.

  • Aortic insufficiency murmur - aortic dissection.

  • Cardiac tamponade - aortic dissection, pericarditis.

  • Diminished breath sounds - esophageal rupture, pneumonia.

  • Elevated blood pressure - aortic dissection.

  • Fever - pneumonia, pericarditis and myocarditis.

  • Heart sounds with audible crepitus (Hamman's crunch) - esophageal rupture.

  • Hyper-resonance of percussion of the lungs - pneumothorax.

  • Increased respiratory rate - pulmonary embolism.

  • Jugular venous distension - aortic dissection (with cardiac tamponade), pericarditis (with cardiac tamponade).

  • Neurologic deficits - aortic dissection.

  • Pericardial friction rub - pericarditis.

  • Pressure to the head causing pain (Spurling's maneuver) - cervical disc disease.

  • Pulse deficit - aortic dissection.

  • Pulsus paradoxus - pericarditis (with cardiac tamponade).

  • Reproducible pain - chest wall pain.

  • Subcutaneous air in thorax or neck - esophageal rupture.

  • Tracheal deviation - tension pneumothorax.

3. Laboratory, radiographic and other tests that are likely to be useful in diagnosing the cause of this problem.

Laboratory data

  • Troponin - ischemic heart disease.

  • Complete blood count - pneumonia, pericarditis, myocarditis.

  • D-dimer - pulmonary embolism.

  • B-type natriuretic peptide (BNP) - ischemic heart disease/ congestive heart failure.

  • Comprehensive metabolic panel: renal failure / biliary diseases.

  • ABG: Not routinely recommended but an elevated A-a gradient can provide some help in diagnosing or excluding PE.

  • Urine drug screen: when cocaine-induced ischemia is suspected.

Radiographic data

  • CXR

    • Displacement of aorta - aortic dissection.

    • Enlarged cardiac silhouette - pericarditis.

    • Free air - perforated ulcer.

    • Infiltrate - pneumonia.

    • Lack of vascular markings (Westermark's sign) - pulmonary embolism.

    • Loss of aortic contour - aortic dissection.

    • Pleural effusion - aortic dissection, pulmonary embolism, esophageal rupture.

    • Pneumomediastinum - esophageal rupture.

    • Pneumothorax - pneumothorax.

    • Widened mediastinum - aortic dissection, esophageal rupture.

  • Computed tomography (CT) - aortic dissection, pulmonary embolism, esophageal rupture, pneumonia. Currently, studies are ongoing for triple-rule-out (TRO) CT scans to simultaneously rule out Aortic dissection, CAD and PE. These TRO CT scans are associated with increased radiation exposure.

  • Magnetic resonance imaging (MRI) - aortic dissection.

  • Abdominal ultrasound - biliary disease.

  • Ventilation perfusion scan - pulmonary embolism.

Cardiac testing

  • EKG.

    • Concave ST segment elevation with T wave inversions and PR depression - pericarditis.

    • Low voltage in limb leads - cardiac tamponade (which is associated with pericarditis and aortic dissection).

    • Left ventricular hypertrophy (LVH) - aortic dissection.

    • Right heart strain - pulmonary embolism.

    • S1Q3T3 (prominent S wave in lead I, Q wave in lead III and inverted T wave in lead III) - pulmonary embolism.

    • Concave ST segment elevation with T wave inversions and PR depression - pericarditis.

    • Low voltage in limb leads - cardiac tamponade (which is associated with pericarditis and aortic dissection).

  • Transthoracic echo - aortic dissection, pericarditis, ischemic heart disease.

  • Transesophageal echo - aortic dissection: useful for rapid testing especially in unstable patient.

  • Cardiac CT - ischemic heart disease.

  • Cardiac MRI - ischemic heart disease, aortic dissection, cardiomyopathies.

  • Stress Test (exercise, adenosine, dobutamine) with nuclear cardiac imaging - ischemic heart disease.

C. Criteria for Diagnosing Each Diagnosis in the Method Above.

Diagnosis: Ischemic heart disease

  • History - pain: a) can be characterized by pressure, tightness and squeezing, b) can be associated with increased activity and relieved by rest, c) can be associated with shortness of breath and nausea. Risk factors include diabetes, hypertension, hypercholesterolemia, tobacco abuse, and family history of ischemic heart disease.

  • Physical exam - no specific maneuvers.

  • Labs - a) troponin elevation - not detected in the blood of healthy people, both sensitive and specific, b) brain natriuretic peptide (BNP) - assists in risk stratification only.

  • Radiology - CXR to rule out other causes of chest pain.

  • Cardiac testing.

    • EKG - presence of ST segment elevation, presence of ST segment depression, presence of T wave inversions. If standard EKG is inconclusive and patient continues to have ischemic symptoms, additional leads should be recorded to detect right ventricular infraction or left circumflex occlusion (detected on V3R and V4R and V7- V9).

    • Stress echocardiography - wall motion imaging and risk stratification.

    • Cardiac CT - anatomic coronary artery delineation: useful for low- to intermediate-probability chest pain patients presenting to emergency department without signs of ischemia on EKG and or inconclusive cardiac troponin to exclude CAD. It is not useful in patients with known CAD.

    • Cardiac MRI - anatomic and function imaging: Can differentiate scar from recent infraction as well as other cardiomyopathy, such as myocarditis and Takotsubo cardiomyopathy.

    • Stress test (Exercise/ Adenosine/ Dobutamine) with nuclear imaging- perfusion imaging and risk stratification.

Diagnosis: Aortic dissection

  • History - pain is characterized by tearing and ripping, radiating to the back with sudden onset and severe in nature. Can present with syncope. Risk factors include hypertension, arteriosclerosis, advanced age, Marfan syndrome, connective tissue disease, and Turner's syndrome.

  • Physical exam - the following can be present: hypertension, pulse deficit or difference of blood pressure >20 mm between right and left arm, neurologic deficits, aortic insufficiency murmur, cardiac tamponade, and elevated jugular venous distension (if cardiac tamponade present).

  • Labs - obtain troponin and complete blood count (CBC) to rule out other causes. Also, elevated D-dimer can be used to rule out acute aortic dissection in patients with low likelihood of the disease.

  • Radiology - CXR can show the following: widened mediastinum, loss of aortic contour, displacement of aorta, and pleural effusion.

  • Cardiac testing - transesophageal echo, CT of the chest or MRI of the chest can all diagnose and further characterize dissection.

  • Important point - the triad of immediate and maximal tearing or ripping pain, pulse or blood pressure differential, and mediastinal widening can identify up to 96% of patients with aortic dissection.

Diagnosis: Pericarditis

  • History - pain is a sharp pain that can radiate to the back, neck or shoulders and can worsen with inspiration and lying down while improved with sitting up and leaning forward. Dyspnea can be associated with this as well. An upper respiratory infection may precede this.

  • Physical exam - significant findings include a fever, pericardial friction rub and cardiac tamponade with the associated jugular venous distension, hypotension, and pulsus paradoxus.

  • Labs - CBC can show an increased white blood cell (WBC) count; erythrocyte sedimentation rate, lactate dehydrogenase and c-reactive protein can be elevated.

  • Radiology - CXR may show an enlarged cardiac silhouette (water bottle configuration) with clear lung fields suggesting cardiac tamponade. Lateral CXR may show oreo cookie sign.

  • Cardiac testing.

    • EKG - concave ST segment elevation with T wave inversions and PR depression. In patients with pericardial effusion, low voltage complexes with alternams could be seen.

    • Transthoracic echocardiography - can show pericardial effusion. Features which suggest cardiac tamponade includes collapse of any cardia chamber, earliest sign is diastolic collapse of right atrium.

    • Note: Myopericarditis is diagnosed when there is evidence of pericarditis along with either increased levels of cardiac enzymes or new onset of focal or diffuse depressed left ventricular function on imaging in absence of any other cause.

Diagnosis: Pneumonia

  • History - can include fever, cough / phlegm, URI symptoms, and pleuritic chest pain. The elderly can present with alteration in mental status.

  • Physical exam - significant findings include fever, rales, decreased breath sounds, and bronchial breath sounds.

  • Labs - CBC can show increased WBC.

  • Radiology - CXR and chest CT can show infiltrate.

  • Cardiac testing - can obtain an EKG to rule out other causes.

Diagnosis: Pulmonary embolism

  • History - includes pleuritic pain, shortness of breath, syncope, hemoptysis, and cardiac arrest. Risk factors include increased age, recent surgery, malignancy, pregnancy, trauma, and previous thromboembolic disease.

  • Physical exam - can be normal but may have increased respiratory rate, pleural rub associated with pulmonary infarct or dullness to percussion associated with an effusion.

  • Labs - D-dimer is useful in excluding pulmonary embolism in low risk patients.

  • Radiology.

    • CXR - can range from normal to atelectasis, effusion, elevated hemidiaphragm, Rarely, classical signs of PE are seen on CXR including pleural-based wedge shaped defect or Westermark's sign.

    • CT chest by PE protocol - depending on risk stratification can provide diagnosis.

    • Ventilation/perfusion (V/Q) scan - depending on risk stratification can provide diagnosis, frequently results in subsequent imaging because of high number of indeterminant studies.

  • Cardiac testing.

    • EKG - most common finding is sinus tachycardia though right heart strain, complete or incomplete RBBB, and S1Q3T3 (prominent S wave in lead I, Q wave in lead III and inverted T wave in lead III) can be seen.

    • Troponin- can be elevated which suggests increased risk of short-term mortality and serious adverse events.

Diagnosis: Pneumothorax

  • History - presents with pleuritic, sharp pain and shortness of breath. Risk factors include smoking, previous pneumothorax, chronic obstructive pulmonary disease, underlying pulmonary pathologies, trauma, and abrupt changes in barometric pressure.

  • Physical exam - respiratory distress, absence of breath sounds, hyper-resonance to percussion, deviation of trachea (in tension pneumothorax), jugular venous distension (in tension pneumothorax).

  • Labs - obtain CBC and troponin to rule out other causes.

  • Radiology - upright CXR usually provides diagnosis, sometimes may be seen on CT chest obtained for other reasons. CT chest can be used to differentiate pulmonary bleb (small areas of subpleural air pockets) from true pneumothorax.

  • Cardiac testing - obtain EKG to rule out other causes.

Diagnosis: Esophageal rupture

  • History - vomiting followed by severe chest pain, shortness of breath, subcutaneous emphysema, circulatory collapse, signs of sepsis.

  • Physical exam - diminished breath sounds, heart sounds with audible crepitus (Hamman's crunch), subcutaneous air in thorax or neck.

  • Labs - CBC can show elevated WBC.

  • Radiology.

    • CXR can show pneumomediastinum, hypopneumothorax, pleural effusion or mediastinal widening.

    • Contrast esophagogram: usually establishes diagnosis and reveal location and extent of perforation.

    • CT scan of chest can confirm diagnosis: useful in unstable patients or uncooperative patients. Also useful to evaluate intra-thoracic or intra-abdominal collection of fluid that requires drainage.

  • Cardiac testing - obtain EKG to rule out other causes.

  • Important point - up to 50% of patients have no history of vomiting.

Diagnosis: Biliary disease

  • History - nausea, vomiting, fever, abdominal pain that can radiate to the right shoulder area, and jaundice.

  • Physical exam - fever, right upper quadrant pain, Murphy's sign.

  • Labs - CBC shows elevated WBC, liver function tests (LFTs) show elevations of bilirubin and aminotransferases.

  • Radiology.

    • Ultrasound of the abdomen: can differentiate cholecystitis, cholelithiasis, choledocholithiasis. Visualization of radiological Murphy’s signs along with gall bladder wall thickening/edema which is highly suggestive of acute cholecystitis.

    • Hepatobiliary iminodiacetic acid (HIDA) scan: if diagnosis is unclear during ultrasound of abdomen, HIDA could be obtained. If the gall bladder is not visualized after contrast is administered, highly suggestive of acute cholecystitis.

    • CT scan of the abdomen: can be used in adjunction with ultrasound of abdomen; more useful when complication of acute cholecystitis or other diagnosis are being considered. CT may fail to detect all gallstones because many stones are isodense with bile.

    • Magnetic resonance cholangiopancreatography (MRCP): useful when there is concern for stone in common bile duct or cystic duct.

  • Cardiac testing - can obtain an EKG to rule out other causes.

Diagnosis: Pancreatitis

  • History - abdominal pain that can radiate to the back, nausea and vomiting.

  • Physical exam - fever, tachycardia, possible hypotension, abdominal pain, decreased bowel sounds.

  • Labs - CBC may show increased WBC, elevated hematocrit from hemoconcentration, elevated amylase/ lipase. LFTs may show increased bilirubin and chemistry panel may show low calcium, elevated blood urea nitrogen, and hyperglycemia.

  • Radiology

    • Ultrasound of the abdomen: can visualize gallsstones and dilatation of biliary duct.

    • CT scan of the abdomen: useful in establishing presence and extent of pancreatic necrosis and ruling out other complications as well as predicting severity of pancreatitis.

    • MRI / MRCP: to evaluate complication of pancreatitis as well as choledocholithiasis.

  • Cardiac testing - can obtain an EKG to rule out other causes.

Diagnosis: Peptic ulcer disease

  • History - abdominal pain, epigastric pain, nausea, vomiting, dyspepsia. Can present with complications, notably bleeding (evident by hematemesis/melena/ hematochezia), gastric outlet obstruction and perforation.

  • Physical exam - epigastric tenderness, abdominal distension, signs of peritonitis if perforation is present.

  • Labs - can obtain troponin and CBC to rule out other causes.

  • Radiology - barium testing: infrequently used. CT abdomen can be obtained if perforation is suspected or if the diagnosis is unclear.

  • Cardiac testing - can obtain an EKG to rule out other causes.

  • Other testing – upper endoscopy: commonly used to diagnose peptic ulcer and to perform biopsies to rule out malignancy, H. pylori, inflammatory bowel disease, etc.

Diagnosis: Esophageal reflux, spasm and esophagitis

  • History - heart burn, dysphagia, chest pain, chronic cough, laryngitis, morning hoarseness, worsening of asthma.

  • Physical exam - no major physical findings.

  • Labs - can obtain a troponin and CBC to rule out other causes.

  • Radiology - can obtain a CXR to rule out other causes.

  • Cardiac testing - can obtain an EKG to rule out other causes.

  • Esophageal dysphagia is diagnosed with upper endoscopy, trial of proton pump inhibitor therapy/ esophageal pH and impedance testing. If these fail to provide a diagnosis, then manometry is performed to establish a specific esophageal motility disorder.

Diagnosis: Chest wall disease

  • History - pain is positional or reproducible.

  • Physical exam - pain is localized and reproducible.

  • Labs - obtain CBC and troponin to rule out other causes of chest pain.

  • Radiology - obtain a CXR to rule out other causes.

  • Cardiac testing - obtain an EKG to rule out other causes.

Diagnosis: Psychiatric disease

  • History - anxiety and panic attacks associated with palpitations, diaphoresis, tremor, dyspnea, choking, chest pain, nausea, dizziness, derealization / depersonalization, fear of losing control or dying, paresthesias, or hot flushes.

  • Physical exam - typically normal.

  • Labs - can obtain troponin and CBC to rule out other causes.

  • Radiology - can obtain a CXR to rule out other causes.

  • Cardiac testing - can obtain an EKG to rule out other causes.

D. Over-utilized or “wasted” diagnostic tests associated with the evaluation of this problem.

While there are no uniformly wasted diagnostic tests the appropriate tests, appropriate testing strategies must be chosen for the patient, or any of the above tests could be considered wasteful.

III. Management while the Diagnostic Process is Proceeding.

A. Management of chest pain.

When the chief complaint is chest pain the first determination should be if the patient is suffering from a potential life-threatening condition. A limited history, physical and quickly obtained EKG and CXR can help determine this.

If the initial work-up does NOT suggests a life-threatening condition (acute myocardial infraction, aortic dissection, pulmonary embolism, pneumothorax, esophageal rupture, perforating ulcer) administer the following (assuming no contraindications):

  • Intravenous (IV) access.

  • Supplemental oxygen.

  • Cardiac monitoring.

  • Aspirin.

  • Management of pain.

If the initial work-up suggests myocardial ischemia administer the following:

  • IV access.

  • Supplemental oxygen.

  • Cardiac monitoring.

  • Aspirin.

  • Nitrates.

  • Statins.

  • Management of pain.

  • Anticoagulation

  • Cardiology consult.

If the initial work-up suggests aortic dissection administer the following:

  • Large bore IV access.

  • Supplemental oxygen.

  • Cardiac monitoring.

  • Blood type and cross match.

  • Management of blood pressure and cardiac contractility: IV beta-blockers preferred.

  • Management of pain.

  • Immediate surgical consultation.

If the initial work-up suggests a pulmonary embolism administer the following:

  • IV access.

  • Supplemental oxygen.

  • Cardiac monitoring.

  • Arterial blood gas (ABG) / oximetry.

  • Pulmonary vascular imaging.

  • Anticoagulation.

If the initial work-up suggests a pneumothorax administer the following:

  • IV access.

  • Supplemental oxygen.

  • If pneumothorax is < 2-3 cm in size, observation and supplemental oxygen can be used. Serial CXRs are required until there is complete resolution.

  • If pneumothorax is >3 cm in size or if the patient is symptomatic with chest pain or dyspnea, consider needle aspiration or tube thoracostomy. Clinically unstable patients should have chest tube placement.

  • Cardiac monitoring.

If the initial work-up suggests an esophageal rupture administer the following:

  • IV access: Avoidance of oral intake, IV fluid administration.

  • Admission of ICU.

  • Supplemental oxygen.

  • Broad-spectrum antibiotics

  • Intravenous proton pump inhibitor.

  • Immediate consultation with Surgery.

If the initial work-up suggests a perforating ulcer administer the following:

  • IV access: avoidance of oral intake, IV fluid administration.

  • Admission to ICU.

  • Supplemental oxygen.

  • Broad-spectrum antibiotics.

  • Immediate Surgical consultation.

B. Common Pitfalls and Side-Effects of Management of this Clinical Problem.

The most important point in managing these patients is not to miss any potentially life-threatening cause of chest pain. Therefore, a focused history and physical, EKG and CXR should be performed quickly, looking for clues for potentially life-threatening causes of chest pain. If any of these causes are identified, then that diagnosis and treatment must be perused.

Areas of caution

  • Aortic dissection is often missed due to lack of eliciting a proper history and the results are devastating as emergent surgical intervention is required.

  • Misdiagnosis of chest pain is often the result of misinterpretation of the EKG so care should be taken in reading it and early cardiology consultation should be obtained if there are any questions.

  • Response to sublingual nitroglycerin or antacids is not a reliable diagnostic maneuver.

Drugs that may be used in the treatment of chest pain

  • Aspirin - 325 mg orally if ischemia is suspected.

  • Antibiotics

    • Ceftriaxone - 1-2 gm IV daily for community acquired pneumonia in combination with azithromycin.

    • Azithromycin - 500 mg x 1, then 250 mg daily for 4 days for community acquired pneumonia in combination with ceftriaxone.

    • Piperacillin / tazobactam - 2.25-4.5 mg IV every 6-8 hours (needs renal dose adjustment) as broad-spectrum antibiotics in combination with vancomycin.

  • Anticoagulation

    • IV heparin - for myocardial ischemia or pulmonary embolism by weight based protocol.

    • Low-molecular weight heparin - for myocardial ischemia or pulmonary embolism (dose may need to be adjusted based on renal function): enoxaparin SQ 1 mg/kg/dose every 12 hours or 1.5 mg/kg daily or dalteparin SQ 200 units/kg daily. Other less commonly used are tinzaparin SQ 175 units/kg/day and nadroparin SQ 171 units/kg/day.

  • Histamine H2 agonist - for gastroesophageal reflux disease (GERD).

    • Famotidine - (needs renal dose adjustment) 20 mg daily or twice daily; can be IV or oral.

    • Ranitidine - (needs renal dose adjustment) 150 mg daily or twice daily; can be IV or oral.

  • Morphine - 1-4 mg IV for pain relief.

  • Nitroglycerin- for ischemic chest pain.

    • Orally - 0.4 mg sublingual.

    • IV start 10-20 mcg/minute and titrate for relief.

  • Proton pump inhibitor - for peptic ulcer disease.

    • Omeprazole - 20-40.mg orally daily to twice a day.

    • Esomeprazole - 20-40.mg IV or orally daily to twice a day.

  • Blood pressure agents - for myocardial ischemia and aortic dissection.

    • Metoprolol - orally for myocardial ischemia start 6.25 mg every 6-12 hours and titrate as needed.

    • Labetalol - for blood pressure control in aortic dissection 20 mg IV initially then 0.5 to 2 mg/minute.

    • Nitroprusside - for blood pressure control in aortic dissection 0.3mcg/kg/minute and titrate.

IV. What's the evidence?

Kontos. "Emergency department and office based evaluation of patients with chest pain". Mayo Clin Proc. vol. 85. 2010. pp. 284-299.

"Ringstrom and Freedman: Approach to undifferentiated chest pain in the emergency department". The Mount SinaiJournal of Med. vol. 73. 2006. pp. 499-505.

"2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation, Task Force of the European Society of Cardiology (ESC)". First published online: August 29. 2015.

Asha, SE, Miers, JW. "A systematic review and meta-analysis of D-dimer as a rule-out test for suspected acute aortic dissection". Ann Emerg Med. vol. 66. 2015. pp. 368-78.

Masud, H, Khandaker, MD, Raul, E, Espinosa, MD, Rick, A, Nishimura, MD, Lawrence, J, Sinak, MD, Sharonne, N, Hayes, MD, Rowlens, M, Melduni, MD, Jae, K, Oh, MD. Mayo Clinic Proceedings. vol. 85. 2010. pp. 572-593.

Burris, AC, Boura, JA, Raff, GL, Chinnaiyan, KM. "Triple Rule Out Versus Coronary CT Angiography in Patients with Acute Chest Pain: Results from the ACIC Consortium". JACCCardiovasc Imaging. vol. 8. 2015. pp. 817-25.

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