CPG Chest Pain EN PDF
CHEST PAINClinical PracticeGuideline forPrimary HealthCare PhysiciansAmerican International Health Alliance
Chest Pain:ClinicalPracticeGuideline forPrimaryHealth CarePhysiciansThis manual is made possible through support provided by the US Agency for InternationalDevelopment (USAID). The opinions expressed herein are those of the author(s) and do notnecessarily reflect the views of USAID.
Table of ContentsAcknowledgements .i-iiiList of acronyms .3Introduction .6Patient care system .10Basic notions.11Process of providing primary health care.14Characteristics ofchest pain in various conditions .19Ischemic heart disease .19Aortic dissection.23Pulmonary thromboembolism .23Pericarditis .24Pneumothorax .24Gastrointestinal conditions .25Spinal diseases .25Psychogenic pain .26Chest pain in the elderly .26Chest pain in disordersof muscles, bones and joints .28Chest pain in children .31
Table of Contents con’t.Algorithm of diagnosisand treatment of pain syndrome .32Clinical cases .34Patient education .44Provision of preventive services.46Pre-testing .47Post-testing .49Role of health professionals .59References .61
Chest PainAcknowledgmentsThe guideline on management of chest painwas developed by the members of the ArmeniaClinical Practice Guidelines expert group. Wewould like to thank the members for their significant contributions to the process and, indeed, tothe final product. Ruzanna Yuzbashyan, MD, head, Departmentof Primary Health Care, Ministry of Health ofthe Republic of Armenia: Working GroupLeader L.A. Grigoryan, MD, director of ambulanceservices of Yerevan A.S.Arutunan, MD, chief, Yerevan OutpatientClinic #15 L.A. Tatevosan, MD, Yerevan OutpatientClinic #10 M. Narimanyan, MD, DSci, chair, FamilyMedicine Department, Yerevan State MedicalUniversity.Clinical Practice Guidelines for General Practitionersi
Chest PainThe guideline is intended for health care professionals, including family physicians, nurses, pediatricians, and others involved in the organizationand delivery of health services to provide practicaland evidence-based information about management and differential diagnosis of chest pain inadult and pediatric patients. Sections of the guideline were developed for use by patients and theirfamily members.We are also indebted to those individuals on theAIHA CPG Steering Committee who graciouslyshared their knowledge and expertise; their comments and advice were key to ensuring the clarityand accuracy of this document. In particular, wewould like to thank: Dr. Steven Kairys, chairman of Pediatrics,Jersey Shore Medical Center, New Brunswick,New Jersey, Co-chairman of AIHA’s ClinicalPractice Guidelines Region-Wide AdvisoryCommittee Dr. Alan Melnick, director of the JointResidency Program, Department of FamilyMedicine, Oregon University for HealthScience, Portland, OregonThe American International Health Alliance(AIHA) also would like to acknowledge InnaJurkevich, MD, Ruzan Avetisyan, MD, MPH, andLeyla Bagirzadeh, MD, MPH who have providedleadership to the Clinical Practice GuidelineiiClinical Practice Guidelines for General Practitioners
Chest PainCross-partnership Program and who revieweddrafts of the document.Financial and technical support for the development of this manual was provided by the UnitedStates Agency for International Development(USAID).Clinical Practice Guidelines for General Practitionersiii
Chest Pain1. Contributors L.A. Grigoryan, director, Emergency MedicalService Center, Yerevan A.S. Harutunyan, director, #15 Policlinic,Yerevan L.A. Tadevosyan, physician, #10 Policlinic,Yerevan M.Z. Narimanyan, MD, PhD, chief, Chair ofFamily Medicine, YSMU Expert Group Chairman R.A. Yuzbashyan,head, Department of Primary Health Care,Ministry of Health of the Republic of Armenia.In the course of guideline development, consultations of specialists of Emergency Medical Serviceand out-patient clinics were used, along withpertinent electronic and hard copy publications.2Clinical Practice Guidelines for General Practitioners
Chest Pain2. List of Acronyms andAbbreviationsAIHAAmerican International HealthAllianceBPblood pressureCNScentral nervous systemCPKcreatine al tractIHDischemic heart diseaseLDHlactate dehydrogenaseMImyocardial infarctionNSAIDnon-steroidalanti-inflammatory drugsSGOTserum glutamic-oxaloacetictransaminaseYSMUYerevan State MedicalUniversityClinical Practice Guidelines for General Practitioners3
Chest Pain3. Glossary of Terms Echocardiography: the use of ultrasound in theinvestigation of the heart. Marfan’s syndrome: a syndrome of congenitalchanges in the mesodermal and ectodermaltissues, skeletal changes (arachnodactyly, longlimbs, laxness of joints), bilateral ectopia lentis,and vascular defects (typically the aneurysm ofthe aorta). Hyperventilation syndrome: increased pulmonary ventilation, which is incommensurateto the respiratory metabolism and is manifested by various respiratory, cardiovascular, andautonomic disturbances. Unstable angina: a syndrome incorporating anumber of clinical conditions such as restingangina within one week of occurrence; newlyoccurred angina of functional category III orIV according to Canadian classification; variantangina; small-size MI; post-infarction angina(Braunwald 1994).4Clinical Practice Guidelines for General Practitioners
Chest Pain Troponin: blood protein, concentration ofwhich increases dramatically during acutemyocardial infarction. Creatine phosphokinase: an enzyme catalyzingthe transfer of phosphate from phosphocreatineto ADP, forming creatine and ATP; CPK M(Muscle) and B (Brain) isozymes are recognized,with MB-type CPK being specific to myocardium.Clinical Practice Guidelines for General Practitioners5
Chest Pain4. Introduction4.1. ESSENTIALSChest pain complaints are of common occurrencein medical practice. Chest pain frightens thepatient and puts the physician on the alert, as it isoften a symptom of a serious disease. From thediagnostic standpoint, chest pain may present areal challenge to the physician.Although chest pain is a subjective symptom, itdoes have various degrees of intensity. ProfessorR. Aghababyan suggested the following classification of pain:0 degree - no pain1st degree - mild pain; patients are calm; pain maybe identified only during physical examination, isshort-lasting and transient2nd degree - moderate pain that is recurrent innature, with long intervals between episodes;patients appear to be restless6Clinical Practice Guidelines for General Practitioners
Chest Pain3rd degree - sharp pain of increasing intensity;frequent recurrences, with short intervals betweenepisodes4th degree - sharp, extremely severe, intractablepain; patients appear to be very restless, unableto find a comfortable position, and screamAs the pain may be caused by various conditions,careful and detailed medical history is critical,allowing timely and accurate diagnosis to be made.4.2. GOALS OF DEVELOPMENT OF THISCLINICAL PRACTICE GUIDELINEThis guideline was developed to: emphasize the importance of early diagnosis toprevent undesirable outcome; ensure that optimal treatment is provided fromthe time the diagnosis is made; make the patients and their families awareof the need for timely consulting with theirfamily physician; discuss the forms of psychological and socialsupport to provide patients and their familieswith the knowledge for successfully copingwith the disease.Clinical Practice Guidelines for General Practitioners7
Chest Pain4.3. METHOD OF DEVELOPMENT OFTHE CLINICAL PRACTICE GUIDELINEThis guideline is the result of joint efforts ofprimary health care specialists, leading specialistsof Emergency Medical Service, and the Chair offamily medicine. The aim was to develop a guideline, which might become a reference for familyphysicians. In addition, this method was rewarding, since it provided a possibility of involving allthe parties concerned in the process of guidelinecreation. The method was designed to emphasizethe role of nurses, patients and their families, inaddition to that of physicians.4.4. THE SCOPE OF APPLICATION OFTHE CHEST PAIN CLINICAL PRACTICEGUIDELINE INCLUDES THE POPULATION OF THE DISTRICT (ATTACHEDFAMILIES, INDIVIDUALS) SERVED BYA FAMILY PHYSICIAN.4.5. TARGET GROUPS FOR APPLICATION OF THIS GUIDELINE INCLUDE: Patients with a chest pain problem Risk groups of population (e.g., patients withcardiovascular disease) served by primaryhealth care providers8Clinical Practice Guidelines for General Practitioners
Chest Pain4.6. THIS CLINICAL GUIDELINE MAY BEUSED BY:family physicians, district therapeutists, pediatricians, EMS physicians, and nurses. Some sectionsof the guideline are reserved for patients and theirfamily members.4.7. EXPECTED RESULTS1. Increased identification rate of life-threateningconditions.2. Reduced complication rate of a number ofmedical conditions.3. Elimination of medical errors affectingpatients’ health.4. Favorable reports on the part of primary healthcare physicians regarding clarity, acceptability,and local applicability of the clinical practiceguideline developed.5. Patients’ satisfaction by the results of diagnosisand treatment based on the clinical practiceguideline developed.6. Saving financial resources, reducing thenumber of specialty referrals and hospitaladmissions.7. Increased patient referrals to primary healthcare physicians.Clinical Practice Guidelines for General Practitioners9
PATIE acute pain,gnawing pain,pain in the extremities,pain radiating along the nerves and worsening duringthe movements of neck or backmediastinitis, neoplasmChest wall disorders:muscle cramps, muscle spasm, epidemic myalgiaBone disorders:costochondral inflammation, including Tietze’s syndrome,fractured ribs, tumor metastases, osteochondrosis of cervical and thoracic spineNeuralgia:postherpetic, compression of the radicle of a nerveVascular disorders: aneurysm of the aorta and pulmonary artery History of atherosclerosis, hypertension, Marfan’s syndrome (patients are typically tall, have asthenic constitution, conoidal chest with wide intercostal spaces, kyphosis, “spider-like” fingers with long phalanges, hernias,and cardiac defects). Ehlers-Danlos syndrome (characterized by overelasticityof the skin, hypermobility of the joints, spontaneous cutaneous hemorrhages, various types of hernia, pneumothorax, and mitral valve prolapse). injury caused by stubbed instrument difference in blood pressure between arms and legsabove 25 mmHg presence of acute neurological symptoms:paresthesias, syncope risk factors for hea pain worsened by pand being relieved pain located retrost duration of pain accompanying symperspiration, weaknneck, arm, and bac presence of the 3rd pain relief with nit ECG: ST-segmentventricular origin pain as a sign of pewhen the patient is Pain of cardiac myocardial infa angina pectoris,valve prolapseDifMental disorders: anxiety depression hyperventilation indeterminate fedays(discomfortcardiac area, usassociated with hyperventilation
Chest PainNT CARE SYSTEMrt diseasephysical and emotional stress, cold air,at restternally or in the right side or the chestmptoms: nausea, vomiting, anxiety,ness, and radiation of pain to the jaw,ckd tone or murmurtroglycerinchanges, arrhythmia, particularly ofericardial disorders, which is relieveds sitting or bending forwardoriginrction, pericarditis, myocarditis, mitral coughblood spittingshortness of breathpulmonary pain influenced by cough and respiratorymovements tachypnea chest injuries due to surgery, history of deep vein thrombosis, lung disease detected using X-ray or auscultation:bronchitis, pneumonia, pleurisy (pleural friction rub, signsof obstruction)Pain of pulmonary origin pneumonia pulmonary infarction pleurisy, including thoracic form of familialMediterranean fever pneumothorax bronchitisfferential diagnosisGastrointestinal disorders: reflux or spasm aerophagia gall bladder disease, peptic ulcer disease pancreatitisneeling of anxiety lasting hours ort), stinging or squeezing pain in theually radiating to other areas andagitation and exertionn, weakness, palpitations10 tenderness in the right hypochondriac or epigastric area burning pain related to eating relief after eatingClinical Practice Guidelines for General Practitioners
Chest Pain5. Patient Care System5.1. BASIC NOTIONSPractical recommendations In patients complaining of chest pain, diagnosisof IHD should be considered and ruled out first. Medical history plays a major part in diagnosis. Mitral valve prolapse is a common and underrecognized cause of chest pain. Echocardiography is the most appropriate diagnostic technique. Pain related to esophagospasm may be as severeas that in myocardial infarction. Like angina, esophagospasm-related pain isrelieved by nitrates. Intervertebral disc hernia (Th2-Th9) is a veryrare cause of chest pain. In patients with suddenly occurring severedyspnea, diagnosis of myocardial infarction orpulmonary embolism should be considered,even when there is no pain.Clinical Practice Guidelines for General Practitioners11
Chest Pain Sudden occurrence of pronounced dyspneaduring the stable course of myocardial infarction should make you consider the rupture ofinterventricular septum, acute mitral failure, orpulmonary embolism.Diagnosis. Essential questions to askwhile providing primary health care. Show the sore place. Where is the pain radiating to? Describe the pain. How long does it last? Whatgives relief? Does the pain occur during physical exertionor in cold air? Does it pass when you rest? Is the pain accompanied by shortness ofbreath? Dizziness? Sweating? Is the pain worsened by breathing and coughing? Have you ever noticed traces of blood inyour sputum? Is the pain related to eating?Do you have a bitter taste in your mouth? Does the pain occur when you bend or lie onyour back? Does it occur at nighttime? Does the pain disappear after taking antacids?12Clinical Practice Guidelines for General Practitioners
Chest Pain Have you ever had skin rash on your chest? Have you ever had chest or backbone injuries?Main causes of errors Ignorance of IHD epidemiology. Inability to diagnose spinal osteochondrosisand osteoarthrosis, particularly those of thelower cervical spine. Over-diagnosis of neurosis in patients withcombination of anxiety, fear and acute chest pain. Mistaken opinion that any chest pain radiatingalong the medial surface of the left arm iscaused by angina pectoris. Ignorance of the fact that 20% of cases ofpulmonary embolism and myocardial infarction are asymptomatic or atypical, especially inelderly patients as well as those with alcoholismand diabetes mellitus. Mental disorders and simulation Psychogenic pain is usually stinging andprolonged (several days), has indeterminatelocation, and may be severe. It is usually accompanied by palpitations,dyspnea, tremor, agitation, or anxiety. Pain occurs during emotional stress, anxietyand depression.Clinical Practice Guidelines for General Practitioners13
Chest Pain5.2. PROCESS OF PROVIDINGPRIMARY HEALTH CAREAssessmentMedical history takingThe physician should identify location and radiation of the pain, its nature, intensity, duration,time of occurrence, and accompanying symptoms.Factors provoking and relieving the pain must beidentified. The patient should be asked about pastand current illnesses, giving particular attention tohistory of diabetes mellitus, Marfan’s syndrome,anemia, and systemic lupus erythematosus. Ifsevere pain makes the direct history taking impossible, patient’s relatives should be asked.Accompanying symptoms must be taken intoconsideration: Syncopes: myocardial infarction, pulmonarythromboembolism, and aortic dissection mustbe ruled out. Pain worsened on exhalation: pleurisy, pericarditis, pneumothorax, disorders of chestmuscles, bones and joints must be ruled out. Pain in the back: spinal disorders, myocardialinfarction, angina pectoris, aortic dissection,pericarditis, peptic ulcer disease, esophagospasm, and cholecystitis must be ruled out.14Clinical Practice Guidelines for General Practitioners
Chest PainPhysical examinationInspect for visible signs of atherosclerosis: arcussenilis of the cornea, hardening and thickening ofthe arteries. Inspect skin for rash characteristic ofherpes zoster.Assess the pulse at the radial and femoral arteries.Measure BP and body temperature. Palpate the chest and the spinous processes ofvertebrae. Assess for local tenderness, fractures,symptoms of spinal diseases. Percuss the chest(to rule out pneumothorax). Inspect the feet. Rule out deep vein thrombosis. Perform cardiac and pulmonary auscultation: absence of respiration and vocal fremitus—pneumothorax; pleural (pericardial) friction rub—pleurisy (pericarditis); moist rales in the lower lung fields—heart failure; systolic murmur over the apex—mitral valve prolapse; diastolic murmur over the aorta—dissection of ascending aorta. Palpate the abdomen. Epigastric pain maybe seen in diseases of gallbladder, stomach,and duodenum.Clinical Practice Guidelines for General Practitioners15
Chest Pain In myocardial infarction and aortic dissection,algesic shock often develops. Patients are pale,with cold and clammy skin. In myocardial infarction, obtuse cardiacsounds, gallop rhythm, and systolic murmurmay also be heard; in aortic dissection, absenceof pulse at femoral arteries and diastolic murmur over the aorta are observed.Laboratory and other diagnostic studiesIn most cases, ECG at rest, chest X-ray, and bloodenzyme activity testing provides sufficient information for making diagnosis.There are other testing methods. However, they aresophisticated and are reserved for specializedmedical centers.ECG at restECG is the most informative procedure for diagnosing acute ischemia and myocardial infarction.It should be remembered that ECG might showno changes during the first minutes following theonset of MI-related pain attack.Diagnostic criteria for acute myocardial infarction: ST elevation 1 mm in 2 or morecontiguous limb or precordial leads Left bundle branch block, not known tobe old16Clinical Practice Guidelines for General Practitioners
Chest PainECG findings useful for establishing the likelihood ofcoronary artery disease: T segment depression 1mm Inverted T-waves 1 mm in two or morecontiguous leadsECG is useful for differentiating myocardialinfarction from pulmonary thromboembolismand pericarditis. In thromboembolism of largebranches of pulmonary artery, electrical axis ofthe heart deviates to the right. Pericarditis is characterized by depression of waves and elevation ofST-segment in some or all leads.Radiodiagnostic procedures Chest X-ray Radiography of cervical and thoracic spineTotal blood count and clinical chemistry panelAt the pri
Chest Pain 4. Introduction 4.1. ESSENTIALS Chest pain complaints are of common occurrence in medical practice. Chest pain frightens the patient and puts the physician on the alert, as it is often a symptom of a serious disease. From the diagnostic standpoint, chest pain may present a real challenge to the physician.
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III.5. Comparaison de l'efficacité des colonnes en CPL et CPG : u plus faible en CPL qu'en CPG, H plus petit en CPL qu'en CPG, mais L plus grand en CPG ( 50 m) qu'en CPL (25 à 50 cm max (trop de pertes de charge au delà)) En général, meilleure efficacité en CPG (N plus grand). III.6. Optimisation d'une analyse chromatographique
Chest Pain Objectives Discuss a ggpp peneral approach to chest pain Review differential diagnosis Develop an understanding of the diagnosis and management of common and serious causes ofmanagement of common and serious causes of chest pain Background Chest
pain”, “more pain” and “the most pain possible”. Slightly older children can also say how much they are hurting by rating their pain on a 0-10 (or 0-100) scale. Zero is no pain and 10 (or 100) is the worst possible pain. What a child is doing Often children show their pain by crying, making a “pain” face, or by holding or rubbing .
Short-term pain, such as when you suffer a sprained ankle, is called 'acute' pain. Long-term pain, such as back pain that persists for months or years, is called 'chronic' pain. Pain that comes and goes, like a headache, is called 'recurrent' pain. It is not unusual to have more than one sort of pain or to have pain in several places
General discussions of pain often refer simply to three types: 1) Acute (brief that subsides as healing takes place) 2) Cancer 3) Chronic non-malignant pain - "persistent pain" Classification of pain by inferred pathology: 1) Nociceptive Pain 2) Neuropathic Pain (McCaffery & Pasero, 1999) Nociceptive Pain A. Somatic Pain B. Visceral Pain
Knee Pain 1 Knee Pain 2 Knee Pain 3 Knee Pain 4 Knee Pain 5 Lateral Knee Pain Medial Knee Pain Patella Pain 1 Patella Pain 2 Shin Splint. 7 Section 6 Ankle/Foot Big Toe 89 . For additional support, wrap another tape around the last finger joint. Step 3. No stretch is applied during application. 30 Step 1 Step 2 Finger Pain. 31 Requires;
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