As discussed in last Tuesday’s column, chest pain is a common symptom that can arise from various causes, ranging from benign conditions to life-threatening emergencies.

A timely and accurate diagnosis is crucial for providing appropriate treatment and preventing potential complications.

How to approach chest pain?

∎ Initial clinical evaluation

It begins with a detailed patient history, including the description, duration, and characteristics of the chest pain, and any associated symptoms, along with the patient’s medical history and cardiac risk factors. A focused physical examination follows to assess vital signs and cardiovascular system. All these different details and findings help the healthcare provider in formulating a preliminary analysis, especially towards labelling the chest pain cardiac or non-cardiac, and in targeting the subsequent work-up towards that initial diagnosis.

∎ Electrocardiogram

It records the electrical activity of the heart, helping to identify acute cardiac pain (or what is called a coronary syndrome), heart attack (or myocardial infarction), and arrhythmias like atrial fibrillation or heart block.

∎ Laboratory work

Elevated levels of specific cardiac proteins called troponins in the blood indicate damage to the heart muscle, which can occur in conditions like myocardial infarction. Serial measurements of these biomarkers over time can help determine the severity and progression of cardiac events.

∎ Chest X-ray

It helps to evaluate the lungs, chest cavity, and bony structures, assisting in identifying pulmonary causes, such as pneumonia or rib fractures.

∎ Echocardiogram

It provides a valuable information regarding heart muscle performance, valves’ abnormalities, fluid around the heart or other structural defects.

∎ Cardiac CT

When available in an emergency setting, it can quickly scan for any coronary blockages and their severity. If a lung clot or an aortic disease is suspected, an urgent scanner of the chest can unravel these conditions.

∎ Stress test

It is done within a few hours to a few days after the patient is assessed for or admitted to the hospital with chest pain. There are many modalities of stress testing, based on different heart-imaging technologies. A stress test can imply a monitored exercise on a treadmill or a bike if the patient is able to do so, or can be pharmacological using special medications that can stress the heart without the need for physical effort.

∎ Gastrointestinal work up

This may be needed if the chest pain evaluation becomes in favour of a stomach, bowels or gallbladder issue. The above work-up can define the cause of chest pain with an accuracy that exceeds 90 per cent.

How to treat chest pain?

Chest pain treatment depends on the underlying cause identified during the diagnostic process.

1, For cardiac causes, initial medications like nitroglycerin, aspirin, blood thinners, and beta-blockers, may be prescribed to manage myocardial infarction, angina, or arrhythmias.

In more than 80 per cent of these scenarios though, an invasive intervention like coronary angiography, percutaneous coronary intervention (stent deployment), or coronary artery bypass grafting surgery would follow to “fix” the coronary artery disease.

For a fast arrhythmia, an electrical cardioversion (shock to the heart) or an ablation (internal modification of the cardiac electrical circuitry) may be needed. For a slow heartbeat, a pacemaker might be the answer to the problem.

For cardiac valves disease, like aortic stenosis, a transcutaneous procedure or surgery might be required as there are generally no medications for this type of cardiac conditions.

2, For non-cardiac causes treatment may involve antibiotics for infections, asthma “puffs” for respiratory conditions, or stomach tablets for gastrointestinal disorders.

3, Lifestyle modifications such as smoking cessation, blood pressure control, anti-cholesterol medications, weight management, and dietary changes can be recommended to address underlying cardiac risk factors and to prevent future chest pain and recurrent cardiac events.

After initiating treatment, regular follow-up visits with the healthcare provider may be essential to monitor the patient's progress, adjust medications, and assess the need for further counselling and interventions.

• Joe Yammine, MD is a consultant cardiologist at the Bermuda Hospitals Board. The information herein is not intended as medical advice nor as a substitute for professional medical opinion. Always seek the advice of your physician