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Is Chest Pain Always an Emergency? 5 Key in This Article

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Is Chest Pain Always an Emergency? 5 Key in This Article Keywords: Chest pain/Assessment/ Nursing Practice Coronary heart disease Review ●This article has been double-blind Cardiology peer reviewed Chest pain is a complex symptom with a variety of causes. It is essential that health professionals have good communication skills to ensure an accurate diagnosis Is chest pain always an emergency? 5 key In this article... points Causes of chest pain 80,000 people Tools used to assess chest pain 1die of coronary Case studies to illustrate chest pain assessment heart disease each year Chest pain is a Author Helen Gaunt is cardiac nurse Assessment 2common specialist, Rapid Access Chest Pain Clinic, NICE (2010) recommends a structured presenting University Hospitals of Leicester Trust. assessment using algorithms to ensure symptom in Abstract Gaunt H (2014) Is chest pain high-risk patients are identified and treated primary care always an emergency? Nursing Times; 110: appropriately and promptly. It also high- There are 44, 12-14. lights the “red flags” that those carrying out 3non-cardiac Chest pain is a complex symptom, which the assessment should be aware of and sug- causes of chest has a number of underlying causes. gests management plans, including: pain Accurate assessment is vital to ensure » Raised biochemical markers; Accurate patients receive appropriate and timely » Electrocardiogram changes; 4assessment is care. This article provides an overview of » Signs the patient is haemodynamically vital to ensure the causes of chest pain and key features unstable; correct of the assessment process. » Associated symptoms such as nausea management and vomiting, breathlessness or A variety of n the UK around 80,000 people die of marked sweating. 5assessment coronary heart disease (CHD) each year Albarran (2002) suggests nurses’ assess- tools are available (Townsend, 2012). One of the signs of ment of chest pain can be divided into: to assess chest ICHD is chest pain, which 20-40% of » Diagnosis; pain people experience at some time in their life » Therapeutic care; (Ruigomez et al, 2006). However, chest pain » Conveying humanistic concern; is a complex symptom with a number of » Improving and maintaining the causes, some of which are non-cardiac. nurse–patient relationship; Careful assessment is required to ensure » Accountability and legal implications. patients receive appropriate management. Comprehensive assessment and history The National Institute for Health and Care taking is essential to ensure accurate diag- Excellence (2010) stresses the importance nosis. Each episode of chest pain should be of “accurate” and “fast” diagnoses of chest taken on its individual merit, irrespective pain, ensuring patients are treated appro- of whether the patient has been assessed priately and promptly. for chest pain in the past (Zitkus et al, 2010). FIG 1. LEVINe’s sigN In our Rapid Access Chest Pain Clinic we Patients with chest pain do not always see over 2,500 people each year with chest fit into a typical pattern of symptoms, par- discomfort; roughly half have symptoms ticularly when they are anxious. Pain must that are unlikely to be cardiac in origin. be considered along with investigations These patients are discharged to their GP to including ECG and observation of the investigate alternative causes. Differential blood pressure, pulse, respiratory rate and diagnosis of chest pain is given in Table 1. oxygen saturations. Causes of chest pain range from angina Fass and Achem (2011) highlight that and acute myocardial infarction (MI) to patients with a diagnosis of non-cardiac more benign and self-limiting problems, chest pain often have higher levels of anx- such as musculoskeletal pain, and gastro- iety and feel their symptoms are “less con- oesophageal symptoms such as heartburn trollable” than those with a cardiac condi- Alamy (Ebell, 2011). tion. It is important to listen carefully to 12 Nursing Times 29.10.14 / Vol 110 No 44 / www.nursingtimes.net Nursing For articles on cardiology, go Times.net to nursingtimes.net/cardiology TABLE 1. DIFFERENTIAL DIAGNOSES OF CHEST PAIN BOX 1. RISK FactORS FOR CORONARY HEART Diagnosis Symptoms/characteristics DISEASE Myocardial infarction ● Severe, band-like, crushing, gripping, squeezing pain ● Hypertension ● Sudden onset ● High cholesterol ● May be associated with shortness of breath, nausea, ● Diabetes sweating or dizziness ● Smoking ● Patients may also report a fear of impending doom ● Lack of exercise Angina ● Tightness, squeezing, ache or crushing pain that may ● Overweight or obese radiate to the neck, jaw, arms and through to the back ● Family history of coronary heart ● Commonly occurring with exertion and usually relieved disease within minutes of rest ● Ethnic background, for example rates ● Often worse when exercising in colder weather or of CHD in the UK are highest in South after eating Asian communities Musculoskeletal chest ● Can be severe at times pain ● Often a localised tenderness, which is made worse with non-verbal communication, is essential in moving or twisting and tends not to be related to exertion these circumstances. ● Commonly reproduced or made worse by palpation over areas of the chest wall Non-verbal cues ● Relieved by analgesics, such as non-steroidal anti- Assessment should not rely on verbal com- inflammatory drugs munication but should also take into account non-verbal cues. When asked to Gastro-oesophogeal ● Burning pain usually in the centre of the chest may describe their chest pain people often use reflux disease radiate through to the back and up to the throat hand movements to help illustrate their ● May be associated with acid reflux symptoms. Patients with ischaemic chest ● Linked to food and posture pain often place a clenched fist in the ● Relieved by dietary changes, antacids or proton pump middle of their chest to represent their inhibitors description of “gripping”. This is known as Non-organic pain ● The patients may pinpoint localised areas of discomfort, Levine’s sign (Fig 1). Edmondstone (1995) which may be left or right sided studied individuals admitted to coronary ● The symptoms are not usually linked to exertion care and found that if patients used the ● Often related to anxiety and stress and occurs in Levine sign to describe their pain, there younger people, particularly when there is a family history was a 77% chance the pain was ischaemic. of heart disease Patients with pain associated with oesophageal problems tended to point up each patient’s description of their problem it is (McCafferey, 1979) and, as such, is and down through the centre of their chest during the initial assessment. This assess- highly subjective. Albarran (2002) suggests (Edmondstone, 1995), while fingertip pin- ment should consider risk factors for CHD, that although pain scores are quick and pointing to localised areas over the chest gastro-oesophageal reflux disease, muscu- easy to use, they only measure intensity; in wall is linked to musculoskeletal causes of loskeletal chest pain and past medical his- addition, older people may struggle to use chest pain. tory. NICE (2010) recommends an initial them as they may find it difficult to quan- clinical assessment followed by diagnostic tify pain. Case studies tests if these are indicated. Rick factors for The use of open-ended questions, good Case study 1 CHD are outlined in Box 1. listening skills and acknowledging Harry Brown* is 49 years old and usually fit It is essential to assess the impact of the patients’ concerns regarding their health and well. He is anxious as his father had his pain on patents’ lives. Ask them if they are all help to obtain accurate information first MI at the same age and mentions this still able to work and continue with their from patients and enhance the nurse– repeatedly during the assessment. He has usual routine or whether they have modi- patient relationship (Albarran, 2002). no other risk factors for CHD. fied it consciously or subconsciously. Reading patients’ description of their Mr Brown presents with a history of A variety of tools can be used as part of a condition back to them is a good way to new-onset, upper-left-sided chest pain chest pain assessment; selection is often ensure the facts are accurate and allows the after heavy gardening. The pain does not based on individual preference (Oriolo and opportunity for both parties to clarify any radiate and there are no other symptoms. Albarran, 2010). As an example, mne- misunderstandings. The pain is almost constant, is worse when monics (Box 2) can be used to help guide Leicester is a large multicultural city he moves his left arm and is eased a little assessment. and many of our patients do not speak with the help of regular paracetamol and The numerical visual analogue scale is English as a first language. Misunder- non-steroidal anti-inflammatory drugs. often used to assess pain. The patient is standings may occur with the words we Mr Brown rates the constant pain at 4/10 asked to pick a number between 0 and 10, use to describe symptoms. For example, on the pain scale but says it can go up to 7 where 0 = no pain and 10 = the worst pain we may say “in slight discomfort” but or 8 if it is particularly troublesome. The imaginable.This is typically used as an some patients may describe their pain as pain is not associated with exertion. He adjunct to the assessment as it identifies “slowly”, meaning a small amount. Access both feels and looks very anxious and wor- the pain as being whatever the patient says to translators, along with good verbal and ried. His blood pressure,
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