Chest Pain (Thoracic Pain): Diagnostic Tests

Mandatory medical device diagnostics.

• Elicitation of vital signs (note vital threat criteria):
  • Repeated blood pressure measurement on both arms with cuff adjusted for arm circumference. Notice:
    • Vital threat if severe blood pressure dysregulation (blood pressure ≤ 90 mmHg systolic or ≥ 220/120 mmHg).
    • Blood pressure differential and focal neurologic deficit with chest pain → think of: Aortic dissection (acute splitting (dissection) of the wall layers of the aorta (main artery)).
  • Determination of respiratory rate and pulse oximetry (measurement of oxygen saturation (SpO2) of arterial blood and pulse rate)Note:
    • Vital threat if
      • Tachycardia or bradycardia (heart rate > 100/min or < 60/min).
      • Respiratory insufficiency (respiratory failure/respiratory weakness) (SpO2 < 90%).
    • No routine O2 application (oxygen administration); O2 administration if SpO2 ≤ 92 % in the absence of risk of hypercapnia (increased carbon dioxide content in the blood); O2 administration if the patient clearly complains of dyspnea (shortness of breath).
  • Body temperature measurementun
    • Vital threat, if centralization, cold sweating.
  • Other criteria of vital threat are:
    • Disturbance of consciousness
    • Therapy-refractory pain (“unresponsive to therapy”)
• Electrocardiogram (ECG; 12-lead ECG; additional right ventricular leads in unstable patients and if 12-lead ECG is unremarkable; recording of myocardial electrical activity) – to confirm cardiac ischemia (reduced blood flow to the myocardium) [see below “Stages of myocardial infarction (heart attack) on ECG”; if ST elevation is detected on ECG, indication for invasive workup in cardiac catheterization laboratory. Notice:
  • A 12-lead ECG should be derived within the first 10 min after initial contact, regardless of patient age (IB indication)
  • Benign early repolarization is a prognostically benign normal variant commonly found in younger men.
  • An acute coronary syndrome (AKS or. ACS, acute coronary syndrome; spectrum of cardiovascular disease ranging from unstable angina pectoris (iAP; engl unstable angina, UA; “chest tightness”; (iAP; unstable angina, UA; “chest tightness”; sudden onset of pain in the region of the heart with inconstant symptoms) to the two main forms of myocardial infarction (heart attack), non-ST elevation myocardial infarction (NSTEMI) and ST elevation myocardial infarction (STEMI)) cannot be ruled out by a single determination of an ECG and biomarkers (high-sensitivity cardiac troponin T, hs-CTnT). ]

  If ECG and hs-cTnT negative, then only 1.5% of all myocardial infarctions are missed

• X-ray of the chest (X-ray thorax / chest), in two planes – if pulmonary infection (lung infection), pleurisy (pleurisy), pneumothorax (lung collapse, which is further complicated by a valve mechanism), rib fracture (rib fracture), etc. suspected.

Optional medical device diagnostics – depending on the results of the history, physical examination and mandatory laboratory parameters – for differential diagnostic clarification.

• Echocardiography (echo; cardiac ultrasound) – in unstable patients [regional wall motion abnormalities (WBS) evident? ]; in suspected pericarditis [emergency echocardiography and normal findings: cardiac cavities in normal width; good LV function; no pericardial effusion; aorta in normal width].
• Transesophageal echocardiography (TEE; examination is performed via the esophagus, which runs in a segment directly adjacent to the heart) or Angio-computed tomography (synonyms: angio-CT; CT-angio; vascular CT) – for suspected acute aortic syndrome (AAS): clinical pictures that can lead directly or indirectly via aortic dissection (splitting (dissection) of the wall layers of the aorta) to a rupture (“tear”).
• Esophago-gastro-duodenoscopy (ÖGD; endoscopy of the esophagus, stomach, and duodenum)/endosonography (endoscopic ultrasound (EUS); ultrasound examination performed from the inside, i.e., the ultrasound probe is brought into direct contact with the internal surface (for example, the mucosa of the stomach/intestine) by means of an endoscope (optical instrument)). – In cases of suspected:
  • Diseases of the esophagus (esophagus; e.g.B. Perforation of the thoracic esophagus (iatrogenic) after endoscopic surgery; Boerhaave’s syndrome, i.e., spontaneous rupture of the esophagus; usually after massive vomiting; possibly in alcohol excess).
  • Diseases of the stomach (Ulcus ventriculi / gastric ulcer).
  • Diseases of the duodenum (duodenal ulcer).
• Computed tomography of the thorax/chest (thoracic CT) – for suspected bronchial carcinoma (lung cancer), pulmonary embolism, mediastinitis.
• Coronary CT (English Cardiac computed tomography angiography, (CCTA); non-invasive examination to investigate the patency of the coronary arteries) – in acute chest pain for initial diagnosis in patients with stable angina pectoris to exclude coronary artery stenoses with intermediate pretest probability; furthermore, in suspected: Pulmonary embolism and aortic dissection (synonym: aneurysm dissecans aortae): acute splitting (dissection) of the wall layers of the aorta (main artery), with a tear of the inner layer of the vessel wall (intima) and a hemorrhage between the intima and the muscle layer of the vessel wall (outer media), in the sense of an aneurysm dissecans (pathological expansion of the artery).
• Magnetic resonance imaging (MRI) of the spine (spinal MRI) – if cervical (affecting the cervical spine) disc lesion is suspected.
• Cardio-MRI (magnetic resonance imaging of the heart) – unexplained chest pain Note: Not all patients with the clinical signs of myocardial infarction are found to have coronary stenoses (occluded coronary arteries) on cardiac catheterization. In such cases, a cardiac MRI can lead to the correct diagnosis in nine out of ten patients [Communication of the German Radiological Society E. V., 28. 05. 2014].
• Pulmonary ventilation scintigraphy/pulmonary perfusion scintigraphy (nuclear medicine examinations) – in suspected pulmonary embolism.
• X-rays of the spine, ribs – if bony cause is suspected.
• Abdominal sonography (ultrasound examination of abdominal organs) – if cholecystitis (gallbladder inflammation) or pancreatitis (inflammation of the pancreas) is suspected.
• Spirometry (basic examination in the context of pulmonary function diagnostics) – if bronchial asthma is suspected.

Further notes

• In low-risk patients, stress echo, cardio-MRI, and exercise ECG help avoid unnecessary procedures. Stress echo and cardio-MRI resulted in invasive coronary angiography* significantly less frequently than initial CT angiography (odds ratios 0.28 and 0.32, respectively) For exercise ECG, the OR was 0.53. In the comparison of functional testing versus CT angiography as an anatomy-based test, a number needed to harm of 133 was calculated with regard to myocardial infarction risk for the low-risk ACS patients. None of the strategies studied had an impact on the rate of subsequent myocardial infarctions.According to the authors and US guideline recommendations, initial functional testing should also be used in patients with V. a. stable angina. * radiological procedure that uses contrast agents to visualize the lumen (interior) of the coronary arteries (arteries that surround the heart in a wreath shape and supply blood to the heart muscle).

Stages of myocardial infarction in the ECG