Vanderbilt University School of Medicine
VC3 – Vanderbilt Core Clinical Curriculum

Chest Pain

 

Distinguishing chest pain of cardiovascular origin from that occurring as a result of chest wall disorders, pleuropulmonary disorders, gastrointestinal disorders, and psychogenic states is an important training problem for third-year medical students.

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Prerequisites

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Describe and discuss:

  • anatomy of the heart, chest, and abdomen
  • pathogenesis and pathophysiology of cardiovascular disease
  • pharmacology of cardiovascular drugs
  • epidemiology of heart disease

Demonstrate:

  • perform a cardiovascular risk assessment
  • take a medical history and perform a physical exam
  • basic communication skills

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Apply Medical Knowledge in the Clinical Encounter

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1.     Describe seven common life-threatening medical causes of chest pain.

2.     Describe signs and symptoms that:

  • suggest ischemic heart disease
  • are associated with chest pain due to GI disorders
  • are associated with chest pain due to pulmonary disorders
  • are associated with chest pain due to musculoskeletal causes
  • are associated with chest pain due psychogenic causes

(see differential diagnosis for more detail)

3.     Discuss the reasons why the following factors are associated with exacerbating chest pain:

  • anemia
  • hypoxemia
  • hypertension
  • tachyarrhythmia
  • hyperthyroidism

4.     Identify the typical blood pressure values that occur with aortic stenosis, aortic insufficiency, and pulsus paradoxicus.

5.     Discuss common abnormalities that can cause paradoxical and fixed splitting of the S2 and factors that increase or diminish the intensity of S1.

6.     Discuss the consequences of the following risk factors and their association with heart disease:

  • hypertension
  • smoking
  • lipid abnormalities
  • age and gender
  • diabetes mellitus
  • family history of heart disease
  • obesity
  • dietary intake of saturated fat and cholesterol
  • sedentary lifestyle 

7.     Discuss the role of critical pathway or practice guidelines in delivering high quality care for patients:

  • hospitalized with ischemic chest pain
  • outpatients presenting with non-ischemic chest pain 

8.     Describe how lab studies would help in the evaluation of chest pain, including their indications, limitations, and cost.

9.     Describe how imaging studies would help in the evaluation of chest pain, including their indications limitations, and cost.

 

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Diagnose

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1.     Obtain, document, and present an age-appropriate medical history that differentiates among etiologies of disease.

2.     Perform a physical exam to establish the diagnosis and severity of disease.

3.     Generate a differential diagnosis recognizing specific history and physical exam findings that distinguish ischemic chest pain from non-ischemic causes of chest pain (GI, pulmonary, musculoskeletal, or undetermined).

4.     Recommend when to order diagnostic and laboratory tests, both prior to and after initiating treatment, based on the differential diagnosis. Justify ordering them and consider test cost and performance characteristics as well as patient preferences.

5.     Define the indications for and interpret (with consultation) the significance of the results of appropriate clinical tests:

  • echocardiogram
  • exercise stress test and the use of the pretest probability of CAD to interpret results
  • stress thallium (myocardial perfusion radionuclide scan)
  • cardiac catheterization
  • pulmonary angiography
  • CT angiography
  • V/Q scan

 

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Develop a Management Plan

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1.     Describe and discuss indications, mechanism of action, side effects, adverse reactions, and significant interactions of medications that could be prescribed for patients with chest pain:

  • digoxin
  • calcium channel blockers
  • beta blockers
  • angiotensin-coverting enzyme inhibitors
  • nitrates
  • nitroglycerine
  • aspirin
  • heparin
  • warfarin
  • plavix
  • thrombolytic therapy

2.     Describe and discuss the indications, benefits, and disadvantages of interventions and surgical therapy:

  •  PTCA
  • Surgical therapy
  • CABG

3.      Describe and compare the cost-effectiveness of:

  •  various agents within each class of medications
  •  interventional strategies
  • surgical approaches

4.     Recommend an approach to treatment for the patient with chest pain based on diagnosis, evidence about treatment options, patient characteristics, and patient preferences.

5.     Formulate a prognosis for the patient with chest pain based on diagnosis, treatment plan, and patient characteristics.

6.     Communicate the diagnosis, treatment plan, and prognosis of the disease to patients and their families in a caring and compassionate manner, reflecting an understanding of the emotional impact of the diagnosis and its potential effect on lifestyle (work performance, sexual functioning, etc.).

7.     Provide education for the patient about his or her treatment plan.

8.     Provide counseling to patients when indicated about the following issues related to prevention:

  • smoking cessation
  • dietary saturated fat and cholesterol reduction
  • dietary sodium reduction
  •  weight reduction
  •  increased physical activity

9.     Communicate information about primary and secondary prevention of cardiovascular disease appropriately to all patient groups, including the elderly patient.

10.  Refer for psychological support if indicated.

11.  Access and utilize appropriate information systems to ascertain information about health system and community resources.

12.  Plan for follow-up.

 

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Differential Diagnosis

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Seven common life-threatening medical causes of chest pain

  • acute MI
  • tension pneumothorax
  • aortic dissection
  • tamponade
  • pulmonary embolus
  • pneumonia
  • ruptured esophagus

Clinical features that help to differentiate one etiology from another

  • right- and left-sided congestive heart failure
  • ischemic heart disease
  • valvular heart disease (aortic stenosis, aortic insufficiency, mitral stenosis, mitral regurgitation)

Signs and symptoms that suggest ischemic heart disease

  • angina pectoris (typical and atypical)
  • prinzmetal angina (variant angina)
  • acute myocardial infarction
  • unstable angina
  • non-ischemic cardiovascular pain
  • mitral valve prolapse
  • dissecting aortic aneurysm
  • pericardial pain (acute)
  • cardiomyopathy

Signs and symptoms associated with chest pain due to GI disorders

  • gastroesophogeal reflux
  • peptic ulcer disease
  • biliary colic
  • pancreatitis

Signs and symptoms associated with chest pain due to pulmonary disorders

  • pneumonia
  • spontaneous pneumothorax
  • pulmonary embolism
  • pulmonary hypertension
  • inflammation of the pleura

Signs and symptoms associated with chest pain due to musculoskeletal causes

  • costochondritis (Tietze's syndrome)
  • muscular strain

Signs and symptoms associated with chest pain due to psychogenic causes

  • depression
  • anxiety
  • somatization
  • hyperventilation syndrome
  • malingering

Other

  • zoster