Chest Pain: The Other Diagnoses

Taking an academic approach to chest pain may assist you in making the appropriate assessment


   At 0730 on December 24 you and your partner are called to respond to a 59-year-old male office worker with a history of mild, well-controlled hypertension who is complaining of chest pain. As you head for the ambulance, you turn to your partner and say, "Well, there won't be much guesswork on this call. It has to be cardiac-related." Your partner agrees. You are both aware of the statistics: Heart attacks are more common in the morning and during holiday times, when people tend to eat and drink too much and become more stressed. Besides that, your patient is male, middle-aged and has hypertension. It's a no-brainer, right? Maybe...maybe not!

   Upon your arrival, you find him sitting in a chair and appearing to be in slight discomfort. His vital signs include a blood pressure of 142/80, pulse of 84 and regular respiratory rate of 14/minute and a pulse oximetry of 97% on room air. He denies any such episodes in the past, and describes the pain as being substernal and burning in nature. He complains of slight nausea, but denies vomiting, shortness of breath or diaphoresis.

   In accordance with local protocol, you run a 12-lead ECG strip, which your partner interprets as normal. The machine's interpretation agrees with your partner. An intravenous line is started, and the patient is given four 81 mg aspirin tablets to chew, a sublingual nitroglycerin spray and 25 mg of metoprolol orally. A repeat set of vital signs shows little change, and the patient is transported to the nearest hospital emergency department for further evaluation.

Discussion

   This is a scenario that occurs multiple times each day in virtually every region of the country. In most places, the responding providers would have followed this exact sequence of evaluation and medication administration, or a comparable one, because the working diagnosis would be either acute myocardial infarction (AMI), unstable angina or the newer term, "acute coronary syndrome" (ACS). The reality, though, is that in many of these cases, this diagnosis would turn out to be incorrect.

   As a prehospital provider, it is very helpful, while following the algorithm in your region for chest pain, to consider some of the other possible causes of chest pain. This serves not only to prevent interventions that are unnecessary, but also to enable you to develop a more academic thought process. This type of approach will certainly be of value on the next call and will also help keep you sharp.

The "Other" Diagnoses

   Some of the non-cardiac causes of chest pain are common and some are rare, but all of them may cause patients to complain of chest pain. As is often true in medicine, the proper treatment for some of these disorders may, in fact, be detrimental in others. This reinforces the need for an accurate diagnosis prior to instituting treatment.

GERD (Gastroesophageal Reflux Disorder)

   This is the most common gastrointestinal disease in the United States, and it is not surprising that a disease which causes "heartburn" can be mistaken for cardiac disease. GERD is caused by increased production of acid in the stomach and regurgitation of that acid into the esophagus. In many cases, people with this condition develop a burning substernal chest discomfort with radiation toward the neck, especially after eating or when reclining. They may also experience nausea, hoarseness and/or sore throat. The symptoms are improved by the use of antacids.

   One way to attempt to determine if GERD is the cause of the patient's symptoms is to obtain a complete list of the patient's medications. Often they will be taking medication to decrease the amount of acid produced by the stomach. These medications might include H2 blockers (Zantac, Pepcid, Tagamet or Axid) or proton pump inhibitors (Nexium, Aciphex, Protonix or Prilosec). Additional history would also help to distinguish GERD from cardiac disease. Does the pain occur when recumbent? Did the pain begin after a large meal? Does the pain improve after using an antacid?

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