Chapter 17 The objectives of this chapter are the following: 1 To describe the physiology and incidence of chest pain 2 To discuss the difference in symptomology of cardiogenic versus noncardiogenic chest pain, as well as “atypical” chest pain patterns in certain patient populations 3 To briefly discuss stable versus unstable angina 4 To provide the physical therapist with a clinical framework for how to proceed if a patient complains of chest pain Please refer to Appendix A for a complete list of the preferred practice patterns, as individual patient conditions are highly variable and other practice patterns may be applicable. Chest pain, a common complaint for which many patients seek medical attention, accounts for approximately 5.5 million emergency department visits per year in the United States. Of these patients, 13% are diagnosed with acute coronary syndrome (ACS).1 Thus the physical therapist in the acute care setting should be familiar with the various etiologies of cardiogenic and noncardiogenic chest pain and should be competent in taking an efficient history when a patient complains of chest pain. Cardiogenic chest pain may be ischemic or nonischemic. Ischemic chest pain may be caused by atherosclerosis, coronary spasm, systemic or pulmonary hypertension, aortic stenosis, aortic or mitral regurgitation, hypertrophic cardiomyopathy, endocarditis, tachycardia (due to dysrhythmia such as atrial fibrillation), or severe anemia.2 Nonischemic chest pain may be caused by aortic dissection or aneurysm, mitral valve prolapse, or pericarditis.2 (Refer to the Acute Coronary Syndrome section in Chapter 3 for a description of stable, unstable, and variant [Prinzmetal’s] angina and to Figure 3-10 for the possible clinical courses of patients admitted with cardiogenic chest pain.) The probability of having chest pain caused by coronary artery disease (CAD) is increased if patients present to a primary care setting with four to five of the following variables3: Certain patient populations may present with “atypical” anginal patterns. Female patients may not necessarily have mid-chest pain, but rather may have mid-back pain, left-sided chest pain, heaviness or squeezing, or pain in the abdomen.4 In addition, females often present with indigestion, cold sweats, sleep disturbance, or vague symptoms such as fatigue and anxiety.5 Elders over the age of 85 often present with anginal equivalents, especially dyspnea or syncope.5 Patients with diabetes often present with fatigue, dyspnea, nausea and vomiting, or confusion.5 Noncardiogenic chest pain can arise from a wide range of diseases and disorders, which makes the differential diagnosis of chest pain challenging. Afferent fibers from the heart, lungs, great vessels, and esophagus enter the same thoracic dorsal ganglia and produce an indistinct quality and location of pain.6 With overlapping of the dorsal segments, disease that is thoracic in origin may produce pain anywhere between the jaw and epigastrium.6 Table 17-1 describes the most common differential diagnoses of noncardiogenic chest pain, each with its own distinctive associated signs and symptoms. Refer to Table 8-1 for gastrointestinal pain referral patterns. TABLE 17-1 Possible Etiologies, Pain Patterns, and Associated Signs of Noncardiogenic Chest Pain Data from Cannon CP, Lee TH: Approach to the patient with chest pain. In Libby P, Bonow RO, Mann DL et al, editors: Braunwald’s heart disease: a textbook of cardiovascular medicine, ed 8, Philadelphia, 2008, Saunders; Goldman L: Approach to the patient with possible cardiovascular disease. In Goldman L, Ausiello D, editors: Cecil medicine, ed 23, Philadelphia, 2008, Saunders; Runge MS, Ohman EM, Stouffer GA: The history and physical examination. In Runge MS, Patterson C, Stouffer GA, editors: Netter’s cardiology, ed 2, Philadelphia, 2010, Saunders.
Physical Therapy Considerations for Patients Who Complain of Chest Pain
Preferred Practice Patterns
Physiology of Chest Pain
Incidence of Chest Pain
Presentation of Chest Pain
Origin
Possible Etiology
Pain Pattern and Associated Signs and Symptoms
Pulmonary/pleural
Pneumonia, pulmonary embolus, tuberculosis, pleuritis, pneumothorax, mediastinitis, chronic obstructive pulmonary disease
Pain with respiration, of sudden onset, usually well localized (lateral to midline) and prolonged.
Pain is associated with abnormal breath sounds, increased respiratory rate, cough, hemoptysis, or pleural rub.
Gastrointestinal
Hiatal hernia, esophagitis, esophageal spasm, gastroesophageal reflux or motility disorder, acute pancreatitis, peptic ulcer, cholecystitis
Pain is epigastric, visceral or burning in nature, of moderate duration or prolonged, and usually related to food/alcohol intake.
Pain is relieved by antacids, milk, or warm liquids.
Nausea, vomiting, burping, or abdominal pain may be present.
Musculoskeletal
Muscle strain, rib fracture, costochondritis, cervical disk disease, shoulder bursitis or tendonitis, thoracic outlet syndrome
Pain is achy, increased with movement of the head/neck/trunk or upper extremity, or reproducible with palpation.
Signs of inflammation may be present, or there may be a history of overuse/trauma.
Psychological
Panic disorder, anxiety, depression, or self-gain
Pain is often precordial with report of pain moving from place to place, moderate duration or situational, and unrelated to movement or exertion.
Pain is associated with sighing respirations and accompanied by other evidence of emotional distress/disorder.
Infectious
Herpes zoster (shingles)
Burning, itching pain that is prolonged and in a dermatomal pattern.
Pain is localized with a vesicular rash in the area of discomfort.
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