Table 1

MODULE 17: Cardiology Causes of chest pain 3

PART 9 Cardiovascular
• Myocardial infarction

Assessment of • Unstable angina pectoris

• Pericarditis
• Dissecting aortic aneurysm

chest pain • Myocarditis

• Apical ballooning syndrome (Tako tsubocardiomyopathy)

Pulmonary
• Pleurisy
by Kate O’Donovan
• Pulmonary embolism
• Pneumothorax
The final part in this series will focus on the assessment of • Pneumonia
chest pain. This symptom is one of the most common present-
Haematological
ing complaints seen in primary and secondary care1,2 and is the
• Sickle cell anaemia
leading cause of emergency department visits after abdominal
pain. Assessment and differentiation of the various chest pain Musculoskeletal
presentations can be challenging due to variation in clinical • Costochondritis
presentation, patient history of the symptom and the potential • Trauma
for atypical presentation in women, older people, and those with
diabetes or chronic kidney disease. Through structured nursing Gastrointestinal
assessment it is possible to identify those at high risk. The aim of • Reflux
this article is to provide an overview of the assessment of chest • Ulcers
pain and differential diagnosis of chest pain. • Gallstones
• Pancreatitis
There are many causes of chest pain as outlined in Table 1 but
acute coronary syndrome is one of the potentially more serious
Non organic
causes that require rapid identification and implementation of • Anxiety
treatment in an attempt to preserve myocardial function and pre-
vent the development of arrhythmias, heart failure or cardiogenic patient assessment must be systematic and comprehensive with-
shock. Acute coronary syndromes are an umbrella term used to out the use of leading questions. In the author’s experience the
describe the clinical presentation of ischaemic heart disease and tool ‘OLD CARTS’ (see Table 2) is most commonly used in clinical
encompasses unstable angina pectoris, non ST segment eleva- practice when assessing chest pain. The following is an overview
tion myocardial infarction and ST segment elevation myocardial of ‘OLD CARTS’.
infarction. It is defined by the European Society of Cardiology Onset
Guidelines4 as a life threatening manifestation of atherosclerosis Establishing the onset of chest pain is vital in helping to
caused by rupture of a vulnerable atherosclerotic plaque with differentiate between acute and chronic pain. Patients with mus-
subsequent thrombus formation, which causes a sudden com- culoskeletal pain caused by injury or chronic conditions may
plete or critical reduction in coronary blood flow, which results in present to the emergency department days after the injury has
the clinical presentation of chest pain. occurred as a consequence of inability to carry out routine daily
Assessment of chest pain should focus on the history of the tasks or worsening of the chronic condition.6 Ischaemic chest
pain, cardiovascular risk factor profile, previous personal history pain in comparison may occur with exertion and relieve with rest
of ischaemic heart disease and prior relevant investigation. All or with sublingual GTN spray.
but the history of chest pain has been presented in part one and Location
two of this series. A clear history of chest pain and its associated Despite popular belief left sided chest pain is unlikely to indi-
symptoms are pivotal in guiding investigations and treatment. cate a cardiac origin. 1 Ischaemic chest pain is located central
There are numerous chest pain assessment tools and scores and or slightly to the left of central chest, but according to Hamm 7
a sample of these are presented in Tables 2 and 3, which can aid ischaemic chest pain may be experienced anywhere from the
in the assessment of chest pain pubis region to the top of the head and in some people they may
According to Oriolo and Albarran1 there is no specific recom- only experience pain in the areas of radiation such as arm, neck,
mendation as to which is the most appropriate tool to use, but jaw and not in the chest. Atypical symptoms include absence of

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 Continuing Education

Table 2

Example of assessment using OLD CARTS framework 5

Description Patient report

Onset When did the pain begin?

Location Where is the pain?

Duration How long does the pain last?

Characteristics Describe the pain? Crushing, stabbing, indigestion like, dull, ache for example.

Associating factors Other symptoms associated with the pain such as nausea and/or vomiting, weakness, fatigue,
breathlessness, syncope, cold and clammy?

Relieving factors/radiation Does the pain radiate such as down the arm, up into the neck for example?
Relieving factors: pain stops when activity ceases, relieved by sitting forward or resting?

Treatment/temporal factors Use of GTN, pain was relieved by rest or decrease in physical activity. Pain non comparable to
previous ischaemic chest pain

Severity (intensity) A numerical scale (1 no pain – 10 worse pain experienced ) is used to gauge pain severity

pain but instead epigastric fullness, fatigue and indigestion. These Table 3
symptoms may be seen in those who experience autonomic
neuropathy secondary to diabetes. In addition atypical presenta- Chest Pain Assessment Tools5
tion maybe experienced in younger (25-40 years) and older (>75 P – precipitating or provoking factors
years) patients, women and in those with chronic renal failure or Q – quality (intensity/pain score)
dementia. Absence of chest pain leads to under recognition of R – radiation, region
the disease and under treatment.7 S – severity/symptoms/duration
Duration T – timing
Differentiating chest pain according to duration of pain can
C – commenced when
be helpful marker in aiding diagnosis. According to Oriolo and
H – history/evidence of risk factors
Albarran1 if the pain is continuous or prolonged, eg. after exer-
E – extra/additional symptoms
cise, it is unlikely to be anginal in nature. In addition, pain that S – stays/radiation
rapidly comes and goes lasting less than a minute is also unlikely T – timing, how long has it lasted?
to be cardiac related. In contrast pain caused by ischaemic heart
disease can last for as long as 20 minutes or more and it is usu- P – place/location
A – what alleviates/aggravates the pain
ally relieved by GTN within one to five minutes of administration.
I – intensity scoring
But remember pain caused by oesophageal spasm can also be
N – nature and characteristics
relieved by GTN spray.
Character itate chest pain symptoms. Despite knowledge of ACS related to
Ischaemic chest pain has several descriptors depending on the substance abuse it is not routinely asked about or documented
patient’s perception of pain. Descriptors include pressure, heavy in clinical notes.
feeling, feeling of indigestion stabbing and sharp pain. Pain that Other associated symptoms related to chest pain include nau-
is reproducible on palpation, sharp or pleuritic pain, pain worse sea, vomiting, diaphoresis, shortness of breath, syncope or pre
on inspiration or coughing is unlikely to be ischaemic in nature syncope. If present then the presence of acute coronary syn-
although cannot be excluded. drome should be high.
Typical angina pain is defined as chest discomfort that is aggra- Relieving factors/radiation
vated by exertion and relieved by rest or GTN. It is necessary to It is necessary to enquire about how the chest pain is relieved. As
explore other aggravating/associating factor to aid in differential mentioned previously pain relieved by change in body position
diagnosis.2 Classically ischaemic pain maybe described as exer- or respiratory pattern or by antacids tend not to be ischaemic
tional pain, pressure or discomfort in the neck shoulder or arm. in nature. In comparison pain relieved by GTN or rest suggest
Atypical descriptors include cramping, grinding, pricking. Rarely ischaemia.
is tooth or jaw pain experienced as ischaemia. Hamm7 describes the radiation pattern of ischaemic chest pain
Associating factors as common in the left arm, neck or jaw. Radiation is less common
Typical ischemic pain is normally relieved by rest and/or GTN. in the right arm or both arms simultaneously, the back, abdomen
Pain that is relieved by change in body position, adjusting breath- and the teeth.
ing pattern or by antacids is unlikely to be cardiac in nature. 1 Temporal factors
When assessing the patient about the nature of their chest pain it From clinical experience people with a prior history of ischae-
is also important to obtain information regarding the use of rec- mic heart disease are able to recognise their ischaemic chest pain
reational drugs, herbal or over the counter medications as these from other forms of chest pain. For those who present for the
may interfere with patient’s prescribed medication and/or precip- first time with chest pain this is impossible and provides a chal-

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lenge when assessing the pain. Also temporal factors address the
treatment used to relieve pain and how often the treatment is
administered in order to obtain relief.
Severity
Pain is subjective so the use of pain scores, visual analogues
and pain scales are helpful in quantifying the severity of chest
pain and the effectiveness of the treatment administered. In our
clinical practice the pain scale is used and for those that can-
not use the pain scale due to communication barriers a visual
analogue is available. The pain scale is recorded in the nursing
documentation along with the assessment of chest pain.
In addition, recording the vital signs is essential and underpins
the subsequent physical examination. Vital signs that directly
relate to the cardiovascular system are the pulse and blood pres-
sure, but respiratory rate, temperature and level of consciousness
maybe beneficial in establishing differential diagnoses. Regarding
the recording of blood pressure Tough3 advises recording blood
pressure in both arms when a patient presents with chest pain. A
difference of greater than 20mmHg may indicate aortic dissec-
tion and can assist in formulating a diagnosis.
Attaching the patient to a cardiac monitor to observe for
ST segment deviation or occurrence of arrhythmias is also
recommended.
Recording 12 lead ECG has a central role in the early assess-
ment of patients with suspected ischaemic chest pain. It is
recommended that recording and interpreting a 12 lead ECG
within 10 minutes of patient presentation is best practice.7 Ideally
an ECG should be recorded when the patient has pain and com-
CardioWINNov-SM-KOD-AM.indd 3
Continuing Education
pared with an ECG recorded when the patient is pain free.
In addition to the ECG routine bloods such as full blood count,
coagulation screen, renal function should be observed to rule
out non-cardiac causes of chest pain and also to gain insight
into how other systems are functioning. Cardiac markers such as
troponins should also be noted, these serve to identify and risk
stratify patients into high, intermediate and low risk. Troponins
are highly sensitive for myocardial necrosis caused by occlusion
of the coronary artery.
Conclusion
Chest pain is a common presenting complaint with numerous
possible causes. A systematic approach as outlined above, sup-
plemented with vital signs, ECG and the relevant bloods will aid
in diagnosis, risk stratification and treatment options.
Kate O'Donovan is course co-ordinator for the postgraduate diploma in
cardiovascular nursing in the Mater Hospital, Dublin
References
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ing (10th Ed). Lippincott Williams & Wilkins: Philadelphia 2009: 323-389.
3. Tough J. Assessment and management of chest pain. Nursing Standard 2004; 18(26): 45-53
4. Bassand JP, Hamm CW, Ardissino D Et al. Guidelines for the diagnosis and treatment of non
st-segment elevation acute coronary syndromes. Task force for diagnosis and treatment of non
st-segment elevation acute coronary syndromes of European Society of Cardiology. Eur Heart
J 2007; 28: 1598-1660
5. Seidel HM, Ball JW, Dains JE, Benedict GW. Mosby’s Guide to Physical Examination (6th Ed).
Mosby: St Louis, 2003.
6. Hoskins R. Assessing and managing the patient with musculoskeletal chest pain. In: Albar-
ran JW, Tagney J (eds). Chest Pain: Advanced Assessment and Management Skills. Blackwell
Publishing: Oxford, 2007.
7. Hamm CW, Mollmann H, Bassand JP, Van de Werf F. (2009)Acute Coronary Syndromes.
The ESC Textbook of Cardiovascular Medicine. Oxford 2009: 535-596.
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