Chest Pain Assessment: What to Do When Your Patient Has Chest Pain

Regardless of whether your patient is 25 or 85 years old, when they report chest pain, you should always treat it seriously.

Maybe the cause of the chest pain is nothing more than indigestion, a muscle strain, or some other innocuous problem. However, chest pain can potentially point to a more serious and life-threatening cause, such as an acute myocardial infarction (AMI).

For this reason, chest pain must always be considered cardiac in nature until proven otherwise.

Note: This article is intended as a refresher and should not replace best-practice care. Always refer to your facility’s policy on addressing chest pain.

Making an Accurate Chest Pain Assessment

One of the most important skills available to the healthcare worker in this situation is the ability to perform an accurate pain assessment. This is particularly the case when a patient is experiencing chest pain, as it will help to determine whether the pain is cardiac in nature. Just as important, is the ability of the healthcare worker to conduct this assessment in a calm and controlled manner.

There are many different ways of assessing chest pain, however one of the most popular is the ‘PQRST’ pain assessment tool.

PQRST Pain Assessment Tool

P – Position/Provoking Factors

• Where is the pain? Can you point to it?
• What provoked the pain?
• What makes the pain better?
• What makes the pain worse?
• What were you doing when the pain started?
• Did the pain occur at rest or during exertion?
• Does the pain change with repositioning?

Tip: Repositioning tends not to change chest pain caused by an AMI. If repositioning improves the pain, perhaps the issue is of musculoskeletal origin, pleuritic, or pericarditis (where the pain is sometimes relieved by sitting up and leaning forward). Women who experience AMI often present with atypical chest pain and other symptoms such as dyspnea, weakness and fatigue (Mehta et al. 2016).

Q – Quality

• Can you describe the pain or discomfort?
• Is it dull, sharp, squeezing, pressure, burning, aching, pounding, cramping, stabbing or crushing?

Tip: The majority of patients experiencing an AMI will report with chest pain (Malik et al. 2013; Lichtman et al. 2018), however, sometimes the pain is atypical or even absent (a silent myocardial infarction) (Draman et al. 2013). It must be remembered that every patient is different and they will not all present with the classic substernal chest pain.

R – Radiation

• Does the pain radiate to any other areas?
• Can you point to it?

Tip: Roughly 65% of patients with an AMI will experience radiating pain (Granot et al. 2019). Common sites include the anterior chest, shoulders, arms, neck and jaw. Some patients describe jaw pain feeling like a dull ache or a toothache, whilst some may describe the radiation as a band around the ribs.

S – Severity/Symptoms

• Can you rate the pain out of ten?(0 being no pain experienced and 10 being excruciating pain.)
• Are you experiencing any other symptoms?

Tip: Accompanying symptoms of an AMI may include nausea, vomiting and diaphoresis. The patient may also experience dizziness, hypotension and bradycardia or a feeling of impending doom and feeling scared (Heart Foundation n.d. a).

T – Time

• How long have you had the pain for?
• Was the onset slow or sudden?
• Is the pain intermittent (starts and stops) or is it continuous (ongoing)?
• Have you had the pain previously?
• Is it the same as last time, or different?

Tip: Angina is typically short-lived and lasts for 2-5 minutes if the precipitating factor is relieved, for example exercise (Heart Foundation n.d. b; Heart and Stroke Foundation of Canada 2018). Pain associated with AMI is not usually intermittent, though can be.

I Think the Chest Pain May Be Cardiac in Nature… What Now?

There are a few important principles that need to be considered when managing cardiac-related chest pain. Firstly, the heart is a muscle that needs its own blood supply. The harder the heart works, the more oxygen it requires. Basically, we want to increase oxygen supply to the heart and reduce oxygen demand (Zefari et al. 2019).

Goal Directed Oxygen Therapy

In regards to oxygen therapy, clinical guidelines on the management of acute coronary syndromes (ACS) published by the National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand state:

‘The routine use of oxygen therapy among patients with a blood oxygen saturation (SaO2) >93% is not recommended, but its use when the SaO2 is below this level is advocated despite the absence of clinical data [21–24]. However care should be exercised in patients with chronic obstructive airways disease where the target SaO2 is to be 88-92%.’

(Chew et al. 2016)

Coronary Vasodilators (Nitrates)

Nitrates act on vascular smooth muscle, producing a vasodilator effect on the veins and arteries, which in turn reduces intracellular calcium levels and leads to vasodilation.

Nitro-glycerine (e.g. glyceryl trinitrate - GTN) is often indicated in the setting of cardiac-related chest pain as it dilates the coronary vessels, improving coronary perfusion and oxygen supply to the heart (Australian Medicines Handbook 2020; Chew et al. 2016).

Note: GTN has several contraindications, including its use by a patient with hypotension (AMH 2020), as it can further decrease blood pressure due to its effect on the reduction on preload and stroke volume (Chew et al. 2016). Always check your health institution policy regarding GTN administration.

Antiplatelet Aggregators (Aspirin)

Aspirin may be prescribed (if not contraindicated) in the setting of chest pain to reduce the risk of thrombus formation in blood vessels (Chew et al. 2016). Aspirin reduces the formation of thromboxanes, which mediate vasoconstriction and platelet aggregation (AMH 2020).

Rest, Reassure and Relieve Pain

In the setting of severe chest pain, opioid analgesia (e.g. morphine, fentanyl) may be considered (Chew et al. 2016).

Always refer to the patient’s doctor/prescriber’s advice regarding analgesic prescription and administration.

What Else Should I do?

• Perform and document vital signs, including the ‘PQRST’ pain assessment.

• Inform senior staff immediately.

• Perform a 12-lead ECG and have it checked by a medical officer as soon as possible.

  Performing and interpreting a 12-lead ECG is a vital assessment in the setting of chest pain. An ECG will help the medical team determine if and when a patient requires reperfusion therapy to treat the cause of the chest pain.

  Nurses may be encouraged to review a 12-Lead ECG with an experienced clinician to identify ECG changes that indicate a patient experiencing an ischaemic event. It is imperative that a medical officer, cardiologist or intensivist reviews the ECG. Always ensure you are treating the clinical signs and symptoms of the patient to maximise oxygenation and perfusion to the myocardium. It is suggested that a nurse should obtain a previous ECG conducted on admission or previous cardiac event. Early CPR and Defibrillation decrease mortality rates.

• Ensure easy access to a defibrillator.

  Maintaining access to a defibrillator is included in the current guidelines on the management of acute coronary syndromes (ACS) as a priority in the acute management of chest pain (Chew et al. 2016). This is because access to a defibrillator avoids early cardiac death caused by reversible arrhythmias. Patients who are having an AMI can have associated arrhythmias.

• Senior medical staff may then order diagnostic blood tests such as a full blood examination (FBE), troponin, biochemistry and electrolytes.

  Lastly, diagnostic blood tests may be ordered. Commonly, this includes testing a patient’s troponin levels. Troponin is a cardiac enzyme or marker of ischaemia/infarction.

Conclusion

An accurate assessment of a patient’s chest pain helps identify the likely cause of the pain and leads to prompt and appropriate responses to alleviate the pain and treat the cause. Maintaining a calm and controlled environment is not only essential for the patient’s comfort, but for yours, too!

Additional resources:

• Australian Clinical Guidelines for the Management of Acute Coronary Syndromes: https://www.heartfoundation.org.au/...Management_of_Acute_Coronary_Syndromes_2016.pdf.

References

• Australian Medicines Handbook 2020, Australian Medicines Handbook Online, AMH, viewed 7 April 2020, https://amhonline.amh.net.au/.
• Chew, DP, Scott, IA, Cullen, L, French, JK, Briffa, TG, Tideman, PA, Woodruffe, S, Kerri, A, Branagan, M & Aylward, PEG 2016, ‘National Heart Foundation of Australia & Cardiac Society of Australia and New Zealand: Australian Clinical Guidelines for the Management of Acute Coronary Syndromes 2016’, Heart Lung and Circulation, vol. 25, pp. 895–951, viewed 24 March 2020, https://www.heartfoundation.org.au/images/uploads/publications/Clinical_Guidelines_for_the_Management_of_Acute_Coronary_Syndromes_2016.pdf.
• Draman, MS, Thabit, H, Kiernan, TJ, O’Neill, J, Sreenan, S & McDermott, JH 2013, ‘A silent myocardial infarction in the diabetes outpatient clinic: case report and review of the literature’, Endocrinology, Diabetes & Metabolism Case Reports, viewed 23 March 2020, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3921998/.
• Granot, M, Dagul, P & Aronson, D 2019, ‘Resting blood pressure modulates chest pain intensity in patients with acute myocardial infarction’, Pain Reports, vol. 4, no. 3, viewed 24 March 2020, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6749909/.
• Heart and Stroke Foundation of Canada 2018, Angina, Heart and Stroke Foundation of Canada, viewed 24 March 2020, https://www.heartandstroke.ca/heart/conditions/angina.
• Heart Foundation n.d. a, Heart Attack Symptoms, Heart Foundation, viewed 24 March 2020, https://www.heartfoundation.org.au/your-heart/heart-attack-symptoms.
• Heart Foundation n.d. b, Angina, Heart Foundation, viewed 24 March 2020, https://www.heartfoundation.org.au/your-heart/heart-conditions/angina.
• Lichtman, JH, Leifheit, EC, Safdar, B, Bao, H, Krumholz, HM, Lorenze, NP, Daneshvar, M, Spertus, JA & D’onofrio, G 2018, ‘Sex Differences in the Presentation and Percetpion of Symptoms Among Young Patients with Myocardial Infarction’, Circulation, vol. 137, no. 8, pp. 781-90, viewed 7 April 2020, https://www.ahajournals.org/doi/full/10.1161/circulationaha.117.031650.
• Malik, MA, Khan, SA, Safdar, S & Taseer, I 2013, ‘Chest Pain as a presenting complain in patients with acute myocardial infarction (AMI)’, Pakistan Journal of Medical Sciences, vol. 29, no. 2, pp. 565-8, viewed 23 March 2020, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3809224/.
• Mehta, LS, Beckie, TM, DeVon, HA, Grines, CL, Krumholz, HM, Johnson, MN, Lindley, KJ, Vaccarino, V, Wang, TY, Waton, KE & Wenger, NK 2016, ‘Acute Myocardial Infarction in Women’, Circulation, vol. 133, no. 9, pp. 916-47, viewed 23 March 2020, https://www.ahajournals.org/doi/10.1161/CIR.0000000000000351.
• Zafari AM, Abdou, MH, Talavera, F, Ali, YS, Yang, EH, Garas, SM, Jeroudi, AM & Reddy, SV 2019, ‘Myocardial Infarction Treatment & Management’, Cardiology, 7 May, viewed 24 March 2020, https://emedicine.medscape.com/article/155919-treatment#d1.