Chest pain is a very common condition. Many patients are aware that they are a warning sign of possible life-threatening diseases, and request a review to minimal symptoms. Other patients, including many with serious illnesses, trivialize or ignore the warning signs. Pain perception (both type and severity) varies greatly between individuals and between men and women. Anyway he describes chest pain should never be dismissed without a cause statement. Pathophysiology The heart, lungs, esophagus and great vessels pass on afferent visceral impulses through the same thoracic autonomic ganglia. A painful stimulus in these organs is typically felt as if it would result in the chest. However, since the afferent nerve fibers overlap in the dorsal ganglia, the chest pain may be felt (as considered indicative of pain) somewhere between the navel and the ear, including the upper extremities. Painful stimuli thoracic organs can cause unpleasant sensations that are perceived as pressure, tearing, air with a Aufstoßdrang, upset stomach, burning or pain. Rarely chest pain are also described as stabbing or like a sharp needle-like pain. If the sensation is visceral in origin, deny many patients that they have pain, and insist that it is only discomfort. Etiology Many diseases cause chest pain or discomfort. These diseases can cardiovascular, GI, pulmonary, neurological or musculoskeletal systems concern (see table: Some causes of chest pain). Some diseases are immediately life-threatening: Acute coronary syndromes (acute myocardial infarction / unstable angina) Thoracic aortic dissection tension pneumothorax pulmonary embolism oesophageal rupture Other causes range from serious potential threats to life to causes that are simply unpleasant. Often no cause can be confirmed even after full investigation. In general, the most common causes are chest wall disorders (ie those that affect the muscles, ribs, or cartilage) Pleuralerkrankungen GI disorders (eg. As gastroesophageal reflux, esophageal spasms, ulcer disease, cholelithiasis) Acute coronary syndromes and stable angina In some cases, no etiology of chest pain are determined. Some causes of chest pain cause * Suggestive findings diagnostic approach † Cardiovascular 1Myokardischämie (acute myocardial infarction / unstable angina / angina) acute, overwhelming pain radiating to the jaw or arm exertion pain at rest (angina) S4 gallop goes Sometimes systolic murmurs of mitral regurgitation often serious findings ‡ Serial ECG and cardiac markers; consign or observe stress imaging test or CT angiography is negative ECG findings and no cardiac markers considered in patients often cardiac catheterization and coronary angiography if the findings are positive 1Thorakale aortic dissection sudden, tearing pain radiating in the back Some patients have syncope, stroke or ischemia in the legs pulse or Butdruck which may be unequal in the extremities age> 55 hypertension Serious findings ‡ chest x-ray with findings that transesophageal diagnosis suggest high-resolution CT scan of the aorta to confirm echocardiography 2Perikarditis constant e or intermittent shooting pains that are often complicated by breathing, swallowing food or supine position and relieved by sitting or bending over front pericardial friction rub jugular venous expansion ECG usually diagnostic cardiac markers i. S. (sometimes show minimally elevated troponin with normal CK-MB levels) transthoracic echocardiography 2Myokarditis fever, dyspnea, fatigue, chest pain (at myopericarditis), recent viral or other infection Sometimes findings of heart failure, pericarditis or both ECG Cardiac markers i. S. BSG C-reactive protein Usually echocardiography GI 1Ösophagusruptur sudden, severe pain after vomiting or instrumentation (z. B. esophagogastroduodenoscopy or transesophageal echocardiography) Subcutaneous crepitation, which is detected during auscultation Several serious findings ‡ chest x-ray Ösopgauskontrasteinlauf with water-soluble contrast to confirm 2Pankreatitis epigastric pain or lower chest that is often made worse when laid flat, and remove when leaning forward vomiting Pressure kdolenz the upper abdomen shock Often history of alcohol abuse or biliary tract disease serum lipase Sometimes abdominal CT 3Magengeschwür Recurring vague epigastric discomfort or those in the right upper quadrant in a patient who smokes or excessively consumed a lot of alcohol, which facilitates by food, antacids or both No serious findings ‡ Clinical evaluation Sometimes endoscopy Sometimes tests for Helicobacter pylori 3Ösophagealer reflux (GERD) Recurring, burning, radiating from the epigastric the larynx pain worse by preventing or lying down u nd antacids are alleviated. Clinical evaluation Sometimes endoscopy Sometimes Motilitätsstudien 3Erkrankung biliary tract Recurring complaints in the right upper quadrant or epigastric discomfort after meals (but not after exertion) Persistent ultrasonography gallbladder 3Ösophagus-Motilitätserkrankungen pain who work slowly and accompany swallowing may or may not usually include difficulty swallowing Barium enema Esophageal pulmonary 1Lungenembolie often pleuritic pain, dyspnea, tachycardia Sometimes mild fever, hemoptysis, shock likely if risk factors are present (see table: Clinical Prädiktionsregel for the diagnosis of pulmonary embolism) Varies with clinical suspicion (. LE-test algorithm) 1Spannungspneumothorax Significant dyspnea, hypotension, jugular venous distension, unilaterally decreased breath sounds and hyper resonance at percussion Sometimes subcutaneous air usually clinically in chest x-ray obviously 2Pneumonie fever, chills, cough, and purulent sputum often dyspnea, tachycardia, Of consolidation chest x-ray 2Pneumothorax Sometimes unilaterally decreased breath sounds, subcutaneous air chest x-ray 3Pleuritis pneumonia, pulmonary embolism, or viral respiratory infection may precede pain when breathing, coughing Sometimes pleural rub, but otherwise unobtrusive investigation Usually clinical evaluation Other 3Muskulo-skeletal chest wall pain (eg. As a result of trauma, overuse or costochondritis) Often by history indicated pain usually persistent (typically days or more), gets worse with passive and active movement diffuse or focal tenderness Clinical evaluation 3Fibromyalgie almost constant pain, several areas of the body as well as the thorax affect usually fatigue and sleep timer Several Clinical examination 2Verschiedene thoracic tumors Variable, but sometimes “pleuritic” sometimes pain chronic cough, smoking history, signs (a chronic disease weight maybe loss, fever), cervical lymphadenopathy chest x-ray chest CT when chest x-ray findings are striking bone scan considered in persistent, focal rib pain 3Herpes zoster infection Sharp, band-like pain unilateral thoracic Classic linear, vesicular rash pain may rash preceded by several days clinical evaluation is 3Idiopathisch Various features No serious findings ‡ diagnosis diagnosis of exclusion * swing Rega d of the causes varies as indicated: 1Unmittelbare threats to life. 2Potenzielle threats to life. not dangerous 3Unangenehm, but usually. † Most patients with chest pain should receive pulse oximetry, ECG and chest X-ray (basic tests). When a suspected coronary ischemia persists, cardiac markers (troponin, CK-MB) i should. S. are checked. ‡ The serious findings include abnormal vital signs (tachycardia, bradycardia, tachypnea, hypotension), signs of hypoperfusion (z. B. confusion, ashen color, diaphoresis), shortness of breath, asymmetric breath sounds or pulse, new heart murmur or paradoxical pulse> 10 mmHg. S4 = 4. heart sound. Assessment history The history of the present illness should note localization, duration, nature and quality of the pain. The patient should be all-causing events (eg. As tension or overuse of chest muscles) and all triggering and mitigating factors be questioned. Specific factors that are considered include whether the pain occurs during exercise or at rest, whether psychological stress is present, whether the pain when breathing or coughing occur whether swallowing or relationship with the meals available and positions that relieve pain or exacerbate (lie z. B., lean forward). Past like episodes and their circumstances should be noted, with similarities or lack of similarities deserve attention. Important associated symptoms, is to look for those, dyspnea, palpitations, syncope, diaphoresis, nausea or vomiting, cough, fever and chills are. The review of systems should look for symptoms of possible causes, including leg pain, swelling, or both (deep vein thrombosis [DVT] and therefore possible pulmonary embolism) and chronic weakness, malaise and weight loss (cancer). The history should document known causes, particularly cardiovascular and GI disorders and all cardiac investigations or proceedings (eg. As stress tests catheterization). Risk factors for coronary heart disease (CHD -. Eg hypertension, hyperlipidemia, diabetes, cerebrovascular disease, smoking) or LE (. Eg injuries of lower limb, recent surgery, immobilization, known cancer, pregnancy) should also be noted. The substance history should note the substance use of coronary spasms (eg. As cocaine, triptans, phosphodiesterase inhibitor) or a GI disease (especially alcohol, NSAIDs) can cause. Family history should be the history of myocardial infarction (particularly in the first degree relatives at a young age: <55 in men and <60 for women) and hyperlipidemia einbeziehen.Körperliche investigation vital signs and weight are recorded and calculated the body mass index (BMI) , The pulse is sampled in both the arms and legs, blood pressure measured in both arms and the pulsus paradoxus is detected. The overall appearance is noted (eg. As pallor, diaphoresis, cyanosis, anxiety). The neck is examined for venous expansion and hepatojugulären reflux and venous waveforms are recorded. The neck is scanned for carotid pulse, lymphadenopathy or thyroid disease. The carotid arteries are auscultated by noise. The lungs are percussed auscultated and for the presence and symmetry of breathing sounds, signs of congestion (dry or moist rales, Rhonchi), consolidation ( "pectorilloquy") Pleural effusions and (decreased breath sounds, steamed percussion). The cardiological examination, the intensity and the time of the first heart sound (S1) and the second heart sound (S2), the respiratory movement of the pulmonary component of S2, pericardial rubbing noises and Galoppe on. If noise is detected, time, duration, pitch, shape and intensity and responding to changes in position, repeated fist and the Valsalva maneuver should be noted. If Galoppe be detected should be a differentiation between the 4th heart sound (S4), which is frequently present at diastolic dysfunction or myocardial ischemia, and the third heart sound (S3), which is present in systolic dysfunction, are made. The breast is inspected for skin lesions due to injury or herpes zoster infection and crepitus (on subcutaneous air suggesting) and tenderness touched. The abdomen is scanned on tenderness, organomegaly and masses or tenderness, particularly in the epigastric region and in the upper right quadrant. The legs are to arterial pulses, Perfusionsadäquanz, edema, varicose veins and signs of DVT (eg, swelling, redness, tenderness.) Untersucht.Warnzeichen Certain findings reinforce the suspicion of a seriously the etiology of the thorax Pain: Abnormal vital signs (tachycardia, bradycardia, tachypnea, hypotension) signs of hypoperfusion (z. B. confusion, ashen skin color, diaphoresis) shortness of hypoxia on pulse oximetry Asymmetric breath sounds or pulses New heart murmurs paradoxical pulse> 10 mmHg interpretation of the findings symptoms and complaints of thoracic diseases vary widely and those with serious and not serious conditions often overlap. Although serious findings indicate a high probability of a serious medical condition and many diseases “classical” manifestations (see Table: Some causes of chest pain), have put many patients who have a serious medical condition, not with these classic symptoms and complaints before. For example, patients can sue or myocardial ischemia only about indigestion on palpation have a very druckdolente chest wall. A high index of suspicion is important when patients are evaluated with chest pain. However, some distinctions and generalizations are possible. The duration of pain may provide clues to the severity of the disease. Long-lasting pain (d. H. For weeks or months) are not an expression of a disorder that is immediately life-threatening. Such pain is often musculoskeletal, although a gastrointestinal cause or cancer should be considered, especially in patients who are older. Similarly, results in short (<5 seconds), sharp, temporary pain rarely from serious illnesses. Severe diseases manifest themselves typically in pain, lasting minutes to hours, although the episodes can be recurrent (z. B. unstable angina may be multiple attacks of pain on one or more days cause). The age of the patient is useful in the evaluation of chest pain. Chest pain occur in children and young adults (<30 years) are less likely by myocardial ischemia, although myocardial infarction in 20 may occur to 30 year olds. Musculoskeletal and pulmonary diseases are frequent causes in this age group. Exacerbation and relief of the symptoms are also helpful in assessing chest pain. Although angina everywhere consistently connected between the ear and the navel (and often not in the chest) can be felt, it is usually with physical or emotional stress, d. H. Patients experience on a day no angina while climbing a staircase and tolerated 3 steps the following day. Nocturnal angina is characteristic of acute coronary syndromes, heart failure or coronary artery spasms. The pain of many diseases, both heavy and light, can be aggravated by breathing, movement or palpation of the breast. These findings are not specific to an origin in the chest wall. About 15% of patients with acute myocardial infarction show tenderness on palpation of the breast. Nitroglycerin can alleviate pain in both myocardial ischemia as well as in non-cardiac smooth muscle spasm (z. B. esophageal or biliary disease). Its effectiveness or lack thereof should not be used for diagnosis. Associated findings may also provide clues to the cause. Fever is non-specific, but if it is accompanied by cough, it suggests a pulmonary cause. Patients with Raynaud's syndrome or migraine sometimes have a coronary spasm. The presence or absence of risk factors for coronary heart disease (eg. As hypertension, hypercholesterolemia, smoking, obesity, diabetes, family history) changes the probability of underlying coronary artery disease, but does not help in determining the cause of acute chest pain episode. Patients with these factors may also have another cause of chest pain and patients without them can have an acute coronary syndrome. However, increases a known coronary heart disease in a patient with chest pain, the probability that this diagnosis is the cause (especially if the patient's symptoms as "like my angina 'or' as my last heart attack," describes). A history of peripheral vascular disease also increases the likelihood that the cause of angina chest pain assay of In adults with acute chest pain must be ruled out an immediate threat to life. Most patients should receive an initial dose of pulse oximetry, EKG and a chest X-ray recording. If the symptoms indicate an acute coronary syndrome, or when no other cause is clear (especially in patients at risk), troponin levels are measured. When an LE is considered possible, D-dimer tests are performed. A rapid evaluation is important because the patient for an urgent cardiac catheterization should be considered (if available) when heart attack or other acute coronary syndrome exists. Some abnormal findings in these tests confirm a diagnosis (eg. As acute myocardial infarction, pneumothorax, pneumonia). Other anomalies indicate a diagnosis or at least on the need to make further investigation (eg. As indicated an unusual Aortenkontur in chest X-ray to the need to test for Thoraxdissektion the aorta). So if this first test results are normal, thoracic aortic dissection, tension pneumothorax and oesophageal rupture are highly unlikely. But in acute coronary syndromes, the ECG may remain unchanged for several hours sometimes not change or and LE, the oxygen supply can be normal. Consequently, other tests may be required based on the evidence from history and physical examination (see table: Some causes of chest pain). Since a single set of normal cardiac markers does not exclude a cardiac cause, patients whose symptoms suggestive of an acute coronary syndrome should receive a serial measurement of cardiac marker troponin and ECG, which are at least 6 hours apart. Some clinicians follow up (acute or within a few days) a stress ECG or stress imaging test on these tests. Drug treatment is started while the results of the second troponin levels are expected, unless contraindicated. A diagnostic test with sublingual nitroglycerin or an oral, liquid antacid can not adequately differentiate between myocardial ischemia and reflux esophagitis or gastritis. Both drugs can relieve the symptoms of both disorders. Troponin is for all acute coronary syndromes that cause heart damage, and often with other diseases that damage the myocardium (z. B. myocarditis, pericarditis, aortic dissection with coronary artery flow, LE, heart failure, severe sepsis), increased. CK may be increased due to the damage to any muscle tissue, but CK-MB increase is specific to Myokardiumschädigungen. However, troponin is now the standard markers of myocardial injury. A ST-segment changes in the ECG may be non-specific or caused by previous disease, so that a comparison with previous ECGs is important. The probability of pulmonary embolism is caused by a number of factors (see Table: Clinical Prädiktionsregel for the diagnosis of pulmonary embolism), which may be used in an algorithm to derive an audit approach (LE-test algorithm.). In patients with chronic chest pain immediate threats to life are unlikely. Most clinicians initially undertake a chest x-ray picture and then put other tests based on the symptoms and complaints. Clinical Prädiktionsregel for the diagnosis of pulmonary embolism I. Clinical determine probability - adding up points in order to determine the total value and probability. Clinical risk points Clinical signs and symptoms of DVT (objective leg swelling, pain on palpation) 3 LE as likely as or more likely than alternative diagnosis 3 heartbeat> 100 beats / min 1.5 immobilization ?3 days 1.5 Surgery over the past 4 weeks. 1.5 previous DVT or PE 1.5 hemoptysis 1 malignancy (including in patients, the treatment of cancer within 6 Mo. end) 1 Total points probability> 6 High Moderate 2-6 use <2 Low II. pretest probability to determine test. DVT = deep vein thrombosis, pulmonary embolism = LE, V / Q = ventilation / perfusion. LE-test algorithm. use pretest probability to determine test. Treatment Identified specific diseases are treated. If the etiology is not clearly benign, patients are usually admitted to hospital or to a monitoring station for cardiac monitoring and a more detailed diagnosis. Pain if necessary, using NSAIDs (NSAIDs) or opioids depending on the diagnosis treated. Pain relief after treatment with opioids should not reduce the urgency to exclude serious and life-threatening diseases. Central geriatric aspects, the probability of serious and life-threatening diseases increases with age. Many older patients recover more slowly than younger patients, but survive for a considerable time, if they are properly diagnosed and treated. Drug doses are usually lower and the rate of dose escalation lower. Chronic diseases (eg. As decreased renal function) are common and can complicate diagnosis and treatment. Summary First, immediate threats to life must be excluded. Some serious diseases, especially coronary ischemia and pulmonary embolism, often have no classical presentation. Most patients should receive pulse oximetry, ECG, cardiac markers, and chest x-ray absorption. The evaluation must be done quickly, so patients with ST elevation MI within a 90-minute standards can be in a cardiac catheterization laboratory (or thrombolysis received). When LE is very likely an antithrombin drug should be given while the diagnosis is pursued. Another embolus in a patient who does not receive anticoagulants, can be fatal.


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